Abstract
Keywords
The American Occupational Therapy Association’s (AOTA’s) Centennial Vision states, “We envision that occupational therapy is a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society’s occupational needs” (AOTA, 2007, p. 614). Three elements that are viewed as relevant to a shared vision include evidence-based decision making, science-fostered innovation in occupational therapy practice, and the power to influence. The American Journal of Occupational Therapy clearly has the capacity to play a key role in meeting the Centennial Vision. The journal has the potential to guide practitioners to make evidence-based decisions via the dissemination of well-designed clinical trials; make practitioners, clients, and third-party payers aware of science- and evidence-based innovations that have the potential to improve participation and quality of life; and eventually influence health care decisions for present and future clients. Indeed, one of the four strategic directions that were identified to support the vision is increasing research capacity and productivity (AOTA, 2007).
Until relatively recently, the practice area of neurorehabilitation has been plagued by an overreliance on anecdotal interventions and the overuse of nonstandardized assessments. Occupational therapists have realized the need to raise the bar first and foremost so that we can provide cutting-edge and high-quality services to those we serve and ensure the viability of occupational therapy as a reimbursable and necessary service. Fortunately, a renewed focus on evidence-based and occupation-based practice has resulted in a substantial increase in the research available to interpret and implement. Even a cursory review of the American Occupational Therapy Association’s Evidence-Based Practice and Resource Directory demonstrates the significant increase in neurorehabilitation research. Certainly, over the past 10–15 yr, the literature has suggested substantial changes in neurorehabilitation techniques firmly based in current research. Commonly used interventions historically considered to be tried and true are being rethought, questioned, or, in some cases, not recommended on the basis of the available evidence. This change is particularly true in the substantial areas of motor control (Rao, 2004) and cognitive and perceptual rehabilitation (Gillen, 2009). The positive result is the development of innovative interventions that may hasten clients’ recovery and ultimately improve their quality of life. In this article, I review all neurorehabilitation research published in the American Journal of Occupational Therapy (AJOT) in the past 2 years (2008–2009) to determine the types of research published and to assess how well the journal is meeting the Centennial Vision.
Analysis: What Type of Research Studies Were Published in 2008–2009?
I identified a total of 24 neurorehabilitation-related research studies in this review. This total includes 9 (37.5%) effectiveness studies (Denham, 2008; Fong & Howie, 2009; Goverover, Arango-Lasprilla, Hillary, Chiaravalloti, & DeLuca, 2009; Guiffrida, Demery, Reyes, Lebowitz, & Hanlon, 2009; Hill-Hermann et al., 2008; Lin, Wu, Lin, & Chang, 2008; Rand, Weiss, & Katz, 2009; Rosenstein, Ridgel, Thota, Samame, & Alberts, 2008; Rowe, Blanton, & Wolf, 2009), 7 (29.2%) studies related to instrument development and testing (Arnadóttir & Fisher, 2008; Baum, Connor, Morrison, Hahn, Dromerick, & Edwards, 2008; Classen, Levy, McCarthy, Mann, Lanford, & Waid-Ebbs, 2009; Faddy, McCluskey, & Lannin, 2008; Hartman-Maeir, Harel, & Katz, 2009; Shih, Rogers, Skidmore, Irrgang, & Holm, 2009; Toglia & Cermak, 2009), 6 (25%) studies related to basic research (Erez, Rothschild, Katz, Tuchner, & Hartman-Maeir, 2009; Guidetti, Asaba, & Tham, 2009; Nakamura, Abreu, Patterson, Buford, & Ottenbacher, 2008; Turner, Ownsworth, Cornwell, & Fleming, 2009; Warren, 2009; Wolf, Baum, & Connor, 2009), and 2 (8.3%) efficacy studies (Doig, Fleming, Cornwell, & Kuipers, 2009; Smallfield & Karges, 2009). I identified no systematic reviews or meta-analyses over this 2-yr period. All studies used quantitative methods with the exception of 3 qualitative studies (Doig et al., 2009; Guidetti et al., 2009; Turner et al., 2009). See Tables 1 and 2.
Summary of Neurorehabilitation Research Published Between 2008 and 2009 in the American Journal of Occupational Therapy
Note. N/A = not applicable. The following rating system for levels of evidence was used to rate the effectiveness studies: Level I: systematic reviews, meta-analyses, and randomized controlled trials, Level II: two groups, nonrandomized studies such as cohort or case-control designs, Level III: one-group, nonrandomized studies such as pretest and posttest designs, Level IV: descriptive studies including analysis of outcomes such as single-subject designs or case series, Level V: case reports and expert opinion including narrative literature reviews and consensus statements.
Systematic Review of Neurorehabilitation Research Published Between 2008 and 2009 in the American Journal of Occupational Therapy
Note. ADLs = activities of daily living; SD = standard deviation; TBI = traumatic brain injury; ANOVA = analysis of variance; N/A = not applicable; COPM = Canadian Occupational Performance Measure; s/p = status post; MMSE = Mini-Mental State Examination; ANC0VA = analysis of covariance; lADLs = instrumental activities of daily living; MET = Multiple Errands Test; MANOVA = multivariate analysis of variance; A-ONE = AD L-focused Occupation-based Neurobehavioral Evaluation; EFPT = Executive Function Performance Test.
Most studies identified were effectiveness studies (i.e., dealing with the effect or outcome of intervention), arguably the most critical area of focus for occupational therapy research. In terms of rating these studies’ level of evidence, I used the following rating system (Lieberman & Scheer, 2002):
Level I: Systematic reviews, meta-analyses, and randomized controlled trials
Level II: Two groups, nonrandomized studies such as cohort or case-control designs
Level III: One group, nonrandomized studies such as pretest and posttest designs
Level IV: Descriptive studies including analysis of outcomes such as single-subject designs or case series
Level V: Case reports and expert opinion including narrative literature reviews and consensus statements.
Of the nine effectiveness studies, four (44.4%) were classified as Level II (Fong & Howie, 2009; Goverover et al., 2009; Guiffrida et al., 2009; Lin et al., 2008), one (11.1%) as Level III (Rand et al., 2009), and four (44.4%) as Level V (Denham, 2008; Hill-Hermann et al., 2008; Rosenstein et al., 2008; Rowe et al., 2009). I identified no Level I or Level IV studies.
After effectiveness studies, the most commonly identified studies focused on instrument development and testing. This area remains critical for occupational therapists to examine because the choice of assessment and the specific items included help to demonstrate occupational therapy’s unique focus. AJOT published six basic neurorehabilitation research articles (i.e., those that examined a clinical phenomenon but did not assess treatment) from 2008 to 2009. Finally, two articles examined the clinical efficacy (e.g., dealing with safety, client satisfaction, cost or time efficiency) of occupational therapy.
Assessment: How Well Did the Journal Meet the Centennial Vision in the Past 2 Years in the Practice Area of Neurorehabilitation?
Overall, I identified many articles published over the past 2 years (2008–2009) that will be helpful as we strive to meet the Centennial Vision in the practice area of neurorehabilitation. I should note that this review included a special issue of the American Journal of Occupational Therapy (Gutman, 2009) focused on stroke and brain injury rehabilitation and that 12 (50%) of the articles identified were from that one specific issue. Clearly, the publication of a special issue serves as a catalyst to generate research in a focused area of practice.
Most identified studies were related to effectiveness and testing various occupational therapy interventions. Interventions that were focused on motor control impairments used techniques such as occupational therapy combined with botulinum toxin A (Denham, 2008), task-specific training while wearing a neuroprosthesis (Hill-Hermann et al., 2008), reaching tasks with varied task parameters (Lin et al., 2008), combined repetitive task practice and robotic therapy (Rosenstein et al., 2008), and constraint-induced movement therapy (Rowe et al., 2009). Interventions that focused on cognitive impairments used techniques such as problem skills training (Fong & Howie, 2009), whereas interventions that focused on learning specific skills used techniques such as blocked and random practice (Guiffrida et al., 2009), spacing effect strategies (Goverover et al., 2009), and virtual reality (Rand et al., 2009).
Various outcome measures were used that can be categorized at the impairment level and included measures of spasticity, decreased active range of motion, executive function impairment, difficulties with problem solving, upper-extremity impairment, and altered upper-limb kinematics. Outcome measures that were used and categorized as measures of activity limitations included nonstandardized measures of activities of daily living (ADLs), performance of instrumental activities of daily living (IADLs), performance of specific skills (vocational skills, route learning, paragraph learning), using the upper extremity to support daily function, and self-report of performance of and satisfaction with occupational performance. Finally, outcome measures that can be classified as participation or quality-of-life measures were the least commonly used and in fact were used in only one case study (Rowe et al., 2009).
Because I identified no Level I effectiveness studies, I further analyzed Level II studies on the basis of intervention and outcomes. Only two (Guiffrida et al., 2009; Goverover et al., 2009) of the four Level II studies identified used learning specific daily living skills as an outcome measure. Findings from the four studies included that
Interventions for problem-solving impairments caused by acquired brain injury using a metacomponential approach have some advantage compared with conventional cognitive training as indicated by 2 of 10 scores included on the Metacomponential Interview but do not generalize to real-life problem solving (Fong & Howie, 2009);
Use of blocked or random practice has a positive effect on learning specific vocational skills that is retained for ≥2 wk for people living with a traumatic brain injury, and random practice seems to be advantageous in terms of transferring learning to a new and similar task (Guiffrida et al., 2009);
Use of a spacing effect strategy to learn and remember specific skills is superior to massed learning conditions for people with traumatic brain injury and healthy control participants (Goverover et al., 2009); and
A combination of speeded instruction and ipsilateral reach may optimize movement performance of the less affected limb in those living with stroke (Lin et al., 2008).
The one identified Level III study tested the emerging use of virtual reality with stroke survivors and, despite a small sample size, documented improvement in performing multiple errands in a shopping mall. The four remaining effectiveness studies were classified as Level V. All four studies examined the effect of various interventions on managing the neurologic upper extremity. All of the studies included various impairment measures. Specific activity and participation outcome measures used included a nonstandardized assessment of basic ADLs and IADLs (Denham, 2008), the Canadian Occupational Performance Measure (Hill-Hermann et al., 2008), and the Stroke Impact Scale (Rowe et al., 2009). In addition, some studies included measures that quantify upper-extremity function (Hill-Hermann et al., 2008; Rosenstein et al., 2008; Rowe et al., 2009).
After effectiveness studies, the most commonly identified studies focused on instrument development and testing. A clear pattern noted in these studies is a renewed focus on performance-based assessment and assessments that appear to have high ecological validity. In the realm of cognitive rehabilitation, ecological validity refers to the degree to which the cognitive demands of the test theoretically resemble the cognitive demands in the everyday environment, sometimes termed functional cognition. A test with high ecological validity identifies difficulty in performing real-world functional and meaningful tasks (Chaytor & Schmitter-Edgecombe, 2003). The issue of ecological validity is of paramount importance when developing occupational therapy assessments (Gillen, 2009). Assessments that were further developed and tested for validity and reliability included ecologically valid performance-based cognitive assessments such as the ADL-focused Occupation-based Neurobehavioral Evaluation (A--ONE), which uses observations of basic ADLs and mobility to ascertain underlying neurobehavioral deficits that affect functional status (Arnadóttir & Fisher, 2009); the Executive Function Performance Test, which uses four everyday tasks (cooking, using the telephone, managing medications, and paying bills) to document the presence or impact of executive function deficits (Baum et al., 2008); and the Kettle Test, which uses the task of preparing hot beverages to tap into basic and higher-level cognitive processes (Hartman-Maeir et al., 2009). In addition, the use of dynamic assessment to examine learning potential for those with unilateral neglect continues to develop (Toglia & Cermak, 2009).
Measurement of specific living skills also emerged as an identified pattern. Identified studies examined the development of a Handwriting Assessment Battery for Adults (Faddy et al., 2008), recommended assessments to predict driving ability for those living with traumatic brain injury using an evidence-based literature review approach (Classen et al., 2009), and examined existing measures of ADLs for stroke survivors using Rasch analysis (Shih et al., 2009).
The next most common area of inquiry was focused on basic neurorehabilitation research. Findings from basic neurorehabilitation research included
Documenting the presence of deficits in executive functions, participation restrictions, and a significant correlation between these two variables in those with mild traumatic brain injury (Erez et al., 2009);
Identifying the meaning of context in the process of regaining the ability to participate in self-care after stroke or spinal cord injury using qualitative methods (Guidetti et al., 2009);
Identifying motor deficits via kinematic analysis in the presumed-to-be-unaffected upper extremity after brain injury (Nakamura et al., 2008);
Using qualitative methods to explore the experiences of reengagement in meaningful occupations during the hospital-to-home transition after acquired brain injury (Turner et al., 2009);
Documenting mild difficulties performing basic ADLs and significant limitations in IADLs in those with visual field deficits (Warren, 2009); and
Documenting how the health care community’s understanding of stroke is changing as the age of stroke is decreasing; most strokes are mild to moderate in severity, and most discharge decisions are based on impairment measures (Wolf et al., 2009).
Many of the studies classified as basic research are easily translated into clinical practice. Examples include providing guidance for choosing appropriate assessment tools to identify areas for occupational therapy intervention after mild traumatic brain injury (Erez et al., 2009) and identifying priority areas for assessment and intervention in those with hemianopsia (Warren, 2009).
Last, two studies examined clinical efficacy:
Using qualitative methods, Doig et al. (2009) documented that goal-directed therapy is described positively and that a structured goal-setting process in which the client, therapist, and significant others work in partnership seems to enhance the process of goal setting and goal-directed community-based rehabilitation.
Smallfield and Karges (2009) classified the type of occupational therapy intervention used during inpatient stroke rehabilitation. They observed that most (65.77%) occupational therapy sessions were classified as prefunctional (i.e., not consisting of an actual occupation) in nature compared with 48.26% of sessions focused on relearning daily living tasks.
Notable Concerns
I noted three trends in this review that are cause for reflection: the ability of research to influence practice, an absence of highest-level research from the perspective of level of evidence, and choice of outcome measures.
The findings of Smallfield and Karges (2009) are disconcerting and discordant with current trends in neurorehabilitation research, including the articles analyzed for this review. That is, a clear and consistent finding in current neurorehabilitation research is that specific and repetitive task practice is a key therapeutic factor in relearning specific skills (Denham, 2008; Guiffrida et al., 2009; Hill-Hermann et al., 2008; Rao, 2004; Rosenstein et al., 2008; Rowe et al., 2009). Of concern is that on the basis of Smallfield and Karges’s (2009) findings and those of others whom those authors eloquently cite, practice trends are still not embracing this core concept. Questions emerge related to bridging research and practice and the ability of AJOT (and other professional journals) to influence practice.
Although all levels of evidence are potentially useful to practitioners, the lack of studies published in AJOT that are classified as Level I evidence is troublesome. This is not to say that occupational therapists are not generating this level of evidence but that they may be choosing to publish this research in other journals. It is imperative to identify the factors associated with researchers choosing other journals to publish their most powerful and potentially influential research.
In terms of outcome measures, our unique occupational therapy focus is assumed to be on enhancing performance in areas of occupation and likewise decreasing activity limitations and participation restrictions to ultimately improve quality of life. That being said and understanding that impairment measures are also useful, only two of the effectiveness studies that were consistent with Level II evidence used an activity-level measure, and only one identified study (Level V) used a measure of participation or quality of life as an outcome measure. It is concerning that the outcome measures that are being chosen are not reflective of overarching occupational therapy goals. By contrast, occupational therapists have developed and continue to develop powerful measures that reflect their unique focus (Law et al., 2005). This review continues to reflect the trend of occupational therapists developing and testing their own instruments. These tools should be integrated into both practice and research.
Directions for Future Research
The American Journal of Occupational Therapy is clearly a potentially powerful tool to hasten meeting the Centennial Vision. On the basis of the findings reported here, I make several recommendations for future research.
Occupational therapy researchers should commit to ensuring that in addition to impairment measures, measures of activity or participation and quality of life are consistently integrated into the profession’s research agendas. The profession as a whole must continue to support and cultivate researchers to carry out and publish all levels of evidence, but the publication of effectiveness studies categorized as Level I evidence is particularly important.
Finally, over the past few years the emphasis has been on testing new technology to improve neurorehabilitation outcomes. This trend is reflected in this review. This work is cutting edge, relevant, and exciting and has the potential to make important changes in clients’ lives. However, multiple interventions have and continue to be used on a day-to-day basis that are considered core or foundational occupational therapy interventions for this population (e.g., the use of adaptive devices to improve IADLs, adaptations for those living with one functional upper extremity, splinting, positioning, wheeled mobility prescription) that have been yet to be tested in any depth, if at all. I recommend that in addition to cutting-edge technologies, day-to-day interventions that appear to be tried and true be tested with rigor so that we can feel confident that “occupational therapy is a powerful, widely recognized, science-driven, and evidence-based profession” (AOTA, 2007, p. 614).