Multimodal Interventions for Caregivers of People With Stroke (January 1,1999– December 31,2019)

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 for caregivers of people who have had a stroke that facilitate maintaining participation in the caregiver role?”

Current Theme Reported

The main theme of the studies included in this Systematic Review Brief is multimodal caregiver interventions.

Clinical Scenario

Caregiving often has negative effects on caregivers of people who have had a stroke, including their employment, finances, and physical or emotional health (Collinson & De La Torre, 2017; Loh et al., 2017; National Academies of Sciences, Engineering, and Medicine, 2016; National Alliance for Caregiving & AARP Public Policy Institute, 2015). Negative effects for the caregiver increase the likelihood that the person who has had a stroke will have a greater incidence of institutionalization, hospital stays, and poorer outcomes (Bakas et al., 2014). Stroke guidelines recommend interventions for the caregiver, including counseling, stroke education, skills training, community resources information, development of a support structure, and financial assistance (Winstein et al., 2016). Occupational therapy practitioners must understand which caregiver interventions, delivery formats, and lengths of time are effective in helping caregivers maintain participation in the caregiving role. This Systematic Review Brief examines the efficacy of multimodal interventions for this population, including combinations of three or more interventions, such as education or training, problem solving, other cognitive–behavioral therapy techniques, and support to determine whether they improve caregiver outcomes, such as those related to knowledge, depression, burden, or coping.

Summary of Key Findings

Three articles reporting on 2 Level 2b randomized controlled trials (van den Heuvel et al., 2000, 2002; Wilz & Barskova, 2007) that implemented multimodal interventions aimed at maintaining caregivers’ participation in the caregiver role (Table 1) met the criteria for inclusion in this systematic review. One study had a medium risk of bias (van den Heuvel et al., 2000, 2002), and the other had a high risk of bias (Wilz & Barskova, 2007). Moderate strength of evidence supports this type of intervention. The levels of evidence used in this review are from the Oxford Centre for Evidence-Based Medicine (2009).

Bottom Line for Occupational Therapy Practice

Multimodal interventions that provide information about stroke education, training, coping strategies, support, counseling, and problem-solving techniques led to improvements in psychological and social support outcomes. Occupational therapy practitioners have the educational training to address each of these types of intervention.

Both studies included interventions with caregivers in a group-based format. This may help to explain the positive psychological and support outcomes. Occupational therapy practitioners have substantial training in determining the best mode of intervention, individual or group, and in using both. However, van den Heuvel et al. (2000, 2002) found no significant differences when the same intervention was delivered in a group-based format versus an individual, in-home format. It is therefore important for occupational therapy practitioners to tailor the format of any multimodal intervention to the caregiver’s needs (e.g., recommending in-home sessions for a caregiver who is unable to leave a stroke survivor to attend meetings).

These 2 studies provide little guidance for practitioners to determine what the most effective intervention dosage should be because there is a large difference in the number of sessions each offered. The feasibility of providing long-term occupational therapy services to caregivers is questionable in today’s health care payment models. Because of this, more evidence is needed to determine what combination of interventions is most effective in helping caregivers and what length is optimum for participation.