Understanding Occupational Therapy Practitioners’ Use of Upper Extremity–Focused Home Programs for Persons Post Stroke

PURPOSE: After stroke, upper-extremity hemiparesis is a persistent problem that directly impacts quality of life. However, many individuals poststroke lack access to services, further contributing to long-term disability. Home programs are often used by occupational therapy practitioners (OTPs) to bridge the gap of limited access to services. Yet, adherence to home programs is often low. Possible reasons for low adherence include fatigue, pain, low motivation, and frustration (Donoso Brown, Dudgeon, Gutman, Moritz, & McCoy, 2015; Jurkiewicz, Marzolini, & Oh, 2011). Factors found to facilitate adherence to home programs poststroke include participation in a group, motivation to improve overall health, and desire to reduce musculoskeletal issues (Leijon, Faskunger, Bendtsen, Festin, & Nilsen, 2011). While the literature reports patient perspectives relative to home programs for upper-extremity rehabilitation, there is only one published study that looks broadly at the implementation of home exercise programs for individuals with neurological impairments (Proffitt, 2016). Our investigation focused specifically on how OTPs working with individuals poststroke design, implement, and monitor home programs, including the use of technology, to improve upper-extremity motor function (HP–UEs).

DESIGN AND METHOD: This study is a descriptive, clinician-reported online survey. Researchers obtained a convenience sample of licensed OTPs (N = 73) within the United States who had within the past 2 mo created at least two HP–UEs for adults poststroke. The survey was developed based on previous literature related to the experience of home programs poststroke, as well as techniques reported in the literature for upper-extremity rehabilitation. The survey went through interprofessional review followed by pilot testing with OTPs prior to deployment. The final survey included questions on reported methods for home program creation, strategies for home program training, use of technology, and perceived barriers and facilitators to home program use. Demographic data were also collected. Participants were recruited through occupational therapy state associations, occupational therapy program directors, American Occupational Therapy Association discussion boards, and emails to current practitioners known by the researchers. Data were collected via SurveyMonkey (San Mateo, CA), and descriptive analysis occurred within that program. Data gathered from open-ended questions were qualitatively coded by the primary researcher and a student research apprentice.

RESULTS: A convenience sample of 73 licensed OTPs had complete survey responses. Fifty-three OTPs (68%) reported creating HP–UEs greater than 80% of the time; however, strategies to ensure adherence were not strongly reported. The most common strategies used to instruct clients included direct training, visual demonstration, and discussion. Most OTPs (n = 54, 74%) identified using home exercise handout creation software 50%–100% of the time. However, implementation of novel technology reported was limited. OTPs ranked the most common facilitators to adherence as personal motivation and family support, while the two most commonly perceived barriers were low motivation and cognitive impairments.

CONCLUSION: This preliminary description of OTPs’ implementation of HP–UEs for individuals poststroke provides further insight into practice patterns. OTPs report using traditional techniques of visual demonstration, direct training, and discussion regularly, while the use of novel technological applications or specific adherence strategies is limited. OTPs perceived that participation in home programs was highly related to motivation and external support. These findings are consistent with the survey completed by Proffitt (2016) but demonstrate that these patterns are also present when working specifically with individuals poststroke. This study impacts future occupational therapy practice because it is critical to understand the nature of current HP–UEs in order to identify the potential active ingredients needed to develop effective client-directed home interventions for persons poststroke. Future research should aim to understand the perspectives of additional stakeholders in this process and begin the testing of potential active ingredients to understand how they may influence HP–UE adherence.

References

Donoso Brown, E. V., Dudgeon, B. J., Gutman, K., Moritz, C. T., & McCoy, S. W. (2015). Understanding upper extremity home programs and the use of gaming technology for persons after stroke. Disability and Health Journal, 8, 507–513. https://doi.org/10.1016/j.dhjo.2015.03.007

Jurkiewicz, M. T., Marzolini, S., & Oh, P. (2011). Adherence to a home-based exercise program for individuals after stroke. Topics in Stroke Rehabilitation, 18, 277–284. https://doi.org/10.1310/tsr1803-277

Leijon, M., Faskunger, J., Bendtsen, P., Festin, K., & Nilsen, P. (2011). Who is not adhering to physical activity referrals, and why? Scandinavian Journal of Primary Health Care, 29, 234–240. https://doi.org/10.3109/02813432.2011.628238

Proffitt, R. (2016). Home exercise programs for adults with neurological injuries: A survey. American Journal of Occupational Therapy, 70, 7003290020. https://doi.org/10.5014/ajot.2016.019729