Occupational Therapy Practice in Adult Rehabilitation of Persistent Postconcussion Symptoms: A Scoping Review

Method

Results

Figure 1 depicts the source selection process guided by the PRISMA-ScR guidelines (Tricco et al., 2018) for this scoping review. An initial 804 sources were retrieved. After 296 duplicates were removed, 508 sources were screened by title and abstract. Gray literature sources were reviewed in full. Of these sources, 60 were included for full-text review, and 19 publications from 16 sources met inclusion criteria and underwent data extraction. Table A.2 in the Supplemental Material outlines details of the 19 articles stemming from 16 unique studies or other sources, with a summary provided below.

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Figure 1.

Flowchart of the source review and selection process undertaken for the scoping review.

Discussion

This is the first review internationally to identify and categorize (using the WHO ICF One-Level Classification) existing literature that describes occupational therapy practice (including both assessments and interventions) in the rehabilitation of adults with PPCS. This is a significant opportunity to enhance the understanding of occupational therapy practice approaches used by therapists treating adults with PPCS against the ICF domains, helping to communicate their role to other health professionals working in this field of neurological rehabilitation. Of the 19 eligible publications from 16 unique sources included in this review, most were published in the past 5 yr, showing an increased focus on occupational therapy and its role within concussion rehabilitation. Evidence was varied across both assessment and intervention types (mapped to the ICF One-Level Classification) demonstrating breadth of the occupational therapy role. This review also identified that sources were published from middle-high income countries in the northern hemisphere. Although the profession has previously had an identified broad scope of practice in PPCS rehabilitation (CAOT, n.d.), review findings support the need for further research into occupational therapy service provision and the development of discipline-specific clinical practice guidelines that assist the rehabilitation of adults with PPCS across all global regions. The implications of these findings will now be discussed with respect to occupational therapy practice, research, and policy.

Implications for Occupational Therapy Practice

Despite the small yield identified, some valuable insights into occupational therapy practice—including assessments and interventions used with adults experiencing PPCS—were found. The review highlighted that in the published evidence that exists, occupational therapy assessments and interventions are more often reported to the body structures and body functions level, with a focus on remediation of PPCS symptoms. Less focus is given to the use of assessments and interventions that impact activities and participation domains, as well as environmental factors to address participation restrictions (e.g., return-to-work and study). Research that targets these fundamental areas of occupational therapy practice is needed to grow an evidence base that aligns with the profession’s practice, while ensuring holistic, person-centered treatment of PPCS is achieved (Boone et al., 2024; Permenter et al., 2023; WFOT, 2023).

Despite evidence supporting the benefits of occupational therapy over physician assessment alone (Harris et al., 2019), this review highlighted limited contemporary evidence to substantiate the occupational therapy role in adult PPCS rehabilitative care. Although various eligible studies (Jaber et al., 2019; Marwaa et al., 2023; Pundlik et al., 2020; Wallace et al., 2022) did report the inclusion of occupational therapy within concussion rehabilitation teams, studies highlighted its limited representation and/or a lack of specific outcome-related information from occupational therapy interventions. One systematic review (Marwaa et al., 2023) mentioned the inclusion of occupational therapy in rehabilitation programs with limited findings (one of the 10 included publications in the review). These findings highlight the need to further establish the role of occupational therapy (including outcomes) in PPCS rehabilitation (Jaber et al., 2019; Wheeler & Acord-Vira, 2023). Without published research about the specific offerings and outcomes of adults who receive occupational therapy during PPCS rehabilitation programs, practice guidance on the role the profession will remain sparse. This in turn has limitations on defining and substantiating—particularly within an evidence-based practice lens—the capacity and unique expertise that occupational therapy can offer concussion rehabilitation teams (Strate & Ullucci, 2023).

Previous research (Jackson et al., 2024; Jennings & Islam, 2023; Tan, 2017) reported the most used assessments by occupational therapists are the RPQ and/or COPM. Both assessments, in addition to the QOLIBRI, were most frequently reported within eligible sources in the current review (Bonn et al., 2023; Jones et al., 2019; Li, 2023; Thastum et al., 2017, 2018, 2019; Vikane et al., 2017). Assessments reported primarily mapped to the ICF domains of Body Functions and Body Structures, showing a weighting toward assessments that focused on PPCS symptom or impairment identification. A small proportion of assessments mapped to Activities and Participation (e.g., COPM). Functional nonstandardized assessments was reported in one source (Wallace et al., 2022). These findings are significant as they demonstrate limited use of occupation-focused assessment and nonstandardized measures (that therapists typically use in clinical practice) within published evidence that may inform occupational therapy practice. This finding aligns with recent calls for increased use of performance-based assessments to ensure measurement of occupational therapy interventions and associated occupational performance outcomes (Wheeler & Acord-Vira, 2023). Other literature has also suggested the use of both standardized and nonstandardized assessments during occupational therapy practice (CAOT, n.d.; Tan, 2017). Thus, an important direction for future research includes establishing consensus on occupational therapy assessment processes in PPCS rehabilitation, which can help define the occupational therapy role. This consensus work should also examine the use of standardized assessments and performance-based/nonstandardized assessments in the treatment of adults with PPCS.

Mapping of interventions to the chapter level of ICF One-Level Classification demonstrated the occupational therapy role can be wide-ranging, evidencing the need for clinical practice guidance for occupational therapy practice in the rehabilitation of adults with PPCS. Mapping interventions to the ICF demonstrated the use of vision and visual perceptual assessments, and interventions were reported across various sources (Akinbobuyi, 2023; Bonn et al., 2023; Brayton-Chung et al., 2016; Houston et al., 2021; Li, 2023; Pundlik et al., 2020; Wallace et al., 2022). This highlighted the role of occupational therapists in visual perceptual assessments and interventions in PPCS rehabilitation. These findings align with other published literature that describes the role of occupational therapists in the assessment and treatment of vision and visual perceptual impairments following traumatic brain injury (Aravich & Troxell, 2021; Jackson et al., 2024; Mills et al., 2024; Schurr et al., 2024).

Although clinical practice guidelines do exist, they tend to provide broad information about the role of occupational therapy in the acute and postacute management of concussion and PPCS (Centers for Disease Control and Prevention, 2024; Marshall et al., 2015; Ontario Neurotrauma Foundation, 2018; Tan, 2017). Some clinical guidelines focus on moderate-severe TBI management (Bayley et al., 2023) or the broad categories of the TBI population (Wheeler & Acord-Vira, 2023). Others focus specifically on an area of practice (Aravich & Troxell, 2021). Thus, evidence-based holistic resources that inform the implementation of specific occupational therapy assessments and interventions during adult PPCS rehabilitation are needed (Finn, 2019; Lew & Waskiewicz, 2020; Roelke et al., 2022).

Implications for Research

Although findings indicate a recent growth of interest in research about adults experiencing PPCS, published literature about the efficacy of occupational therapy offerings in concussion management is sparse; especially PPCS in adults (Finn, 2019; Jaber et al., 2019; Jennings & Islam, 2023; Marwaa et al., 2023; Roelke et al., 2022; Wheeler & Acord-Vira, 2023). The heterogeneity of sources found in the current review emphasizes the need for future consensus work that focuses on the use and efficacy of occupational therapy assessments and interventions that can evidence-inform occupational therapy practice (Jackson et al., 2024).

Health care teams consisting of medical and allied health professionals—including rehabilitation physicians, physical therapists, and occupational therapists—play an important role in PPCS rehabilitation (Mills et al., 2024). Although research points to benefits of an interdisciplinary approach to the treatment of adults with PPCS (Jennings & Islam, 2023), the current scoping review has further demonstrated evidence gaps remain on discipline-specific evidence, including for occupational therapists (Jaber et al., 2019). The two review articles included in this study highlight limited published research about the role of occupational therapy and that the profession is not always included in adult PPCS rehabilitation teams (Jaber et al., 2019; Marwaa et al., 2023).

The geographical locations of included sources—United States of America, Denmark, Canada, and Norway—highlight that recent research has occurred in middle-high income countries in the northern hemisphere. This finding is consistent with other literature, which points to research gaps in low-middle income countries and southern global regions (Jackson et al., 2024). Although clinicians can draw upon insights and learnings provided in this international literature—including practice resources reported by Li (2023)—it is important to note the inherent differences across global regions and health care systems (Schütte et al., 2018).

Implications for Policy

Given the growing global incidence of concussion, it is highly likely the proportion of adults who experience PPCS—and thus health care investment—will increase (Möller et al., 2021). It is therefore important that concussion rehabilitation services are available and accessible to those who need them (CAOT, n.d.). Rehabilitation services also need to comprise various health disciplines to provide services that can meet the heterogeneous needs of the adult PPCS population (Möller et al., 2021; Wheeler & Acord-Vira, 2023). This includes one-to-one and group-based interventions, depending on a person’s goals and needs (Wheeler & Acord-Vira, 2023). Findings from included sources reported the use of both individual and group-based interventions (Bonn et al., 2023; Jones et al., 2019; Li, 2023; Wallace et al., 2022). Due consideration regarding structure and delivery of individual versus group-based occupational therapy services is needed when developing adult PPCS rehabilitation services.

Finally, although the current scoping review methodically documented occupational therapy practice reported in the literature, it has also demonstrated the need for increased education and advocacy regarding the occupational therapy role—including screening, assessment and participation-based interventions—within concussion rehabilitation programs (Marwaa et al., 2023; Strate & Ullucci, 2023). Without this, health care teams and funders may overlook the inclusion of, or referral to, an occupational therapist, as recent research suggested difficulty with health professionals identifying the profession’s possible value or contribution to concussion care (Strate & Ullucci, 2023).

Limitations

There are limitations in the current review. Sources were limited to English and published within a 10-yr period (2013–2023). Despite justifying these parameters—including cost- and time-related considerations and ensuring selection of contemporary literature—non-English sources beyond the 10-yr range may provide relevant information.

The PPCS inclusion criteria for this study of 4+ weeks postinjury is a potential limitation. Given the variance across PPCS definitions within the literature, criteria set for this review may have resulted in exclusion of some publications. Notably, recent updates of the PPCS definition within concussion guidelines to include all age groups from four-weeks postinjury (Patricios et al., 2023) align the PPCS inclusion criteria with contemporary literature.

Authors of this review worked diligently to identify and categorize existing literature using the WHO ICF One-Level Classification. Although mapping to Second- or Third-Level categories would have provided more detail for the reader, the mapping process was reliant on the level of detail reported within each source and thus was not possible beyond One-Level Classification. When coupled with heterogeneity of the data, this poses a limitation previously identified by other researchers (Marwaa et al., 2023).

Implications for Occupational Therapy Practice

This scoping review has the following implications for occupational therapy practice:

▪ Occupational therapists can assist adults with their recovery from PPCS in concussion rehabilitation programs via structured assessments and targeted interventions across all domains of the ICF.

Conclusion

The objective of this scoping review was to identify and categorize existing literature (using the WHO ICF One-Level Classification) describing occupational therapy practice in the rehabilitation of adults with PPCS after concussion. Important insights were gained through this review, including the identification and reporting of a range of assessments and interventions used by occupational therapists to support people in their recovery from PPCS. This review highlights that, of the evidence examined, the role of occupational therapy in adult PPCS rehabilitation is broad and includes supporting the return to everyday activities. With the increase in PPCS internationally, future work to establish evidence-informed clinical practice guidelines for occupational therapists working with adults with PPCS as part of multidisciplinary teams is warranted and will offer practice guidance to achieve meaningful rehabilitation outcomes.

Supplemental Material