Impairment-Based Interventions to Improve Social Participation Outcomes for Adults Poststroke (January 1,2009

Abstract

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on stroke and impairment-based interventions to improve social participation for adults poststroke.

This brief presents findings from the systematic review on stroke and impairment-based interventions within the scope of occupational therapy practice to improve social participation for adults poststroke.

Full Systematic Review Question

This systematic review addressed the following question: What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve the performance of and participation in education, work, volunteering, and leisure activities, and on social participation, among adult stroke survivors?

Current Theme Reported

The main theme of the articles included in this Systematic Review Brief is upper extremity, cognitive, and visual scanning interventions.

Clinical Scenario

Stroke can result in impairments that affect a person physically and mentally. These impairments can greatly affect the participation of stroke survivors in daily life activities, including participation in leisure. Leisure participation increases quality of life, making it an important focus for occupational therapy intervention.

Summary of Key Findings

Twenty-three articles were included in the review related to impairment-based interventions to improve social participation outcomes for persons with traumatic brain injury. These 23 articles were further divided into three main themes, each with subthemes depending on the type of intervention (Table 1). The levels of evidence used in this review are based on Oxford Centre for Evidence-Based Medicine (2009).

Table 1.

Evidence Table for Impairment-Based Interventions to Improve Social Participation Outcomes for Adult Stroke Survivors

Author/Level of Evidence	Intervention	Statistically Significant Improvement From Intervention
UE Interventions
VR With OT There is moderate strength of evidence from 1 Level 1b study supporting OT combined with VR for UE interventions to improve social participation (SIS score).
Shin et al. (2016) Level 1b	Population Poststroke with minimal cognitive impairments Intervention Standard OT (ROM, strengthening, ADLs), plus RAPAEL Smart Glove with sensor device and software application. Participants played training games involving the forearm, wrist, hand, and fingers. Games use an algorithm to adjust difficulty level and ROM. Delivery Method Individual; inpatient setting Dose Standard OT (30 min, 5 days/wk, for 4 wk). RAPAEL Smart Glove additional 30 min (5 days/wk for 4 wk)	Participation (SIS)
Accelerated Skills Acquisition Program There is low strength of evidence, because of a lack of significant findings, from 1 Level 1b study to support an ASAP-based task-oriented approach to improve social participation.
Lewthwaite et al. (2018) Level 1b	Population Stroke in prior 106 days and hemiparesis with some active finger extension. Intervention ASAP for paretic arm recovery. Participants selected meaningful tasks to promote acquisition of skilled movements; this intervention was intended to promote capacity for and confidence in fostering meaningful task engagement in the natural environment and intrinsic motivational enhancement. Delivery Method Individual; outpatient setting Dose 30 1-hr sessions over 16 wk	None
Virtual Reality and rTMS There is low strength of evidence, because of a lack of significant findings, from 1 Level 1b study that combined VR with rTMS to improve social function in people with UE impairment poststroke.
Zheng et al. (2015) Level 1b	Population Adults 1–14 wk poststroke, ages 40–80 yr, mild to moderate UE deficits (Brunnstrom Stage 3 or greater), ≥20° of shoulder flexion and abduction against gravity, no severe cognitive impairment Intervention Standard inpatient OT and PT, plus rTMS + VR training. rTMS was applied using a 70-mm figure-of-eight coil to the primary motor area; VR training used the BioMaste system, composed of wearable gloves with sensors to train the wrist, elbow, and shoulder. Graded training programs were based on therapist assessment and patient goals. Participants were seated and completed the training session within 10 min after the application of rTMS. Delivery Method Individual; inpatient setting Dose 30 min 6×/wk for a total of 24 sessions	None
VR Interventions There is low strength of evidence from 3 Level 2b studies to support VR UE intervention to improve social participation for adults poststroke with UE impairment because of inconsistent results.
Park et al. (2019) Level 2b	Population >3 mo first stroke with UE impairment Intervention VR UE rehabilitation tool Smart Board intervention incorporating planar exercises focused on proximal UE training. 30 min of standard OT after each session. Delivery Method Individual; setting not reported Dose 20 30-min sessions over 4 wk	None; both intervention and control (standard OT) groups showed improvement.
Shin & Park (2015) Level 2b	Population First stroke with hemiparesis, Brunnstrom scale score of 2–5, no severe cognitive impairment or aphasia Intervention 30 min of standard OT (ROM and strengthening, tabletop activities, ADL training); 30 min of RehabMaster system (game-based VR system using depth sensor; 10 min of rehabilitation training and 20 min of rehabilitation games) Delivery Method Individual; inpatient rehabilitation setting Dose 30-min session; number of sessions and period of time unknown	Decreased role limitations due to physical problems
Şimşek & Çekok (2015) Level 2b	Population Poststroke: first diagnosis of hemiplegia Intervention Participants selected from among 5 Nintendo Wii games for upper limbs and balance training. Each game was three sets with 5-min intervals between each set. Therapist monitored vital signs, established in-game targets, and minimized compensatory strategies. Sessions were video recorded and viewed by participants to improve motivation and provide feedback on performance. Delivery Method Individual; inpatient rehabilitation setting Dose 10 wk (45–60 min/day, 3 days/wk)	None (no difference between the intervention and control groups)
CIMT Interventions There is low strength of evidence, due to lack of significant findings, from 3 Level 2b articles (2 studies) to support the long-term effects of CIMT to improve social participation for people poststroke.
Stock et al. (2017) Level 2b Thrane et al. (2015) Level 2b	Population Diagnosis of stroke, persistent unilateral arm or hand paresis within 5–26 days after stroke, able to extend 2 fingers or the wrist Intervention Early CIMT intervention ≤28 days poststroke. Shaping tasks, behavioral strategies, standard task practice. Received standard OT and PT during follow-up period according to guidelines. Delivery Method Individual; inpatient rehabilitation setting Dose Traditional CIMT protocol; 10 consecutive workdays with 3 hr treatment daily	None
Lin et al. (2009) Level 2b	Population Poststroke; Brunnstrom Stage 3 or better for the proximal part of the limb, considerable nonuse of the affected upper limb, no serious cognitive deficits, no balance problems compromising safety when wearing constraint device, no excessive spasticity Intervention CIMT consisting of repetitive functional training of the affected upper limb. The less affected upper limb was constrained by a mitt for 5 hr/day, 5 days/wk, for 3 wk. Delivery Method Individual; inpatient rehabilitation setting Dose CIMT; 2-hr session, 5×/wk for 3 wk, and less affected upper limb was constrained by a mitt for 5 hr/day, 5 days/wk, for 3 wk	None
Robotics/Exoskeleton Interventions There is low strength of evidence from 2 Level 2b studies to support the use of robotic and exoskeleton devices for improving social participation for people poststroke because of the levels of evidence and inconsistent findings.
Dehem et al. (2019) Level 2b	Population After first ischemic or hemorrhagic stroke; <1 mo delay since stroke; age >18 yr Intervention Robotic-assisted therapy; an exercise program on a robot consisting of a game and involving moving the paretic hand along a reference trajectory while passing through checkpoints. The robot guided the participants as needed. Delivery Method Individual; inpatient rehabilitation setting Dose ∼45 min, 4×/wk	Significantly higher improvement in social participation
Wu et al. (2012) Level 2b	Population Unilateral stroke ≥6 mo prior, mild to moderate UE impairment, no severe spasticity in paretic arm, no serious cognitive impairment Intervention Robotic bilateral arm training was delivered by an OT. Participants practiced identical tasks with each arm simultaneously. Physical assistance was provided to affected arm if needed. Participants practiced a variety of bilateral functional tasks, such as lifting up and stacking checkers and received feedback on results and information on performance. Delivery Method Individual; inpatient rehabilitation setting Dose 90–105 min, 5×/wk for 4 wk	None
Electromyography (EMG) Interventions There is low strength of evidence from 1 Level 2b study to support an EMG-controlled brace paired with task training to improve social participation for people poststroke.
Page et al. (2012) Level 2b	Population UE Fugl–Meyer score ≥10 and ≤25, detectable EMG in the biceps brachii of the paretic UE, stroke >12 mo prior Intervention EMG-controlled brace + task-specific training in 4 common tasks (2 bilateral, 2 unilateral) Delivery Method Individual; outpatient rehabilitation setting Dose 3 1-hr sessions for 8 wk	None
Cognitive Training
Group CBT Interventions There is moderate strength of evidence from 1 Level 1b study to support the use of group CBT combined with task-oriented balance training to reduce fear of falling and improve community integration/participation.
Liu et al. (2018) Level 1b	Population Single stroke in prior 1–6 yr, ability to independently walk 10 m Intervention 45 min of group-based cognitive–behavioral training with the purpose of improving balance self-efficacy and 45 min of task-oriented balance training Delivery Method Group; research laboratory setting Dose 90-min sessions 2×/wk for 8 wk	Significantly greater improvement in community integration
VR Interventions There is low strength of evidence from 1 Level 2b study to support a VR-based simulation of ADLs set in a virtual city. Simulation was not significantly better than cognitive training in terms of social participation.
Faria et al. (2016) Level 2b	Population Poststroke, no hemispatial neglect Intervention VR-based simulation of ADLs called Reh@City that required participants to accomplish common ADLs in a virtual city. Attention training was a main focus of this intervention. Delivery Method Individual; outpatient and inpatient rehabilitation settings Dose 12 sessions over 4–6 wk	None (no difference between intervention and control groups; both improved)
Self-Directed Web-Based Interventions There is low strength of evidence from 1 Level 2b study supporting a web-based, self-directed cognitive intervention related to memory, attention, and reasoning to improve social participation.
van de Ven et al. (2017) Level 2b	Population Stroke 3–5 mo before enrollment, age 30–80 yr, cognitive impairment, able to work with a computer Intervention Participants used the www.braingymmer.com website to complete training. The cognitive flexibility training had 9 tasks in the domains of attention, memory, and reasoning. Included fast task switching every 3 min, graded in difficulty. Delivery Method Individual; outpatient rehabilitation setting Dose 30-min session 5×/wk for 12 wk (58 total sessions)	None
CBT With OT Interventions There is low strength of evidence from 1 Level 2b study to support CBT in addition to standard outpatient OT to improve social participation levels.
Kootker et al. (2017) Level 2b	Population Low to moderate anxiety and depression, >3 mo poststroke, age >18 yr, only mild cognitive impairments (Mini-Mental State Examination score >27/30) Intervention CBT: Consisted of setting realistic daily life goals with part of intervention being CBT to alter irrational or negative thoughts. In addition to CBT, participants received 3 sessions of OT. Delivery Method Individual; outpatient rehabilitation setting Dose 13–16 1-hr sessions within a 4-mo period	None
Visual Scanning Interventions There is low strength of evidence from 1 Level 2b study to support a standardized therapy intervention focused on static visual scanning for stroke survivors with homonymous hemianopia training to improve social participation.
Crotty et al. (2018) Level 2b	Population Stroke between 2 wk and 6 mo prior, homonymous hemianopia, corrected vision of at least 6/18, able to mobilize a distance of 35 m independently or with supervision or standby assistance Intervention Standardized static scanning training using the NVT scanning device and 4 wk (12 sessions) of mobility training using NVT scanning techniques. NVT scanning device: pattern of systematic visual search strategies, defining the perimeter of the affected visual field as a starting point for consistent visual search patterns. Standardized program: panel of colored lights requires the client to use both head and eye movement. Delivery Method Individual; laboratory setting Dose 3×/wk for 7 wk (length of session not reported)	None
Exercise and Balance Interventions
Individual Delivery Because of inconsistent findings, there is low strength of evidence from 1 Level 1b study and 2 Level 2b studies to support individual exercise/balance training combined with education to improve social participation.
Logan et al. (2014) Level 1b	Population >18 yr, >6 wk poststroke Intervention Participants received verbal education and handouts regarding travel and rehabilitation with exercises and activities to improve outdoor mobility training (e.g., walking, bus usage), including overcoming psychological barriers. Delivery Method Individual; outpatient rehabilitation setting Dose ≤12 sessions (Mdn = 7 sessions) over 4 mo (length of session not reported)	None
Aidar et al. (2016) Level 2b	Population Ischemic stroke ≥1 yr before testing, hemiplegia or hemiparesis and no aphasia Intervention Warm-up of walking followed by strength training. Participants performed 3 sets of 8–10 repetitions at the same intensity. The recovery interval between sets was 120 s and was controlled by the participants with the help of 2 examiners and an analog clock. Adjustment of the loads occurred over the 12 wk when the participant reported ease in performing the repetitions. Delivery Method Individual; setting not reported Dose 45- to 60-min sessions of strength training, 3×/wk for 12 wk	Significant improvement in social participation
Brouwer et al. (2018) Level 2b	Population First major unilateral hemispheric stroke requiring inpatient rehabilitation, adequate verbal communication, scheduled for discharge home Intervention Participants identified 3 specific goals, 2 of which related to mobility. Sessions included strength/power, balance, cardiovascular endurance, motor coordination, education about community resources and how to monitor their mobility and activities. Delivery Method Individual; home based Dose Tune-up interventions consisted of 6 individualized treatment sessions in the home, 1 hr, 3×/wk for 2 wk	None
Group Delivery There is moderate strength of evidence from 2 Level 1b studies and 1 Level 2b study to support group-based exercise programs to improve social participation.
Harrington et al. (2010) Level 1b	Population Age >49 yr at time of stroke, returned to living in the community for ≥3 mo, and felt able to participate in group activities Intervention 13 groups with 9 participants each met in community centers. Each session consisted of 1 hr of exercise (to improve balance, endurance, strength, flexibility, function, and well-being) and 1 hr of education led by different health care professionals and stroke experts. Other foci of the education hour were goal-setting and social interaction skills. Delivery Method Group; community center Dose 2×/wk for 8 wk	None (both the intervention and control [standard stroke care and information sheet] groups improved)
Stuart et al. (2009) Level 1b	Population Chronic phase of stroke recovery (>9 mo poststroke), mild to moderate hemiparetic gait, age >39 yr, no aphasia Intervention Stroke program, group classes of 9–13 people for 6 mo. Program includes walking, strength, and balance training exercises. Delivery Method Group; community based Dose 1 hr/day, 3 days/wk	Social participation improved.
Holmgren et al. (2010) Level 2b	Population 3–6 mo poststroke, age >54 yr, fall risk as assessed by a PT, ability to walk 10 m Intervention High-intensity exercise group training program. Sessions focused on physical activity, functional performance, and fall risk education. Delivery Method Group; outpatient setting Dose: 5 wk with 7 sessions/wk divided over 3 days (35 sessions total)	None

Note. ADLs = activities of daily living; ASAP = Accelerated Skill Acquisition Program; CBT = cognitive–behavioral therapy; CIMT = constraint-induced movement therapy; EMG = electromyography; NVT = neurovisual therapy; OT = occupational therapy/occupational therapist; PT = physical therapy/physical therapist; ROM = range of motion; rTMS = repetitive transcranial magnetic stimulation; SIS = Stroke Impact Scale; UE = upper extremity; VR = virtual reality.

Bottom Line for Occupational Therapy Practice

A large number of impairment-based (vs. occupation-based) interventions are available that include an outcome related to social participation in adults poststroke. However, the majority had low strength of evidence and would not be considered evidence-based practice. Of note is that many of the interventions were short in duration and did not include follow-up time points for measuring social participation. In addition, most of the measures of social participation came from the subscales of the 36-item Short Form Survey (Ware et al., 1994) or the Stroke Impact Scale (Duncan et al., 2003). The upper extremity training approaches that showed statistically significant findings combined the virtual reality intervention with traditional occupational therapy (Dehem et al., 2019; Shin & Park, 2015). The one individual strength training intervention (Aidar et al., 2016) was not designed as a group-based approach; however, the structure of the program involved participants rotating through stations in a large indoor gymnasium. This setup likely allowed for interactions between study participants. In further support of group-based approaches, the other two positive findings for social participation included group-based cognitive–behavioral therapy (Liu et al., 2018) and a group-based exercise program (Stuart et al., 2009). Three of the intervention groups achieved moderate strength of evidence and could be considered if appropriate. Using a group setting, pairing the intervention with standard occupational therapy, or both was helpful when trying to improve social participation.

Footnotes

*

Indicates articles included in the Systematic Review Brief.

Acknowledgments

We thank Lauren Alldredge, Brianna Carter, and Katie Cox for their assistance with the systematic review process. We also thank the American Occupational Therapy Association’s Evidence-Based Practice team for their assistance and support throughout the process.

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Impairment-Based Interventions to Improve Social Participation Outcomes for Adults Poststroke (January 1,2009–December 31,2019)

Abstract

Full Systematic Review Question

Current Theme Reported

Clinical Scenario

Summary of Key Findings

Bottom Line for Occupational Therapy Practice

Footnotes

*

Acknowledgments

References