Date Presented 04/04/19
The evidence to support stroke rehabilitation has grown. There are no studies that have examined the nature of usual and customary OT for outpatient stroke rehabilitation. The findings from this study describe this based on data from a large, multisite Phase III clinical trial.
Primary Author and Speaker: Rachel Proffitt
Additional Authors and Speakers: Sara Benham, Pamela Roberts
PURPOSE: Stroke rehabilitation, including outpatient occupational therapy, has evolved from expert opinion and clinical tradition to one focused on recent advances in the neuroscience of development, physiology, imaging, and cognition (Carter et al., 2010). Overall, stroke rehabilitation in a hospital has been studied but the effectiveness of outpatient rehabilitation care is less known. The available evidence to support occupational therapy practice in stroke rehabilitation has grown exponentially. However, there have been no published studies that examine the nature of usual and customary occupational therapy for subacute stroke rehabilitation. The Interdisciplinary Comprehensive Arm Rehabilitation Examination (ICARE) study conducted from 2009 to 2014 by Winstein and colleagues included two usual and customary care (occupational therapy) arms (Winstein et al., 2016). The data collected from this multi-site trial provide a starting point for examining the nature of services provided. The two research questions for this study were: 1. What does an episode of stroke care look like for hospital based outpatient rehabilitation? and 2. What are the activities of usual and customary occupational therapy for individuals with a stroke for mild and moderate stroke?
DESIGN: The original study was a multi-site, randomized, single-blinded Phase III clinical trial conducted from 2009-2014 (Winstein et al., 2013). This study was a mixed-methods (quant-qual) secondary analysis of an existing dataset (Dose-Equivalent Usual and Customary Care [DEUCC] and Usual and Customary Care [UCC]).
METHOD: Quantitative: Variables included CPT codes, time from evaluation to first OT session, time from hospital discharge to first OT session, time from stroke onset to evaluation, number of sessions missed, total number of OT sessions (minutes) (UCC only), stroke motor severity (Fugl-Meyer Assessment- Upper Extremity), and cognitive status (dichotomous by DKEFS score). Qualitative: A sample of treatment notes to include all seven treatment sites were electronically transcribed by two trained research assistants. Two separate researchers coded the treatment notes, building and refining a code set. Themes were allowed to emerge from the codes and refined as coding progressed.
RESULTS: Patient engagement and goal-directed treatment were substantial themes for both DEUCC and UCC groups. Occupational therapy practitioners also prescribed a functional home program from nearly the first day of treatment. For individuals with mild stroke, there was significantly more sessions focused on ADL and IADL tasks and less on therapeutic exercise when compared to those with moderate stroke. Although the screening criteria for the original ICARE study excluded individuals with cognitive impairment, there were still billing codes for cognitive rehabilitation (97532). Those sessions typically involved strategy development for memory and attention during work and IADL tasks (such as cooking).
CONCLUSION: This study sheds some much needed light on the nature of hospital-based outpatient rehabilitation for individuals with stroke. The findings also help explain the lack of difference found between the investigational treatment (ASAP) and usual and customary occupational therapy (Winstein et al., 2016). Much of what we do as occupational therapists were the principles of the “investigational” treatment.
IMPACT STATEMENT: These findings suggest that outpatient therapy occupational therapy for stroke is evidence-based and occupation-based. It helps demonstrate our distinct value as occupational therapy practitioners to patients, providers, and insurers.
References
Carter AR, Conner LT, and Dromerick A (2010). Rehabilitation after stroke: current state of the science. Current Neurol Neurosci Rep, Vol 10: 158-166.
Winstein, C., Wolf, S., Dromerick, A., Lane, C., Nelsen, M., Lewthwaite, R., Blanton, S., Scott, C., Reiss. A., Yong Cen, S., Holley, R., & Azen, S. (2013). ICARE: A randomized controlled trial protocol. BMC Neurology, 13(5), 1-19.
Winstein, C., Wolf, S., Dromerick, A., Lane, C., Nelsen, M., Lewthwaite, R. . . . Azen, S. (2016). Effect of a Task-Oriented Rehabilitation Program on Upper Extremity Recovery Following Motor Stroke: The ICARE Randomized Clinical Trial. JAMA, 315(6), 571-581.
