Behavioral Interventions to Improve Performance in Activities of Daily Living for Adults With Stroke (2012

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 for behavioral interventions to improve outcomes in activities of daily living for adults with stroke, including cognitive, self-management, falls prevention, psychosocial, and creative/recreation interventions.

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 performance and participation in activities of daily living (ADL) for adult stroke survivors?”

Current Theme Reported

The main theme of the studies included in this systematic review brief is behavioral interventions (i.e., psychosocial, cognitive, creative/recreation, self-management, and falls prevention).

Clinical Scenario

Stroke is a common cause of adult disability in the United States, affecting more than 795,000 people each year (Virani et al., 2021). Stroke survivors are often limited in independence in ADLs and may report overall dissatisfaction with their lives (Gadidi et al., 2011; Mayo et al., 2002; Hartman-Maeir et al., 2009). In addition, psychosocial factors such as motivation and self-esteem have been positively associated with participation after stroke and should be considered in stroke rehabilitation interventions (Della Vecchia et al., 2021). Behavioral interventions, such as those focused on cognitive or psychosocial needs, may support improvement in performance in ADL. However, further evidence is currently needed to determine the impact of these interventions on functional participation (Gillen et al., 2014; Hildebrand, 2014).

Summary of Key Findings

Thirteen articles were included in the review related to interventions focusing on behavioral interventions with ADL outcomes for stroke survivors. These 13 articles were further divided into five categories: psychosocial interventions (2), cognitive rehabilitation (2), creative/recreation interventions (4), self-management interventions (4), and a falls prevention program (Table 1). The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009). The strength-of-evidence designations are based on the guidelines of the U.S. Preventive Services Task Force (2018).

Table 1.

Evidence Table for Behavioral Interventions to Improve ADL Outcomes for Adults with Stroke

Author YearLevel of EvidenceRisk of Bias (RoB)CountrySetting	Intervention	Statistically Significant Improvement Resulting From Intervention
Behavioral Interventions: Psychosocial Interventions
Cognitive Behavioral Therapy: One Level 1A study provided strong strength of evidence for the use of CBT for individuals with poststroke depression to improve outcomes in basic ADLs.
Wang et al. (2018) Level 1A—Systematic review with meta-analysis RoB Moderate Countries China and Australia Setting Inpatient Community	Population Individuals with poststroke depression. Twenty-three RCTs (1,972 participants) were included in the systematic review. Seven RCTs (753 participants) were included in the meta-analysis of ADL outcomes. Intervention Group and individual CBT alone or CBT with antidepressants. Control group received placebo or same antidepressants as CBT group. Outcome Measures BI (Mahoney & Barthel, 1965), ADL Scale (Dinnerstein et al., 1965), and EADL (Nair et al., 2011) Dose Treatment duration ranged from 3 to 40 wk (mean = 9.5, median = 8). Number of CBT sessions ranged from 3 to 40 sessions (mean = 13.5, median = 14.3).	Between Groups CBT for poststroke depression significantly improved ADL outcomes for the intervention group compared with the control group with a moderate to large effect size. Note: Subgroup analysis (with or without use of antidepressants) was not significant.
Motivational Interviewing: One Level 1B study provided low strength of evidence for motivational interviewing to improve basic performance in ADL after stroke.
Watkins et al. (2011) Level 1B—RCT RoB Moderate Country United Kingdom Setting Inpatient Stroke Unit	Population N = 411. Adult with acute stroke in an inpatient hospital stroke unit. Intervention MI, a patient-centered counseling technique. Discussed personal goals for recovery, barriers, and developed solutions. Control group received usual care. Outcome Measure BI (Mahoney & Barthel, 1965) Dose Received up to four 30-to-60-min individual weekly sessions of MI in addition to usual care.	Between Groups No significant improvement in the MI intervention group compared with the control.
Behavioral Interventions: Cognitive Rehabilitation
Memory Interventions: One Level 1A study on cognitive rehabilitation for memory deficits after stroke provided low strength of evidence for diverse memory intervention to improve ADL outcomes due to very low quality of evidence.
Nair et al. (2016) Level 1A—Systematic review with meta-analysis RoB Low Country United Kingdom Setting Inpatient Community	Population Individuals with memory deficits after stroke. Thirteen RCTs (514 participants) were included in the systematic review. Three RCTs (164 participants) were included in the meta-analysis of ADL outcomes. Intervention Diverse interventions for memory problems included education, compensatory strategies, computerized memory training, strategy training, imagery mnemonics, and external memory aids. Control group received alternative form of treatment or no memory intervention. Outcome Measures FIM (Granger et al., 1986), EADL Scale (Nair et al., 2011), and unspecified ADL measure. Dose Group and individual treatment; ranged 1× wk, from 2 to 10 wk, 30 min to 2 hr	Between Groups No significant differences between groups on ADL measures.
Interventions for Unilateral Spatial Neglect and Hemianopsia: One Level 1A study provided moderate strength of evidence for activity-based interventions to improve ADL outcomes for individuals with unilateral spatial neglect after stroke and low strength of evidence to improve ADL outcomes for individuals with hemianopsia after stroke.
Liu et al. (2019) Level 1A—Systematic review with meta-analysis RoB Moderate Country Australia Setting Hospital, Inpatient Rehabilitation, and Research Center	Population Individuals with USN or hemianopsia after stroke. USN: Twenty RCTs (594 participants) included in systematic review. Five activity-based intervention studies (156 participants) and four combined activity/nonactivity interventions studies (105 participants) included in meta-analysis of ADL outcome. Hemianopsia: Five RCTs (206 participants) included in systematic review. Two activity-based intervention studies (72 participants) included in meta-analysis of ADL outcome. Intervention 1. Activity-based interventions: computer-based training for visual scanning training and optokinetic stimulation, mental practice, mirror therapy, voluntary trunk rotation, and vestibular rehabilitation. 2. Combined activity/nonactivity interventions: electrical somatosensory stimulation with visual scanning training, hemifield eye-patching with cognitive-based rehabilitation, voluntary trunk rotation, optokinetic stimulation, or conventional OT, and prismatic glasses with visual scanning training. 3. Control group received a variety of interventions including conventional therapy, conventional OT, computerized cognitive rehabilitation, visual scanning training, exploration training, and task-specific activities. Outcome Measures FIM (Granger et al., 1986), BI (Mahoney & Barthel, 1965), Catherine Bergego Scale (Azouvi et al., 2003) Dose Ranged from 5 to 30 sessions, 2–10 times per wk, 1 hr 45 min to 30 hr, 4 days to 5 wk	Between Groups Activity-based interventions had a moderate effect on improving ADL outcomes for people with unilateral spatial neglect. However, for hemianopsia, the intervention group was not significantly different than the control on ADL outcomes. Note: Interventions and control conditions were heterogeneous, and visual scanning training was used both in intervention and control conditions, limiting ability to draw conclusions about specific interventions.
Behavioral Interventions: Creative and Recreation Interventions
Music-Supported Therapy: One Level 1A study provided low strength of evidence for the use of music-supported therapy to improve functional mobility.
Zhang et al. (2016) Level 1A—Systematic review with meta-analysis RoB Moderate Country China Setting Hospital Rehabilitation Settings	Population Individuals with motor dysfunction due to stroke. Ten studies (N = 358 participants) included in systematic review. Two studies (n = 73 participants) included in meta-analysis of functional mobility measure. Intervention Music-supported therapy. Trained the subjects with music in an interactive way. Subjects listened to music on a CD player, sang, and played rhythm and percussion instruments. Control group received no music-supported therapy or usual care. Outcome Measure BBS Dose Not reported but length of intervention ranged from 2 wk to 6 mo.	Between Groups No significant differences between groups pertaining to functional mobility outcome.
Creative Recreation Interventions: Two Level 1B studies (three articles) provided moderate strength of evidence for creative and recreation interventions (rhythm and music therapy, horse-riding therapy, and creative art therapy) to improve basic ADL and functional mobility outcomes.
Bunketorp-Käll et al. (2017) and Bunketorp-Käll et al. (2019) (follow up data) Level 1B—RCT RoB Low Country Sweden Setting Community	Population N = 123. Participants with stroke or SAH with hemispheric symptoms Intervention 1. R-MT used rhythm, music, color, and movement. Participants performed rhythmic movements with their hands and feet while listening to music. 2. H-RT included preparing the horse for riding, completion of tailored exercises (balance, trunk rotation, goal-oriented movement, cognition) while the horse was moving, and relaxation and body awareness. 3. Control group received rhythm and music therapy after one-year delay. Outcome Measures SIS (Duncan et al., 2003), TUG (Podsiadlo & Richardson, 2015), BBS (Berg et al., 1995), M-MAS (Loewen & Anderson, 1988) Dose Group; R-MT: 2 × 90 min weekly sessions for 12 wk Group; H-RT: 2 × 240 min weekly sessions for 12 wk	Between Groups Basic ADL R-MT and H-RT improved significantly compared with the control on SIS over three time points postintervention, at 3 mo, and at 6 mo. Functional Mobility H-RT group improved significantly on the TUG and BBS compared with the control group. H-RT group also improved significantly on the M-MAS compared with both R-MT and control (but improvement was not maintained at 6 mo).
Kongkasuwan et al. (2016) Level 1B—RCT RoB Moderate Country Thailand Setting Inpatient Rehabilitation Setting	Population N = 118. Stroke patients in a hospital inpatient rehabilitation unit age 50 and older Intervention Creative art intervention in addition to physical therapy. Intervention included meditation with music, warm-up activity, main activity and group singing activity, and a group-healing circle. Control group received conventional physical therapy only. Outcome Measure mBI (Shah et al., 1989) Dose Intervention group received creative art therapy in addition to physical therapy twice a week for 4 wk (8 sessions, 1.5–2 hr)	Between Groups The intervention group improved significantly on the mBI compared with the control group.
Behavioral Interventions: Self-Management Interventions
Stroke Self-Management for Community Dwelling Individuals: One Level 1A study provided low strength of evidence for the use of stroke self-management interventions for community dwelling individuals after stroke improved outcomes in ADLs.
Fryer et al. (2016) Level 1A—Systematic review with meta-analysis RoB Low Country Australia Setting Community	Population Community dwelling individuals after stroke. Fourteen RCTs (1,863 participants) were included in the systematic review. Four RCTs (260 participants) were included in the meta-analysis of ADL outcomes. Intervention Self-management interventions that were specific to stroke and included at least one of the following: problem solving, goal setting, decision making, self-monitoring, coping, or alternate methods to facilitate behavior change and improvements in physical and psychological functioning. Control group received usual care, waitlist control, information only, or an alternative treatment. Outcome Measures BI (Mahoney & Barthel, 1965), ADL (Dinnerstein et al., 1965), EADL (Nair et al., 2011) Dose Group or individual treatment; treatment duration ranged from 4 wk to 6 mo, number of sessions ranged from several to weekly, length of sessions not reported.	Between Groups No significant difference between groups. Authors reported that further evidence may change finding toward significance in favor of self-management interventions to improve ADLs (small effect size, moderate quality of evidence).
Health Empowerment Intervention for Stroke Self-Management in Ambulatory Setting: One Level 1B study provided moderate strength of evidence for a health empowerment intervention for stroke self-management with stroke survivors in ambulatory rehabilitation to improve performance in ADL.
Sit et al. (2016) Level 1B—RCT RoB Low Country China Setting Community	Population N = 210. Adults with first time stroke and functional difficulties scheduled for ambulatory stroke rehabilitation. Intervention Usual care plus HEISS included self-management skills, self-efficacy activities, and goal-setting/action-planning with workbook. Part 1 included 6 weekly small groups from week 3 to 8 for self-efficacy and self-management skills. Part 2 involved home-based biweekly telephone calls from week 9 to 13 to encourage positive change and help with problem-solving skills. Control group received usual care ambulatory stroke rehabilitation. Outcome Measure BI (Mahoney & Barthel, 1965) Dose Small groups and telephone calls; 6 weekly, 1 hr, small groups (weeks 3–8), biweekly phone calls (weeks 9–13).	Between Groups Significant improvement in basic ADL outcome in intervention group compared with control group at 1-wk, 3 mo, and 6 mo postintervention.
Patient-Centered Self-Management Empowerment Intervention for Inpatient Rehabilitation Setting: One Level 1B study provided moderate strength of evidence for a stroke self-management intervention during inpatient rehabilitation supporting hospital discharge for individuals after stroke to improve performance in ADL.
Chen et al. (2018) Level 1B—RCT RoB Low Country China Setting Community	Population N = 144. Adults with acute stroke in an inpatient rehabilitation setting. Intervention Nurse-led PCSMEI: five daily sessions (self-management knowledge and skills, self-management goals, info on individuated health needs such as stroke risk factors, self-health monitoring, advise, problem solving), small group session (talk with each other regarding stroke management), and four weekly telephone follow-ups postdischarge (assess patients self-management skills and behaviors). Control group received usual care nursing with heath education and received the same number of postdischarge phone calls with general social chatting. Outcome Measure BI (Mahoney & Barthel, 1965) Dose Five 20-min daily sessions in first week, one 60-min small group session in second week, one discharge session, four 20–30-min weekly telephone follow-ups	Between Groups Intervention group had significant improvement in basic ADL outcome at 3 mo postintervention compared with the control.
Home-Based Psychoeducational Intervention: One Level 1B study provided low strength of evidence for a home-based psychoeducational intervention for individuals after stroke and their spouses to improve performance in ADL.
Ostwald et al. (2013) Level 1B—RCT RoB Moderate Country United States Setting Individual Homes	Population N = 159 dyads of adults with stroke and spouses, stroke diagnosis within 12 mo, discharged home from hospital with need for daily assistance from spouse. Intervention Home-based psychoeducation program including home visits for 6 mo by nurses and OT/PT. Topics included stroke recovery, stress of stroke, healthy lifestyle, therapeutic skill training, coping strategies, and community networks. Outcome Measure FIM (Granger et al., 1986) Dose On average, participants received 16 visits, 70-min each, mean total of 36.7 hr of education.	Between Groups No significant difference between groups on basic ADL outcome.
Behavioral Interventions: Falls Prevention Program
One Level 1B study provided low strength of evidence for the use of a falls prevention program to improve outcomes in basic ADLs.
Batchelor et al. (2012) Level 1B—RCT RoB Moderate Country Australia Setting Community	Population N = 156. Individuals with stroke who were discharged home after receiving inpatient rehabilitation and were high falls risk. Intervention Falls prevention program; received multifactorial individually tailored falls prevention program (individualized home exercise program based on Otago Exercise Program, falls risk minimization strategies, education, injury risk minimization strategies). Control group received a fall prevention booklet. Outcome Measure FIM (Granger et al., 1986) Dose Not reported	Between Groups No significant differences between groups on ADL outcome or falls rate.

Note. ADL = activities of daily living; BBS = Berg Balance Scale; BI = Barthel Index; CBT = cognitive behavioral therapy; EADL = extended activities of daily living; FIM = functional independence measure; HEISS = Health Empowerment Intervention for Stroke Self-Management; H-RT = horse-riding therapy; mBI = Modified Barthel Index; MI = motivational interviewing; M-MAS = Modified Motor Assessment Scale; OT/PT =; occupational therapy/physical therapy; PCSMEI = Patient-Centered Self-Management Empowerment Intervention; RCT = randomized control trial; R-MT = rhythm and music therapy; SAH = subarachnoid hemorrhage; SIS = Stroke Impact Scale; TUG = Timed Up and Go Test; USN = unilateral spatial neglect.

Bottom Line for Occupational Therapy Practice

Overall, evidence to support the use of behavioral interventions to improve ADL outcomes after stroke was mixed and is limited by a large variety of interventions, dosages, and treatment methods. Use of cognitive behavioral therapy (CBT) is supported by strong strength of evidence to improve ADL outcomes for individuals with poststroke depression (Wang et al., 2018). There is moderate strength of evidence that activity-based interventions can improve ADL outcomes for individuals with poststroke unilateral neglect (Liu et al., 2019); however, as this meta-analysis pooled results from a wide variety of interventions, clinicians may want to refer to previous reviews for more specific guidance (Gillen et al., 2014). Creative interventions such as rhythm and music therapy or horse-riding therapy may improve performance in ADL for stroke survivors; however, it is unknown how these interventions compare with conventional therapy (Bunketorp-Käll et al., 2017; Bunketorp-Käll et al., 2019). Health empowerment self-management interventions may also improve independence in ADLs although there is low strength of evidence overall for use self-management interventions to improve performance in ADL (Chen et al., 2018; Sit et al., 2016; Fryer et al., 2016). Note that this review only included studies that met criteria for 1A/1B Levels of Evidence, so smaller clinical trials that report emerging evidence were not included. In some studies, the intervention group received more overall therapy than the control group, so further investigation is needed to compare these interventions to conventional occupational therapy. Further research is needed to determine the most effective types and dosages of behavioral interventions to improve participation in ADL.

Footnotes

*

Indicates articles included in the brief systematic review.

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Behavioral Interventions to Improve Performance in Activities of Daily Living for Adults With Stroke (2012–2019)