Occupation-Based Interventions for 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 occupation-based interventions for social participation outcomes for adults poststroke.

This brief presents findings from the systematic review on occupation-based interventions for social participation outcomes for adults poststroke. Improvements in social participation, social functioning, or social roles were primarily found in studies that were occupation based.

Full Systematic Review Question

This systematic review addressed the 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 and social participation among adult stroke survivors?”

Current Themes Reported

The main themes of the articles included in this systematic review brief are enriched environment, occupation-based metacognitive training, and education and training interventions.

Clinical Scenario

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

Summary of Key Findings

Twenty articles were included in the review related to occupation-based intervention to improve social participation outcomes for adults poststroke. These 19 articles were further divided into six categories, depending on type intervention or method of delivery (Table 1). The levels of evidence used in this review are from the Oxford Centre for Evidence-Based Medicine (2009).

Table 1.

Evidence Table for the Effectiveness of Interventions to Improve the Performance of and Participation in Education, Work, Volunteering, and Leisure and Social Participation Among Adult Stroke Survivors

Author/Level Evidence	Intervention	Statistically SignificantImprovement From Intervention
Enriched Environments Because of the limited number of studies, there is low strength of evidence to support providing an enriched environment in combination with tailored individual and group activities to improve social participation.
Rosbergen et al. (2019) Level 2b	Population Stroke unit ≤72 hr of stroke onset, able to complete bed-to-chair transfer with assist of ≤2 people, able to follow 1-step commands, required assistance for basic ADLs Intervention An enriched environment that included communal sitting in public spaces on the unit, stimulating equipment, and tailored individual and group activities (e.g., stroke education, physical activity) Delivery Method Individual session in acute-care hospital Dose 14 wk standard of care plus enriched environments during mealtimes, socializing, and group activities	Participants had significantly more overall activity during communal activity times, weekday nonscheduled activity times, and weekends; communal socializing; listening; and iPad usage.
Occupation-Based Interventions As a result of the limited number of studies and inconsistent results, there is low strength of evidence to support occupation-based interventions.
Beinotti et al. (2015) Level 2b	Population Clinical diagnosis of a first or recurrent unilateral stroke, in the chronic phase (≥365 days after stroke); ages 50–85 yr; and no serious cognitive deficits Intervention HBRT provided by instructors and assistants who followed specific procedures and comprehensive lesson plans Delivery Method Individual HBRT session Dose 1 30-min session/wk for 16 wk	No statistically significant difference was found between the groups in social function.
Ho et al. (2016) Level 2b	Population Stroke diagnosis >6 mo earlier, ability to communicate and express feelings, no other injuries that could interfere with gardening participation Intervention Gardening program with plants with short growing cycles vs. long growing cycles Delivery Method Individual session in acute clinical setting Dose 1 hr/wk for 3 mo	The quick-growing plant group demonstrated greater improvement in social role quality of life (p = .015). No significant differences were found between groups on family role quality of life (p = .615).
Shinohara et al. (2012) Level 2b	Population Resident of a health care facility for the elderly (Japan); stroke without dementia in the past 6–36 mo Intervention OTs who had completed MOHO training administered MOHO assessments to guide intervention selection (focus on volition, role performance, and changes to the physical environment); ADL interventions that also included meaningful occupations such as walking outdoors, picking flowers, washing dishes, and sewing with friends Delivery Method Individual sessions in a health care facility Dose OT intervention 2×/wk for >20–30 min	Compared with the control group, the intervention group showed a significant improvement in social relationships and social function for ≤3 mo.
Tomori et al. (2015) Level 2b	Population Subacute stage of stroke (>30 days); age >40 yr; stroke caused by a cerebral infarct or hemorrhage; no major cognitive deficits, aphasia, or depression; no progressive disease Intervention Participants identified meaningful occupations using the Aid for Decision-making in Occupation Choice application and set activity- and participation-level goals; intervention focused on occupation-based practice. Delivery Method Individual session in subacute rehabilitation unit (Japan) Dose Unclear	None
Metacognitive Training—Individual
Problem-Solving Interventions There was low strength of evidence as a result of the number of studies and nonsignificant findings to support a metacognitive problem-solving intervention to improve social participation for adults poststroke.
Bertilsson et al. (2014) Guidetti et al. (2015) Level 1b	Population Acute stroke in a stroke unit ≤3 mo after stroke onset, dependent in ≥2 ADL domains, not diagnosed with dementia Intervention OT–client relationship was formed to understand client’s life-world experiences. OT observed the client performing an activity of their choice, and together they evaluated the performance to determine ability and perception of ability and created 3 goals. A global problem-solving strategy was learned, and the client discovered and identified difficulties in reaching the first goal. As a team, the OT and client identified specific strategies that would enable successful performance. Delivery Method Individual session in rehabilitation unit Dose Unclear	No significant improvement in social participation and social function among clients using the intervention compared with standard OT.
Alexopoulos et al. (2012) Level 2b	Population Age ≥60 yr with ischemic, embolic, or hemorrhagic stroke and DSM–IV diagnosis of unipolar major depression Intervention The EFT therapist described the prognosis for depression, its interaction with disability, and the role of rehabilitation and that rewarding activities are still possible. Delivery Method Individual session in inpatient rehabilitation hospital and in participant’s home postdischarge Dose 45-min session 1×/wk for 12 wk	None
Kamwesiga et al. (2018) Level 2b	Population Stroke diagnosis; access to and ability to use mobile phone; age >18 yr; resident of Kampala, Uganda; modified Rankin Scale score of 2–4, indicating slight to moderately severe disability; family member who lives with and helps the person with stroke Intervention The F@CE intervention, an 8-wk, family-centered intervention to increase daily activity performance and participation. A problem-solving strategy (target–plan–perform–prove) was used to facilitate learning of participant goals. Participants were provided prompts via text message 2×/day and responded whether and how well they had performed the activity. Delivery Method Family centered in the home Dose 1×/wk for 8 wk	None
CO-OP Intervention Because of the level of evidence and the lack of significant findings, there is low strength of evidence for the use of the CO-OP metacognitive strategy training intervention to improve social participation in the stroke population.
McEwen et al. (2015) Level 2b	Population Ischemic stroke; referred to outpatient rehabilitation at participating sites Intervention Occupation-based training, including metacognitive strategy training Delivery Method Outpatient rehabilitation, individual sessions Dose 45–60-min sessions 2×/wk for 5 wk	Participants showed a significant improvement in social participation.
Poulin et al. (2017) Level 2b	Population <12 mo poststroke with assessed executive dysfunction, MMSE score <22/30, living at home, ability to identify some day-to-day functional difficulties Intervention Occupation-based strategy training intervention (i.e., CO-OP) Delivery Method Individual through home health Dose 16 1-hr sessions, over 8 wk	None
Song et al. (2019) Level 2b	Population First-onset unilateral hemispheric stroke 6 mo earlier, MMSE score ≥24, able to walk 10 m independently without assistance, no visuoperceptual impairment, no orthopedic conditions Intervention CO-OP approach with 2 distinct phases: cognitive strategy training of goal–plan–do–check and motor-based tasks in repetitive action. Participants selected activities and problem solved with the therapist. Participants then performed tasks using their chosen strategy. Delivery Method Individual session in rehabilitation unit Dose 30 min/day, 5 days/wk, for 4 wk	None
Metacognitive Training—Group There is low strength of evidence for the use of group self-management–type interventions to improve social participation because of the lack of significant findings.
Lund et al. (2012) Level 1b	Population Age >65 yr, ability to provide written consent, diagnosis of stroke or transient ischemic attack, MMSE score >23, ADL problems, no severe aphasia Intervention Group-based lifestyle and physical activity over 9 mo; occupation-based Lifestyle Redesign program. Physical activity groups led by a volunteer 1×/wk for 30–60 min. Delivery Method Group sessions in a community center Dose 36 weekly 2-hr sessions over 9 mo	None
Tielemans et al. (2015) Level 1b	Population Stroke; participation problems in vocational, social, or leisure domain; no cognitive impairment; no aphasia; no major depressive or behavioral problems; not receiving structured psychological rehabilitation Intervention Provided by an OT or psychologist. Aimed at teaching proactive action planning strategies with 4 themes: handling negative emotions, social relations and support, participation in society, and less visible stroke consequences. Delivery Method Group of 4–8 participants in an outpatient hospital Dose 6 2-hr sessions and 1 2-hr booster over 10 wk	None
Wolf et al. (2017) Level 1b	Population Mild stroke, age 18–90 yr, ≥1 chronic condition, no aphasia, no history of dementia, no hemorrhagic stroke, no significant depressive symptoms Intervention Chronic disease self-management program based on self-management concepts with 3 primary goals: medical management, role management, and emotional management. Sessions were delivered by an OT Delivery Method Individual session in an outpatient setting Dose 2-hr session 1×/wk for 6 wk	None
Education and Training
Client Oriented There is moderate strength of evidence to support community-based education with a follow-up period to improve social participation outcomes after a stroke.
Geng et al. (2019) Level 1b	Population Age ≥60 yr; first stroke, either hemorrhagic or ischemic; ability to communicate; cognitive competence as indicated by MMSE score ≥20; slight to moderate level of disability; scheduled to discharge from hospital to home Intervention Routine stroke education before hospital discharge, follow-up telephone call 1 wk postdischarge, and a routine check-up with their doctor postdischarge. TC nurse visited participants’ homes and conducted follow-up telephone calls to assess patients’ and caregivers’ needs for 3 mo Delivery Method Individual inpatient session and postdischarge at home Dose 30-min education by a neurologist and nurse practitioner on recovery after stroke 1 day before discharge. Multiple weekly home and telephone follow-ups for 3 mo after discharge.	A significant improvement in interpersonal relationships was found ≤6 mo postdischarge.
Sabariego et al. (2013) Level 1b	Population Stroke diagnosis, ages 18–79 yr, Barthel Index recovery Phases C and D, sufficient cognitive skills to participate in a group discussion Intervention ICF-based patient education program with 3 modules. Patients identified areas of function that were problematic and environmental factors, then identified solutions to problems and helped to seek information or services. Included refresher sessions. Delivery Method Small group session in a rehabilitation clinic Dose 5 1-hr sessions over 5 consecutive days	None
Rochette et al. (2013) Level 2b	Population Mild stroke, discharged home ≤3 mo, telephone access, ability to understand basic instructions and express basic needs Intervention “We Call” interaction focused on new or ongoing issues, including family functioning and individualized risk factors. Additional written information on stroke management and local community services was provided. Delivery Method Individual via telephone or computer Dose Contacted weekly by phone, internet, and written materials (via mail, email or specific web links) for Months 0–2 mo, biweekly for Month 3, and monthly for Months 4–6	No significant improvement was found in social participation.
Ru et al. (2017) Level 2b	Population Age <75 yr; diagnosis of stroke confirmed with CT and MRI; unilateral limb dysfunction; absence of serious cardiac conditions; absence of prior sensory aphasia, severe mental disorder, or cognitive impairment Intervention Community-based comprehensive stroke rehabilitation education protocol consisting of textbooks, brochures, flyers, bulletins, seminars, lectures, and health advisory activities. Participants were grouped according to functional limitations (abilities). Rhyming words were used to help patients coordinate and control movements. Delivery Method Community-based group session Dose 1 hr educational group training 2×/wk and 1.5 hr home-based training to practice the content of the group education 5×/wk over 3 mo	Significant improvement was found on a social functional activities scale.
Caregiver Oriented There is low strength of evidence, due to nonsignificant findings, to support the effects of home health care and rehabilitation programs provided for caregivers of people poststroke to improve social relationships.
Chinchai et al. (2010) Level 1b	Population People with stroke: discharged from hospital for <1.5 yr, physical function recovery level at Brunnstrom Stages 2–4, could communicate well (verbally, nonverbally) with others Caregivers: primary caregivers who were family members or relatives; people who could spend ≥8 hr/day providing care Intervention Education for caregivers to gain knowledge to apply intervention (therapeutic exercise, ADL techniques, adaptive device usage, strategies to prevent complications, socialization, home and environmental modifications) for home use with their care recipients Delivery Method Individual sessions, home health Dose 7-hr session 1×/wk for 3 wk	None

Note. ADL = activities of daily living; CO-OP = Cognitive Orientation to daily Occupational Performance; CT = computed tomography; DSM–IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994); EFT = ecosystem-focused therapy; HBRT = horseback riding therapy; ICF = International Classification of Functioning, Disability and Health (World Health Organization, 2001); MMSE = Mini-Mental State Examination; MOHO = Model of Human Occupation; OT = occupational therapy/therapist; TC = transitional care.

Bottom Line for Occupational Therapy Practice

Improvements in social participation, social functioning, or social roles were primarily found in studies that were occupation based (McEwen et al., 2015; Shinohara et al., 2012; Wolf et al., 2017). Good outcomes related to social participation were generally reported with metacognitive strategy training approaches. In addition, studies that investigated gardening demonstrated positive outcomes (Beinotti et al., 2013; Ho et al., 2016). These approaches are naturally group based and encourage social interactions among participants. Many of the group-based or family-centered approaches also demonstrated positive social participation outcomes. Intervention approaches that are client driven and promote autonomy and client choice may lead to improved and sustained social participation for clients poststroke. Occupational therapy practitioners can use occupation-based approaches to improve social participation outcomes.

Footnotes

*Indicates articles included in the brief systematic review.

Acknowledgments

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

References

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