Effectiveness of Task-Oriented Approaches and Occupation-Based Activities to Improve Performance and Participation in Instrumental Activities of Daily Living (IADL) Among Adult Stroke Survivors (2009–2019)

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 to improve performance and participation in instrumental activities of daily living (IADL) among adult stroke survivors?”

Current Themes Reported

The main themes of the studies included in this systematic review brief are task-oriented/occupation-based approaches and augmenting task-oriented training with cognitive strategies.

Clinical Scenario

There is a large scope of interventions that can be performed with adult stroke survivors to improve their ability to perform and participate in instrumental activities of daily living (IADLs). The most frequently studied intervention category to improve IADLs is task-oriented and occupation-based interventions. Task-oriented interventions are often cited as a preferred neurorehabilitation intervention to improve occupational performance for individuals recovering from a neurological incident (Preissner, 2010). The task-oriented approach to intervention assumes that occupational performance results from the interaction of persons and their environment (Cohn & Coster, 2019). Task-oriented interventions may include a number of techniques, occupations, and activities such as driving simulation, medication management with the use of technology, constraint-induced movement therapy (CIMT), or modified CIMT, and incorporating mental practice into IADL tasks. In addition to the aspects of intervention noted above, occupational therapy practitioners also use cognitive strategies to augment task-oriented approaches. Cognitive exercises and the cognitive orientation to daily occupational performance (CO-OP) approach have both been studied to understand the effect on IADL performance (McEwen et al., 2015).

Summary of Key Findings

Five Level 1B and six Level 2B studies that used task-oriented and occupation-based approaches met the criteria for inclusion in this systematic review and provided evidence for the effectiveness of these types of interventions. The risk of bias for most of the studies was low, with one with moderate risk of bias. The studies in this theme focused on the following interventions: client-centered activities of daily living (CADL), driving simulation, medication management, constraint-induced therapy (CIT), predischarge visit, and mental practice (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).

Two Level 1B and one Level 2B studies that used augmenting task-oriented training with cognitive strategies met the criteria for inclusion in this systematic review and provided evidence for the effectiveness of these types of interventions. The risk of bias for all of these studies was low. The studies in this theme focused on two main types of intervention: cognitive exercise and CO-OP (Table 2).

Bottom Line for Occupational Therapy Practice

The results of the review indicate that occupational therapy practitioners can use task-oriented training and occupation-based interventions when working with individuals who have experienced a stroke. Statistically significant positive results related to medication management were found after the use of external cues (i.e., short message service [SMS] text message, written plans for medication routines; Kamal et al., 2015; O’Carroll et al., 2013). Occupational therapy practitioners should include the use of external cues to support patients’ abilities to manage their medications. Interventions such as customized SMS text messages can improve medication adherence and reduce risk factors.

CIT was used in the studies highlighted in Table 1 as an intervention to address the functional use of the affected upper extremity (Liu et al., 2016; Wu et al., 2012; Hsieh et al., 2016; Lin et al., 2009). Though each study used a unique CIT protocol and measured IADLs using different assessment tools, improved IADL performance was seen in all four studies. Recommended dosages varied and ranged from ten 1-hr sessions over 2 wk to fifteen 2-hr sessions over 3 wk.

Even though there was low strength of evidence for CADL intervention, collaborative goal setting is an important part of occupational therapy practice and something that practitioners should always do. Similarly, even though no significant results were found to support a predischarge occupational therapy home visit, the importance of assessing the patient in his/her natural home environment and addressing safe discharge planning from the inpatient rehabilitation setting to home cannot be overlooked.

Augmenting task-oriented training with cognitive strategies encompasses interventions such as cognitive exercise with the use of computerized cognitive programs focused on attention, visual/spatial memory, and/or cognitive flexibility, as well as the implementation of the CO-OP approach. Learning associated with cognitive exercises performed in the context of computerized programs may be difficult for clients to generalize to actual IADL task performance. CO-OP uses a global strategy (i.e., goal-plan-do-check) that can be taught to clients to use across multiple different performance problems and contexts (McEwen et al., 2015). The number of repetitions used with the CO-OP method depends on the quality and consistency of the client’s performance. Once the participant is satisfied with their performance of a particular task, the global cognitive strategy can be used to address other performance areas.

Occupational therapy’s unique contribution to the stroke rehabilitation team is the profession’s focus on the use of occupation as both a means and an end. In many of the studies included in the review, IADL performance was not a primary outcome, and the studies lacked details about the identified IADL goals when client-centered tools (e.g., Canadian Occupational Therapy Measure [COPM]; Law et al., 2005) were used to measure changes in IADL performance. A goal for future research is to highlight when IADL performance is being measured, to use assessment tools that are sensitive to IADL progress, and to report client goals when using tools such as the COPM.