American Journal of Occupational Therapy

Importance: Changes in health care policy and payment over the past decade have resulted in a greater emphasis on cost effectiveness, quality outcomes, and the health care consumer’s experience. Payers’ response to the new policies and their expectations have created expanded opportunities for occupational therapy practitioners in health care overall but particularly in acute care hospitals.

Objective: The objective of this article is to empower occupational therapy directors, practitioners, educators, and students to be proactive in a rapidly changing acute care setting.

Evidence Review: Research on policy and payment changes since the passage of the Patient Protection and Affordable Care Act (Pub. L. 111-148) was synthesized with evidence related to occupational therapy practice and education.

Findings: Occupational therapy practitioners in acute care environments are experiencing expanded roles in optimizing patient readiness for safe community discharge, decreasing lengths of stay, and protecting them from hospital-acquired conditions.

Conclusions and Relevance: Policy and payment initiatives reward health care organizations for the added value occupational therapy practitioners bring to acute care teams.

What This Article Adds: This article details how occupational therapy practitioners can advance consumer satisfaction, outcomes, and efficiency in acute care, which can lead to increased recognition of the vital role that occupational therapy can play, thus leading to expanded opportunities.

OBJECTIVE. Our objective was to examine demographic, cognitive, emotional, and physical factors that predict return to paid employment for people after neurological injury.

METHOD. Four hundred eighty adults with stroke (n = 149), traumatic brain injury (n = 155), and spinal cord injury (n = 176) completed an occupational outcome questionnaire and physical, emotional, and cognitive assessments at three rehabilitation facilities.

RESULTS. Odds of employment were predicted by being married or partnered, having more education, requiring fewer prompts for task sequencing, and having higher inhibitory control (but were not predicted by specific type of injury). Participants who returned to work within 3 mo were more likely to work with the same employer and to take a full-time position than those who returned later.

CONCLUSION. Executive functioning, in particular sequencing and inhibitory control, strongly predicts employment and highlights the importance of cognitive strategy training during occupational therapy with people who have sustained neurological injuries.

Importance: To develop a practical program in the early phase after nerve repair for more rapid return of function.

Objective: To investigate the effects of touch-observation and task-based mirror therapy on the sensorimotor outcomes of patients with nerve repair.

Design: An assessor-blinded study with a randomized controlled design.

Setting: University hospital.

Participants: We recruited 12 patients with median or ulnar nerve repair between the level of midpalm and elbow referred by the plastic surgeons.

Intervention: The patients were randomized into touch-observation and task-based mirror therapy or control groups, and both groups received training for 12 wk.

Outcomes and Measures: The Semmes–Weinstein monofilament (SWM) test, two-point discrimination test, Purdue Pegboard Test (PPT), Minnesota Manual Dexterity Test (MMDT), and pinch-holding-up activity test were assessed at pretreatment, immediately after treatment, and 12 wk after the last treatment.

Results: The experimental group showed greater improvements in the results of the pinch-holding-up activity test and the PPT Unilateral Pin Insertion, Bilateral Pin Insertion, and Assembly subtests. However, change on the SWM test revealed no significant difference between the two groups.

Conclusions and Relevance: Touch-observation and task-based mirror therapy is an effective but low-cost treatment protocol to optimize sensorimotor control and functional capability of the upper limb in patients with peripheral nerve injury.

We explored parental feeding practices, feeding issues during the first 2 yr of life, and the relationship between feeding issues and levels of maternal distress in preterm infants. Four hundred twenty mothers (239 with preterm infants, 181 with full-term infants) participated in the study. The Behavior-Based Feeding Questionnaire for Infants With Premature History and the Parenting Stress Index–Chinese Version were used as the two outcome measures. The results indicated that preterm infants had different feeding experiences compared with their full-term counterparts. They tended to start solid food later in life and had limited experiences in food variation. Parenting stress was prevalent in parents with preterm infants and was associated with the frequency of feeding issues, especially at later ages when supplementary foods were being introduced.

Importance: Children with autism spectrum disorder (ASD) and other developmental disabilities (DD) commonly display unusual responses to sensory input. Previous work has suggested concurrent associations linking sensory features with aspects of family functioning, including activity participation and caregiver strain. What is unknown, however, is the extent to which sensory features affect family functioning over time, as well as the influence of received services on these relationships.

Objective: To assess hypothesized longitudinal associations between sensory features and family functioning and examine interactions by group and service usage (i.e., educational and therapy services).

Design: Multigroup longitudinal observational study.

Setting: Community.

Participants: A volunteer sample of 81 children (50 with ASD, 31 with DD; 76% male), ages 2–12 yr, and their caregivers participated in assessments at two points, 3.3 yr apart on average.

Outcomes and Measures: Key measures included the Sensory Experiences Questionnaire, Sensory Profile, Sensory Processing Assessment for Young Children, Tactile Defensiveness and Discrimination Test–Revised, Caregiver Strain Questionnaire, and Home and Community Activities Scale. We also measured the amount of time children received educational and therapy services.

Results: Regression analyses confirmed long-term associations linking sensory features with aspects of activity participation and caregiver strain in this population; group and service usage interactions were also identified.

Conclusions and Relevance: Sensory features can affect the everyday experiences of both children and caregivers. It is important for practitioners to understand the potentially enduring effects of children’s sensory features on family functioning so as to begin to identify supportive interventions with more optimal long-term effects.

Importance: The Centers for Medicare & Medicaid Services (CMS) has identified the need to assess functional cognition as part of the postacute care planning process.

Objective: We examined the reliability, validity, and clinical utility of the Menu Task (MT) as a screening measure of functional cognition to assess the need for occupational therapy services.

Design: Cross-sectional study testing a convenience sample of community-dwelling older adults (n = 130) and adults hospitalized for elective orthopedic surgery (n = 60). The MT and four neuropsychological screening tests—the Brief Interview of Mental Status, the Montreal Cognitive Assessment, Trail Making Tests A and B, and an instrumental activities of daily living (IADL) scale—were administered.

Setting: Community-dwelling participants were tested at the University of Wisconsin occupational therapy program and in community settings. Hospitalized participants were tested at the University of Missouri Orthopedic Institute.

Participants: We recruited healthy community-dwelling adults in Madison, WI (community sample; n = 130) and patients hospitalized for elective orthopedic surgery in Columbia, MO (hospital sample; n = 60). Inclusion criteria were age 55 yr or older, living in the community, and willingness to be tested in English; for the hospital sample, participants had to be referred for elective orthopedic surgery requiring a hospital stay and be independent in activities of daily living before being admitted for surgery.

Results: We found significant differences between groups classified as impaired or not impaired on the basis of MT scores. Participants classified as impaired on the MT performed significantly less well than those classified as not impaired on the neurocognitive and IADL measures.

Conclusion: The reliability and validity of the MT were supported.

What This Article Adds: The American Occupational Therapy Association and the occupational therapy experts advising CMS have stressed the importance of a brief performance-based screening tool to identify people who need more comprehensive occupational therapy evaluation. The implementation of a functional cognition screening tool as part of the required CMS assessment protocol should greatly increase the number of patients referred for occupational therapy evaluation and treatment. The MT has the capacity to address the gap in the proposed CMS assessment of Medicare recipients across postacute care settings.

Importance: Forty percent to 75% of community-dwelling older adults are not able to adhere to their medication routine. A medication management assessment can correctly identify the reasons for nonadherence and the barriers contributing to it.

Objective: To further develop the HOME–Rx, an in-home medication management assessment, by modifying scoring metrics, improving clinical utility, and establishing psychometric properties.

Design: In Phase 1, the scoring metrics were modified, and the clinical procedures were evaluated. In Phase 2, the psychometric properties were established.

Setting: The homes of older adults.

Participants: Older adults who took three or more medications, managed their own medications, and lived in their own home were eligible. Older adults with cognitive impairment were ineligible.

Outcomes and Measures: We assessed concurrent validity with the Performance Assessment for Self-Care Skills (PASS) and Medication Management Instrument for Deficiencies in the Elderly (MedMaIDE) and established interrater reliability.

Results: The PASS was positively correlated with the HOME–Rx Performance and Safety subscales; the MedMaIDE was negatively correlated with the HOME–Rx Performance subscale and positively correlated with the Barriers subscale. Interrater reliability was excellent (ICCs = .87–1.00).

Conclusions and Relevance: All relationships were as predicted: The HOME–Rx is a valid and reliable performance-based assessment that provides clinicians and researchers with a measure of older adults’ actual medication management ability in the home using their medications. The results can potentially be used to guide treatment planning and improve medication management.

What This Article Adds: Occupational therapy practitioners can use the HOME–Rx to adequately determine performance problems, safety concerns, and environmental barriers and potentially to guide treatment planning and improve medication management for older adults.

OBJECTIVE. Our objective was to translate the Here’s How I Write: A Child’s Self-Assessment and Goal Setting Tool (HHIW) to Portuguese; adapt it to the Brazilian culture; and analyze its reliability, validity, and clinical feasibility.

METHOD. The study was developed in two steps: adaptation of the HHIW to Brazilian Portuguese, followed by experimental application to examine its validity and reliability. The participants were 60 children and their teachers, divided into two groups: Group 1, whose members had handwriting difficulties, and Group 2, whose members did not.

RESULTS. Children with poor handwriting scored lower on the HHIW for both self- and teacher report. Test–retest reliability of the children’s (.96) and teachers’ (.93) questionnaires as well as internal consistency (.91 and .95, respectively) were excellent. There was good agreement (.74) between the children’s and teachers’ total scores.

CONCLUSIONS. This study adds further evidence of validity and reliability and supports the international use of the HHIW. The HHIW is a useful resource to engage children and teachers in a collaborative relationship to improve handwriting.

Importance: Handgrip dynamometry is probably the most commonly used method to characterize overall human muscle strength.

Objective: To compare and summarize grip strength measurements obtained from two population-based studies.

Design: Secondary data analysis.

Setting and Participants: Data from (1) the 2011–2014 National Health and Nutrition Examination Survey (NHANES) with 13,918 participants and (2) the 2011 normative phase of the National Institutes of Health (NIH) Toolbox project with 3,594 participants.

Outcomes and Measures: The NHANES values used were the mean and best of three trials; the NIH Toolbox value used was the one maximum trial after a practice trial.

Results: General linear model analysis revealed that values obtained from the NIH Toolbox differed from NHANES best values but not from NHANES mean values. The analysis also indicated, regardless of the values used, that grip strength differed significantly between dominant and nondominant sides, males and females, and age groups. We provide updated reference values for handgrip strength.

Conclusions and Relevance: On the basis of these analyses, we summarize grip strength measures obtained from the NHANES and NIH Toolbox for side, gender, and age group strata. Reference values are essential to assist in the interpretation of testing results and clinical decision making.

OBJECTIVE. This study explored U.S. occupational therapists’ perceptions of online competence assessment and associated evidence-based resources.

METHOD. The study used a cross-sectional design with a survey. Respondents were occupational therapists certifying or recertifying with the National Board for Certification in Occupational Therapy in March 2016.

RESULTS. The response rate was 88.6%, with 58.5% indicating they had used the online competence assessment platform. A majority agreed that the platform’s tools helped them identify clinical knowledge (n = 211; 79.9%) and skill needs (n = 160; 60.8%). Of those who obtained copies of the evidence-based resources (n = 98; 45.6%), 72.5% (n = 71) read at least one. Chi-square analysis demonstrated negative relationships between years as an occupational therapist and clinical skills assessment and between highest degree and use of evidence-based practices.

CONCLUSION. Online competence assessment assisted participants in identifying competence needs and evidence-based resources for improving clinical knowledge and skills.

OBJECTIVE. This qualitative study explored occupational therapy practitioners’ perspectives about integrating principles from the field of disability studies (DS) into clinical education and practice.

METHODS. After a conference presentation about DS, three simultaneous focus groups were conducted with 27 occupational therapy practitioners. A constant comparative, grounded-theory approach was used to identify themes across groups.

RESULTS. Identified themes included convergences and divergences between the profession of occupational therapy and the field of disability studies, influence of perspectives of disability on service delivery, clinician navigation of systemic barriers, and incorporation of DS-aligned intervention strategies into practice.

CONCLUSION. Despite points of alignment, occupational therapy has not fully addressed DS critiques. Practitioners recognized professional, systemic, and societal barriers and the need for more educational experiences, resources, and professional reflexivity and dialogue to inform the integration of DS concepts into practice.

OBJECTIVE. Children with a specific learning disability (SLD) have deficits in social and academic competence and executive function (EF). In this study, we used the Model of Human Occupation to investigate the effect of peer-play activities on occupational values and competence as well as EF skills (i.e., behavior regulation and metacognition) in children with SLD.

METHOD. Forty-nine children ages 7–11 yr with SLD were randomly assigned to the peer-play and control groups. Outcome measures were the Behavior Rating Inventory of Executive Function and the Child Occupational Self-Assessment (COSA).

RESULTS. Data analysis showed that the effects of the intervention on EF skills were medium to large. The occupational values and competence did not change according to the COSA.

CONCLUSION. Occupational therapy practitioners can use peer-play activities to enhance EF in children with SLD; however, perceived occupational values and competence may not show any changes with the peer-play intervention using a self-assessment instrument.

OBJECTIVE. Our objective was to evaluate the effectiveness of four adapted feeding utensils with participants with essential tremor (ET) or tremor related to Parkinson’s disease (PD).

METHOD. Participants performed a simulated feeding task under five conditions: (1) standard spoon (control condition), (2) weighted spoon with standard handle, (3) weighted spoon with built-up handle, (4) swivel spoon, and (5) Liftware Steady™ spoon, a product using active tremor cancellation technology. Participants rated each adapted utensil in comparison with the standard spoon regarding performance, ease of use, speed, neatness, and aesthetics.

RESULTS. Participants preferred the Liftware Steady spoon and weighted spoon with standard handle. Friedman’s test did not reveal statistically significant differences in ratings between the two preferred utensils.

CONCLUSION. Participants had varied reactions to the different adaptive utensils and gave different reasons for preferences. These findings support the need for people with tremor related to ET or PD to have access to trial use of all four devices assessed in this study.

OBJECTIVE. Our objective was to determine the extent to which young children at high risk for sensory processing difficulties differed from those who were at low risk.

METHOD. We compared high- versus low-risk young children using standardized measures. High-risk participants had older siblings identified as having sensory processing difficulties after a comprehensive occupational therapy evaluation (n = 13); low-risk participants (n = 16) had typically developing siblings and no family history of sensory or other neurological disorders.

RESULTS. High-risk infants scored significantly lower on the Language and Cognitive scales of the Bayley Scales of Infant and Toddler Development–Third Edition. The high-risk group presented with more atypical positions on the Toddler and Infant Motor Evaluation and fewer sensation-seeking behaviors on the Toddler Sensory Profile–2.

CONCLUSION. Results suggest that sensory, motor, cognitive, and language dimensions may be associated with sensory processing difficulties. Implications exist for the design of future studies and for early intervention.

Vehicle modifications are often essential to ensure that drivers with disabilities can drive independently and safely. Occupational therapy driver assessors and driver rehabilitation specialists routinely prescribe vehicle modifications on the basis of individualized evaluations and support by rehabilitation interventions. After a literature review and consultation with stakeholders, we identified a resource gap in information to support an evidence-based process for vehicle modification prescription. Using an action research approach, we established content validity for draft guideline items and developed consensus-based draft guidelines for vehicle modification prescription that are ready for trialing by occupational therapy driver assessors. We also propose a practice model for vehicle modification prescription that is applicable to international contexts.

OBJECTIVE. We sought to determine the reliability of the Fitbit^® Flex™ compared with the ActiGraph^® Bluetooth^® Smart wGT3X-BT wireless activity monitor and to contribute to the clinical utility of accelerometry measurement of upper extremity (UE) movement.

METHOD. Two studies were conducted at different sites with healthy adult participants. In Study 1, participants wore both accelerometers on both wrists during everyday activities for a 24-hr period. In Study 2, participants wore both accelerometers on the dominant wrist for 4 hr during an active period of the day. All participants wore the accelerometers during regular daily activities.

RESULTS. Data recorded from the Fitbit and the ActiGraph showed a high positive correlation; however, the Fitbit recorded significantly fewer movements than the ActiGraph.

CONCLUSION. Although the Fitbit and the ActiGraph measure UE activity similarly, the Fitbit was not as sensitive as the ActiGraph. This study provides informative data on the clinical utility of the Fitbit compared with the ActiGraph.

Importance: Neuropsychiatric behaviors of persons with dementia, including agitation, aggression, and rejection of care, are almost universal; occur throughout the disease process; and have negative consequences for both persons with dementia and their caregivers. Nonpharmacological approaches are now recognized as first-line treatment to address these behaviors. One promising approach is activity tailored to the person’s interests, abilities, and physical and social environment. An evidence-based program, New Ways for Better Days: Tailoring Activities for Persons With Dementia and Their Caregivers (TAP), draws on occupational therapy principles (person–environment–occupation fit, activity analysis) to meaningfully engage persons with dementia.

Objective: This case report describes the TAP protocol and clinical reasoning processes underlying use of tailored activities as a therapeutic modality to address dementia-related neuropsychiatric behaviors.

Design: This is a case study of an African-American woman in her 60s caring for her father, age 92, who has severe dementia and multiple behaviors.

Outcomes and Measures: Primary outcomes in this case report include the person with dementia’s engagement in an activity and the reported neuropsychiatric behaviors. In addition, the caregiver’s confidence in using activities is reported. These and other measures from the TAP protocol are described in full.

Results: After working with an occupational therapist for eight sessions, the person with dementia’s engagement in activity increased by 50% and his frequency of vocal disturbance decreased, and the caregiver felt more confident in using activities with her father.

Conclusion and Relevance: This case report illustrates how occupational therapists working with families of persons with dementia can use the TAP protocol to help them manage neuropsychiatric behaviors by tailoring activities.

What This Article Adds: Occupational therapists are uniquely qualified to systematically assess the cognitive functioning of persons with dementia, caregivers, and home environments and to integrate this information to derive and implement activities tailored to the person’s capacities and context, thereby reducing neuropsychiatric behaviors and increasing engagement in meaningful activity.

To advance evidence-based practice across rehabilitation professions, clinicians, and researchers could benefit from a structured way to clearly describe the treatment interventions used by their discipline. Development of the Rehabilitation Treatment Specification System is an interprofessional effort to use a theory-driven and systematic approach to define, specify, and quantify the complex nature of rehabilitation treatments. In this article, we introduce this novel approach and provide a case example that illustrates application to clinical practice. We invite occupational therapy practitioners to consider how clear specification of the content and process of their interventions could benefit practice, research, and education.

Health care spending in the United States continues to grow at an unsustainable rate. In 2015, spending increased 5.8%, to reach $3.2 trillion, or $9,990 per person. As a share of the nation’s gross domestic product, health spending accounted for 17.8% (Morgan et al., 2016). A critical component of addressing this issue is eliminating wasteful spending without reducing quality and appropriate care. In 2012, Choosing Wisely^®, an initiative of the ABIM Foundation (American Board of Internal Medicine), started with the aim to encourage meaningful conversations between health care practitioners and clients to ensure that appropriate and quality care is being provided. The American Occupational Therapy Association (AOTA) made a commitment to join Choosing Wisely in 2016. With support and input from AOTA members, the Board of Directors, and staff, AOTA implemented a three-phase process to develop and publish the list, “Five Things Patients and Providers Should Question.” The goal of AOTA’s participation in this initiative is to start dialogue within the occupational therapy profession about providing quality services that are supported by evidence, not duplicative, free from harm, and truly necessary.