Home Exercise Programs for Adults With Neurological Injuries: A Survey

Participants and Procedure

This study involved a survey approach and was approved by the University of Southern California’s institutional review board. The names and addresses of 22,150 members of the American Occupational Therapy Association (AOTA) were purchased from AOTA’s list rental service following the organization’s guidelines (members may opt out). Surveys were mailed to 2,000 occupational therapists who were selected via computer-generated randomization of every fifth name of occupational therapist members. Surveys were distributed via mail, and respondents had the option of returning the paper survey via the enclosed stamped envelope or completing the online version of the survey. The criteria for selection were based on a Boolean search of the following list rental categories:

Instrument

The survey was developed from semistructured interviews and focus groups conducted by the author. The initial survey was distributed to 5 occupational therapists to determine readability and appropriateness of questions. Recommended changes were made to this initial survey, resulting in the refined final version that was distributed in the mailing. Six questions related to demographics: years of experience, specialties or certifications held, practice setting, diagnoses treated, days per week treating clients, and length of occupational therapy treatment sessions. Six open-ended questions were related to HEP treatment dosage, the type of HEP activities, and methods of education that occupational therapists used in HEP. Fifteen questions were Likert-scale questions designed to ascertain occupational therapists’ opinions on the use and value of HEPs for CWNIs (Figure 1). Three open-ended questions asked occupational therapists about the clinical reasoning underlying the prescription and progression (e.g., grading or updating) of HEPs for CWNIs:

Occupational therapists who did not use HEPs in practice had the option of selecting “I do not prescribe HEPs” and providing an open-ended response.

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Figure 1.

Survey questions on HEP activities, methods of client and caregiver education, and opinions and attitudes toward using HEPs with CWNIs.

Data Analysis

Data were entered into a REDCap database (Harvard Catalyst, Boston), validated for accuracy, and checked for missing data. Data were exported to Excel (Microsoft Corp., Redmond, WA), and surveys returned from occupational therapists who were no longer practicing or who held administrative or management positions were analyzed separately. All check box and Likert-scale questions were analyzed using descriptive statistics and frequencies. Post hoc correlations were calculated to identify potential relationships between survey respondent demographics and questionnaire responses.

The open-ended question about HEP dosage was coded separately by the author and one other researcher, and the answers were grouped into categories for descriptive statistics analysis. The other open-ended questions—those related to HEP prescription and progression—were coded by the same two researchers, and themes were allowed to emerge from the data. Occupational therapists who indicated that they did not prescribe HEPs were grouped, and their data were analyzed separately using the same methods.

Demographics and General Clinical Practice

Respondent characteristics are presented in Table 1. The majority of occupational therapists worked in hospital-based settings and treated a diverse range of neurological conditions. The most frequently treated condition was cerebrovascular accident (n = 307). No statistically significant correlations were found between demographic variables and HEP content, dosage, and client or caregiver education.

Home Exercise Program Content, Dosage, and Client and Caregiver Education

The majority of occupational therapists (94%) reported prescribing an HEP for CWNIs. The content of these HEPs varied greatly across occupational therapists (Figure 2A). The most commonly prescribed activities—each selected by more than 250 occupational therapists—were fine motor activities, active range of motion, active assistive range of motion, and whole or partial activity of daily living (ADL) tasks. Occupational therapists were able to state how many days per week they prescribed an HEP for a CWNI, and the most common dosage was 16–30 min daily. Some felt that prescribing anything >30 min/day was burdensome to clients and thus reduced adherence rates.

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Figure 2.

HEP activities as reported by (A) survey respondents and (B) occupational therapist responses to Likert-scale questions on implementation and progression of an HEP.

Methods used to educate CWNIs about an HEP included providing paper copies of the exercises (n = 307; 85.3%), demonstrating exercises (n = 320; 88.9%), asking the CWNI to demonstrate the exercise (n = 309; 85.8%), providing a handout with text and pictures (n = 290; 80.6%), asking the CWNI to practice in front of a mirror (n = 128; 35.6%), and videotaping (n = 29; 8.1%) or photographing (n = 41; 11.4%) the CWNI for his or her own review later. Similarly, methods used to educate caregivers included providing handouts with text and pictures (n = 316; 87.8), answering questions (n = 306; 85.0%), demonstrating exercises (n = 312; 86.7%), providing hands-on learning (n = 218; 60.6%), providing hands-on learning with return demonstration (n = 287; 79.7%), and allowing caregivers to take pictures or videos for later review (n = 72; 20.0%). Although many occupational therapists reported providing CWNIs and their caregivers with paper handouts, only 17% had CWNIs complete a paper checklist to track adherence. The majority (71%) relied on verbal statements from the CWNI or their caregiver to track adherence.

Clinical Reasoning

Occupational therapists reported several factors that guided their clinical reasoning for prescribing HEPs for CWNIs. Client priorities and goals were a primary factor. As 1 occupational therapist stated, “It’s based on what they want to achieve.” As expected, the client’s deficits and functional abilities guided the choice of exercises and the dosage and progression of an HEP over time. Many occupational therapists noted that cognitive deficits played a large role in their choice of activities and timing when prescribing an HEP. More than 90% of occupational therapists agreed or strongly agreed with the following statements: “Proactive clients are more likely to be compliant with HEPs” and “[Clients’] insight, memory, and attention affect their compliance with HEPs.”

Occupational therapists were less in agreement with regard to the practices used to implement and progress (e.g., update or modify) an HEP (Figure 2B). For instance, the point during treatment at which the HEP was implemented varied across occupational therapists. Some prescribed an HEP for CWNIs during the first or second session of treatment because, as 1 occupational therapist stated, “Since the client is the one who will live with [the] deficits, early engagement and ownership is essential.” The methods and clinical reasoning skills used to progress an HEP also varied across occupational therapists. Many relied on observed functional changes in treatment sessions, and others based their decisions on client or caregiver report. Some occupational therapists reported that they used a variety of strategies, such as “clinical progression seen in therapy sessions as well as info[rmation] gleaned from [the] patient and/or caregiver.”

Perceived Benefits of Home Exercise Programs

Prescribing HEPs for CWNIs had many reported benefits. The major theme that emerged from qualitative analysis was that the “client is an active part of rehabilitation/recovery.” A majority of occupational therapists reported that carryover or generalization of an HEP was a benefit because “[it allows for] continuation of services at home when they may not otherwise be available and gives [the] client control over recovery.” More than 95% of occupational therapists agreed or strongly agreed with the statement “HEPs reinforce carryover into the client’s environment.” Occupational therapists also described the formation of an HEP routine by the client as a benefit. For example, occupational therapists felt that an HEP “is a good opportunity to give patients and their family a chance to improve their well-being on their own and create good health habits in their lives.” Nearly 90% of occupational therapists agreed that the amount of one-to-one occupational therapist services that insurance covered was insufficient to meet client goals and was thus a primary reason for prescribing an HEP.

The client factor–related benefits of an HEP included a reduction in deficits, prevention of decline, and allowing for neuroplasticity to occur. Several occupational therapists made comments specifically related to the link between the amount of therapy and the physiological and neurological changes after a neurological injury: “HEPs reinforce brain-to-body connections. Regular opportunities to engage in motor planning and motor control activities are beneficial to overall brain/neurotransmitter functioning.”