American Journal of Occupational Therapy

The recent article by Muntefering et al. (2023) promotes occupational therapy as a tool for the primary prevention of obesity. In this letter, the authors argue that the article is not only misguided but also potentially harmful.

In this response to the Schwartz & Proffitt (2024) letter to the editor, Muntefering et al. (2023) agree that the profession has a duty to support the occupational participation of diverse individuals, including diverse body types, but also affirm that health management is an area of occupation within the practice framework.

The articles in this Special Issue on Recovery of Function After Neurological Injury include an impressive range of clinical diagnoses, scientific approaches, and theoretical frameworks that demonstrate the breadth and depth of occupational therapy in the restoration of function after neurological injury. An emerging theme throughout is the need for the profession of occupational therapy to identify and use more efficient methods for diagnosing and treating people with neurological injuries to improve their quality of life and the impact of care.

This special issue includes a range of clinical diagnoses, scientific approaches, and theoretical frameworks that demonstrate the breadth and depth of occupational therapy in the restoration of function after neurological injury.

Background: Stroke is the third leading cause of permanent disability worldwide. It is associated with difficulties in occupational performance, an area targeted by the Cognitive Orientation to daily Occupational Performance (CO-OP).

Objective: To investigate the evidence available for the effectiveness of the CO-OP in addressing adults’ performance of activities of daily living.

Data Sources: Randomized controlled trials (RCTs) or pilot RCTs of the CO-OP written in English and published through December 2021 were retrieved from PubMed, SCOPUS, ScienceDirect, OTseeker, and EBSCO.

Study Selection and Data Collection: The studies’ participants were adults with stroke, evaluated on occupational performance before and after CO-OP administration. The American Occupational Therapy Association Evidence-Based Practice Project methodology was followed. Quality appraisal was conducted using the Cochrane Collaboration’s Risk of Bias 2 tool.

Results: Four RCTs and 3 pilot RCTs met the inclusion criteria. Inconsistent results are presented for trained and untrained goals, with the last ones being scarcely investigated.

Limitations: The limited number of studies, combined with the methodological limitations observed, did not allow for definite conclusions to be reached.

Conclusions and Relevance: The CO-OP is a promising client-centered, occupation-based approach, but future adequately powered studies addressing the potential for generalization are needed.

Plain-Language Summary: The Cognitive Orientation to daily Occupational Performance is a relatively new treatment method that uses cognitive techniques to guide patients into discovering ways to perform activities of daily living independently. This systematic review presents the available evidence regarding CO-OP’s effectiveness when used with adults after stroke. The findings showed that CO-OP has a positive impact in this population, but further research is needed to reach more concrete conclusions. Stroke patients may benefit from CO-OP because it can be a cost-effective, short-duration, task-oriented treatment.

The Cognitive Orientation to daily Occupational Performance approach can be a cost-effective, short duration, task-oriented treatment for stroke patients.

Importance: Impaired self-awareness (SA) of deficits after an acquired brain injury (ABI) severely affects patients’ independence in activities of daily living (ADLs). However, any assessment tool permits an exhaustive evaluation of SA in the context of ADLs.

Objective: To study the validity of the Breakfast and Dressing Conflict Task (BD Conflict Task) to assess online SA (awareness of performance in the context of a given task) in patients with ABI; to study its interactions with offline SA (general awareness); and to test the validity of a simplified measure of performance monitoring, the ADL Conflict-Monitoring Index.

Design: Convergent validity and correlational study.

Setting: Research laboratory, hospitals, and homes.

Participants: Thirty patients with ABI and 28 neurologically healthy controls.

Outcomes and Measures: Using the BD Conflict Task, measures of emergent awareness, self-regulation, anticipatory awareness, and self-evaluation were assessed and their convergent validity and relationship with offline SA were analyzed. The ADL Conflict-Monitoring Index was calculated, and its convergent validity was tested.

Results: The online SA variables of the BD Conflict Task showed convergent validity with traditional online SA measures. Offline SA correlated with emergent and anticipatory awareness in the Breakfast Task. The ADL Conflict-Monitoring Index proved to be a valid measure of patients’ performance monitoring.

Conclusions and Relevance: These preliminary findings suggest that the BD Conflict Task is a valid tool to assess online SA in patients with ABI and provide further understanding of the online SA–offline SA interaction. Furthermore, the ADL Conflict-Monitoring Index may be a valid and easy-to-use monitoring measure in clinical settings.

Plain-Language Summary: Patients with acquired brain injury (ABI) and reduced awareness of their cognitive deficits face problems performing activities of daily living (ADLs) and may show signs of unsafe behaviors. Being aware of one’s own abilities involves anticipating problems before starting a task, detecting and correcting errors during the task, and evaluating performance afterward. This study provides preliminary validity for the Breakfast and Dressing Conflict Task, a new tool that assesses aspects of self-awareness simultaneously in the context of familiar and significant ADLs. Furthermore, the tool simplifies the assessment of detecting and correcting errors with an easy-to-use index, making it suitable for use in clinical settings.

This study provides preliminary validity for the Breakfast and Dressing Conflict Task, a new tool that assesses aspects of self-awareness simultaneously in the context of familiar and significant activities of daily living.

Importance: Flow can be described as a subjective state that people report when they fully engage in an activity and experience pleasure, satisfaction, and enjoyment. Flow experiences are measured to determine the extent to which patients engage in therapy activities. Several flow questionnaires are used in neurorehabilitation. However, none have been validated for patients with (sub)acute stroke.

Objective: To develop and validate a new flow questionnaire for patients with (sub)acute stroke.

Design: Single-center prospective cohort study.

Setting: Neurorehabilitation unit of the Neurocenter of the Luzerner Kantonsspital in Lucerne, Switzerland.

Participants: Fifty patients with (sub)acute stroke.

Outcomes and Measures: Development of the Flow State Scale for Rehabilitation Tasks (FSSRT) and determination of the psychometric properties of the FSSRT (internal consistency, test–retest reliability, structural and construct validity) in (sub)acute stroke patients.

Results: The FSSRT showed good internal consistency and excellent test–retest reliability. Composed of four components—concentration, pleasure, movement control, and absorption—the FSSRT correlated significantly negatively with the Hospital Anxiety and Depression Scale, indicating good divergent validity.

Conclusions and Relevance: The FSSRT is a reliable and valid questionnaire measuring flow experience in patients with (sub)acute stroke. This questionnaire can be easily used in occupational therapy as well as in physical therapy and gives therapists important information about the flow experience of patients during therapy to adjust the therapy accordingly.

Plain-Language Summary: Measuring flow experience, or the extent to which patients engage in therapy activities, in the context of occupational therapy and physical therapy is a new approach. This study confirmed that the Flow State Scale for Rehabilitation Tasks questionnaire is reliable and valid for measuring the flow experience of patients after (sub)acute stroke. Occupational therapists and physical therapists can use the FSSRT to optimally adjust the therapy program and increase patient engagement during therapy.

This study confirmed that the Flow State Scale for Rehabilitation Tasks questionnaire is reliable and valid for measuring the flow experience of patients after (sub)acute stroke.

Importance: Occupational therapy practitioners’ knowledge of and advocacy for clients with visual symptoms postconcussion can have a considerable impact on recovery.

Objective: To compare the frequency of vision symptoms and occupational performance deficits in a sample of participants with and without concussion.

Design: Cross-sectional study.

Setting: Sports medicine clinic.

Participants: Adolescents and adults with concussion (n = 20) and musculoskeletal injuries (n = 19).

Outcomes and Measures: Measures included monocular amplitude of accommodation, near point of convergence, Binocular Vision Assessment (BVA) computerized screening for phoria, BVA computerized screening for fusional vergence, the Developmental Eye Movement Test, the Canadian Occupational Performance Measure, and the Convergence Insufficiency Symptom Survey–Concussion Version (CISS–CON).

Results: We found significant differences between participants with and without concussion using the CISS–CON (p = .001), positive fusional vergence (p = .02), and near point of convergence (p = .02). Participants with concussion scoring above cutoffs on multiple measures reported poorer performance (p = .005) and satisfaction (p = .004) with valued occupations.

Conclusions and Relevance: Concussion has a detrimental effect on vision and occupation, and occupational therapy practitioners are well-positioned to assess and address issues arising from this relationship.

Plain-Language Summary: Vision symptoms commonly experienced after a concussion are associated with reduced occupational performance and satisfaction and can have a considerable impact on recovery. Occupational therapy assessment for clients with concussion should include screening for vision difficulties.

This study compares the frequency of vision symptoms and occupational performance deficits in a sample of participants with and without concussion.

Importance: Children with unilateral cerebral palsy (UCP) have poor strength and movement control on one side of their body, leading to impaired bimanual coordination skills.

Objective: To compare duration and intensity of all-day habitual movement of the dominant and nondominant upper extremities (UEs) in typically developing (TD) children and children with UCP.

Design: Two-group observational study.

Setting: Children’s naturalistic settings.

Participants: Convenience sample of 9 TD children and 9 children with UCP.

Intervention: Children wore accelerometers on both wrists all day and night for 1 wk.

Outcomes and Measures: We compared the extent of asymmetry in bilateral arm use (intensity and duration) between the 2 groups.

Results: Compared with TD children who use both UEs equally, children with UCP were more likely to use their dominant or unaffected UE than their nondominant or affected UE during daily activities. There were no differences between groups in dominant UE activity. However, children with UCP engaged in lower levels of moderate to vigorous activity and greater levels of light activity with their nondominant or affected UE than their TD peers.

Conclusions and Relevance: Wrist-worn accelerometry can provide objective information on real-world habitual activity with both arms in children. Accelerometers are nonintrusive, easy to use, and well tolerated by children, and they allow prolonged monitoring of UE activity outside therapeutic contexts. Occupational therapists can use wrist-worn accelerometers as sensitive tools to assess asymmetries in UE use at baseline and as an outcome measure to assess the efficacy of behavioral interventions and carryover into real-world settings among children with UCP.

Plain-Language Summary: This pilot study provides promising evidence that supports the use of wrist-worn accelerometry as an accurate, easy-to-use, and objective assessment tool for children with unilateral cerebral palsy (UCP) to detect asymmetries in bilateral real-world arm activity at baseline and after intensive occupational therapy interventions to improve arm function. The authors used wrist-worn accelerometry for one week with 9 typically developing (TD) children and 9 children with UCP to compare dominant or unaffected versus nondominant or affected upper extremity (UE) use for intensity and duration of activity. Compared with TD children, children with UCP had lower relative intensity of activity in the nondominant UE than the dominant UE. Wrist-worn accelerometers seem to be a sensitive measure to detect asymmetries in bilateral all-day UE use in children with UCP. The findings have implications for the use of wrist-worn accelerometers as an outcome measure to assess the efficacy of intensive therapies to improve real-world affected UE activity and bimanual function among children with UCP.

The findings of this pilot study support the use of wrist-worn accelerometry as an accurate, easy-to-use, and objective assessment tool for children with unilateral cerebral palsy to detect asymmetries in bilateral real-world arm activity and to use at baseline and after intensive occupational therapy interventions to improve arm function.

Importance: The machine learning–based Stroke Impact Scale (ML–SIS) is an efficient short-form measure that uses 28 items to provide domain scores comparable to those of the original 59-item Stroke Impact Scale–Third Edition (SIS 3.0). However, its utility is largely unknown because it has not been cross-validated with an independent sample.

Objective: To examine the ML–SIS’s comparability and test–retest reliability with that of the original SIS 3.0 in an independent sample of people with stroke.

Design: Comparability was examined with the coefficient of determination (R ²), mean absolute error, and root-mean-square error (RMSE). Test–retest reliability was examined using the intraclass correlation coefficient (ICC).

Setting: Five hospitals in Taiwan.

Participants: Data of 263 persons with stroke were extracted from a previous study; 144 completed repeated assessments after a 2-wk interval.

Results: High R ² (.87–.95) and low mean absolute error or RMSE (about 2.4 and 3.3) of the domain scores, except for the Emotion scores (R ² = .08), supported the comparability of the two measures. Similar ICC values (.39–.87 vs. .46–.87) were found between the two measures, suggesting that the ML–SIS is as reliable as the SIS 3.0.

Conclusions and Relevance: The ML–SIS provides scores mostly identical to those of the original measure, with similar test–retest reliability, except for the Emotion domain. Thus, it is a promising alternative that can be used to lessen the burden of routine assessments and provide scores comparable to those of the original SIS 3.0.

Plain-Language Summary: The machine learning–based Stroke Impact Scale (ML–SIS) is as reliable as the original Stroke Impact Scale–Third Edition, except for the Emotion domain. Thus, the ML–SIS can be used to improve the efficiency of clinical assessments and also relieve the burden on people with stroke who are completing the assessments.

This study examined the comparability and test–retest reliability of the machine learning–based Stroke Impact Scale with that of the original Stroke Impact Scale–Third Edition in an independent sample of people with stroke.

Importance: Interventions for improving upper extremity (UE) recovery have become a priority in stroke rehabilitation because UE disability can undermine a person’s capacity to perform daily activities after stroke. A better understanding of the use of activity-based task-oriented training (TOT) will inform the development of more effective UE interventions in stroke rehabilitation.

Objective: To examine the effectiveness of activity-based TOT in improving the UE recovery of adults with stroke.

Data Sources: CINAHL Plus, MEDLINE, and PubMed.

Study Selection and Data Collection: Inclusion criteria included quantitative studies published between June 2012 and December 2022 that reported UE recovery as an outcome, including measurements of motor function, motor performance, and performance of activities of daily living (ADLs); a sample age ≥18 yr, with stroke in all phases; and interventions that incorporated real-world daily activities. We assessed articles for inclusion, quality, and risk of bias following Cochrane methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Findings: Sixteen studies (692 participants, Level 1–4 evidence) were included. Strong to moderate evidence supported the effectiveness of activity-based TOT in UE motor function, motor performance, and ADL performance for adults with stroke. Strong evidence supported the effectiveness of hospital-based TOT, and moderate evidence supported the effectiveness of home-based TOT.

Conclusions and Relevance: The results not only showed the value of activity-based TOT as an effective UE intervention in stroke rehabilitation but also supported the occupational therapy philosophy of using functional and meaningful activities in practice. Further research on home-based TOT is needed.

Plain-Language Summary: This systematic review shows the effectiveness and value of using real-life activities in task-oriented training approaches for adult survivors of stroke. The authors found strong evidence for hospital-based task-oriented training interventions and moderate evidence for home-based interventions for improving upper extremity recovery. This review shows the value of upper extremity task-oriented training as an effective intervention in stroke rehabilitation. The review also supports the occupational therapy philosophy of using functional and meaningful activities in practice as well as the profession’s use of evidence-based practice in stroke rehabilitation.

This systematic review shows the value of upper extremity task-oriented training as an effective intervention in stroke rehabilitation.

Importance: Some people experience persistent symptoms after a concussion that greatly affect occupational performance.

Objective: To evaluate the feasibility and preliminary effect of metacognitive strategy training in a sample of adults with postconcussive symptoms.

Design: Single-group, prospective design.

Setting: University research laboratory.

Participants: Adults with persistent concussive symptoms affecting function (N = 14).

Intervention: Ten 45-min sessions of a metacognitive strategy training intervention, Cognitive Orientation to daily Occupational Performance (CO-OP).

Outcomes and Measures: Assessed feasibility outcomes included recruitment, retention, and adherence rates, and intervention acceptability was evaluated with the Client Satisfaction Questionnaire–8. The preliminary effect was measured on occupational performance (Canadian Occupational Performance Measure), concussive symptoms (Neurobehavioral Symptom Inventory), sleep (Pittsburgh Sleep Quality Inventory), vision (College of Optometrists in Vision Development–Quality of Life Outcomes Assessment), and cognition outcomes (Dysexecutive Questionnaire, Weekly Calendar Planning Activity, and National Institutes of Health Toolbox Cognition Battery).

Results: Acceptable recruitment (32%), retention (93%), and adherence rates (100%) were observed, along with a high level of acceptability to participants. Large intervention effects were present for occupational performance, general concussive symptoms, and cognitive functioning.

Conclusions and Relevance: Findings suggest that the CO-OP is feasible to administer for adults with postconcussive symptoms and perceived as suitable for the needs of this population. Feasibility findings, coupled with improvements in occupational performance outcomes, provide the foundation for a future larger scale trial.

Plain-Language Summary: The Cognitive Orientation to daily Occupational Performance intervention is practical to use to address the functional impact of persistent concussive symptoms in adults. Further research is needed to evaluate the efficacy of the CO-OP intervention with this population.

The Cognitive Orientation to daily Occupational Performance intervention is practical to use to address the functional impact of persistent concussive symptoms in adults.

Importance: Stroke is the leading cause of long-term disability in the United States. Providers have no robust tools to objectively and accurately measure the activity of people with stroke living at home.

Objective: To explore the integration of validated upper extremity assessments poststroke within an activity recognition system.

Design: Exploratory descriptive study using data previously collected over 3 mo to report on algorithm testing and assessment integration.

Setting: Data were collected in the homes of community-dwelling participants.

Participants: Participants were at least 6 mo poststroke, were able to ambulate with or without an assistive device, and self-reported some difficulty using their arm in everyday activities.

Outcomes and Measures: The activity detection algorithm’s accuracy was determined by comparing its activity labels with manual labels. The algorithm integrated assessment by describing the quality of upper extremity movement, which was determined by reporting extent of reach, mean and maximum speed during movement, and smoothness of movement.

Results: Sixteen participants (9 women, 7 men) took part in this study, with an average age of 63.38 yr (SD = 12.84). The algorithm was highly accurate in correctly identifying activities, with 87% to 95% accuracy depending on the movement. The algorithm was also able to detect the quality of movement for upper extremity movements.

Conclusions and Relevance: The algorithm was able to accurately identify in-kitchen activities performed by adults poststroke. Information about the quality of these movements was also successfully calculated. This algorithm has the potential to supplement clinical assessments in treatment planning and outcomes reporting.

Plain-Language Summary: This study shows that clinical algorithms have the potential to inform occupational therapy practice by providing clinically relevant data about the in-home activities of adults poststroke. The algorithm accurately identified activities that were performed in the kitchen by adults poststroke. The algorithm also identified the quality of upper extremity movements of people poststroke who were living at home.

This study shows that clinical algorithms have the potential to inform occupational therapy practice by providing clinically relevant data about the in-home activities of adults poststroke.

Importance: Identity disruption and occupational identity disruption are common after traumatic brain injury (TBI), but the relationship between these two phenomena is underexplored. Occupational therapy practitioners should be knowledgeable about identity challenges after TBI and ways to reconstruct a sense of self.

Objective: To sensitize readers to the experience of identity disruption and occupational identity disruption and describe how those two experiences are interrelated and transactional in nature.

Design: We completed an autoethnography, because this method privileges the insider perspective of participants as members of the research team. We interviewed Andi’s family and friends, with textual and nontextual data being reviewed during team meetings that occurred 3 times per month over 3 yr. Data were analyzed by hand-coding transcripts to organize findings until we identified themes and salient text for constructing a narrative.

Setting: Community.

Participants: TBI survivor.

Results: Identity disruption after TBI occurs because of physiological difficulties, psychological changes, and cognitive deficits. Additionally, survivors face interruptions in occupational participation that affect their identity as doers. Andi experienced identity disruption that was exacerbated by being unable to engage in written expression. When he was able to resume writing and regain his occupational identity, Andi was able to reconstruct his sense of self.

Conclusions and Relevance: Identity is created by occupational engagement. Occupational therapy practitioners can better serve their clients by exploring identity disruption and occupational identity disruption after TBI.

Plain-Language Summary: This article describes the lived experience of identity disruption and occupational identity disruption with an emphasis on the transformative nature of occupation. Occupational therapists should work collaboratively with clients to identify key occupations that support their sense of identity.

This article describes the lived experience of identity disruption and occupational identity disruption with an emphasis on the transformative nature of occupation.

Importance: Handedness and motor asymmetry are important features of occupational performance. With an increased understanding of the basic neural mechanisms surrounding handedness, clinicians will be better able to implement targeted, evidence-based neurorehabilitation interventions to promote functional independence.

Objective: To review the basic neural mechanisms behind handedness and their implications for central and peripheral nervous system injury.

Data Sources: Relevant published literature obtained via MEDLINE.

Findings: Handedness, along with performance asymmetries observed between the dominant and nondominant hands, may be due to hemispheric specializations for motor control. These specializations contribute to predictable motor control deficits that are dependent on which hemisphere or limb has been affected. Clinical practice recommendations for occupational therapists and other rehabilitation specialists are presented.

Conclusions and Relevance: It is vital that occupational therapists and other rehabilitation specialists consider handedness and hemispheric lateralization during evaluation and treatment. With an increased understanding of the basic neural mechanisms surrounding handedness, clinicians will be better able to implement targeted, evidence-based neurorehabilitation interventions to promote functional independence.

Plain-Language Summary: The goal of this narrative review is to increase clinicians’ understanding of the basic neural mechanisms related to handedness (the tendency to select one hand over the other for specific tasks) and their implications for central and peripheral nervous system injury and rehabilitation. An enhanced understanding of these mechanisms may allow clinicians to better tailor neurorehabilitation interventions to address motor deficits and promote functional independence.

This rapid review examines the basic neural mechanisms behind handedness and their implications for central and peripheral nervous system injury and rehabilitation.

Importance: Acquired brain injury (ABI) may result in deficits in executive function (EF), which affects engagement in occupations.

Objective: To explore the impact of group yoga on EF in people with ABI.

Design: Single-arm pilot study with preyoga assessments and postyoga assessments (after 8 wk of yoga).

Setting: Yoga classes and assessments were completed within university buildings on a college campus.

Participants: Twelve participants with chronic ABI (>6 mo post-ABI) were recruited through convenience and purposive strategies from the local community.

Intervention: An 8-wk adaptive group yoga intervention was provided by an adaptive yoga specialist. Yoga classes were 60 min and occurred once per week.

Outcomes and Measures: EF was assessed before and after the yoga intervention using the Behavior Rating Inventory of Executive Function—Adult Version (BRIEF–A) self-report form. Normative data were analyzed with paired sample t tests.

Results: Nine participants completed all study procedures. Results from paired sample t tests showed significant improvements on the Behavioral Regulation Index of the BRIEF–A (p = .046). No significant improvements were found on individual EF scales, the Metacognition Index, or the Global Executive Composite (ps > .05).

Conclusions and Relevance: Group-based yoga may improve some aspects of EF for adults with chronic ABI; however, further research with larger sample sizes is needed.

Plain-Language Summary: Yoga, an intervention increasingly used in occupational therapy practice, may be beneficial in improving behavioral regulation (an executive function) for adults with acquired brain injury.

Group yoga may improve behavioral regulation for adults with acquired brain injury.

Importance: Spatial neglect (SN)—failure to respond to stimuli on the side of the body contralateral to a poststroke lesion—is one of the most disabling impairments for stroke survivors, and 80% of stroke survivors may have undetected SN. Occupational therapists’ evaluations should include determining the impact of poststroke SN.

Objective: To investigate occupational therapists’ confidence, knowledge, current practices, barriers, and facilitators when assessing for SN in adult stroke survivors.

Design: A 30-item survey was created with guidance from stroke rehabilitation occupational therapists who reviewed the survey for face and content validity.

Setting: Online survey.

Participants: Occupational therapist survey responders (N = 76).

Outcomes and Measures: Self-report assessments were used to measure occupational therapists’ confidence in identifying SN, SN assessment practices, and barriers to and facilitators of SN assessment. Knowledge of SN signs and symptoms, neuroanatomy, and clinical presentation were measured with a three-question quiz.

Results: Eighty-one percent of the respondents reported a high level of confidence in identifying SN, and 70% reported routinely assessing for SN, with 81% using clinical observation rather than standardized tools as the primary assessment method. Barriers to SN assessment included time and resources.

Conclusions and Relevance: Most respondents, despite reporting high levels of confidence with routine SN assessments, did not use standardized SN measures and demonstrated suboptimal knowledge of SN. These results emphasize the need to increase clinical education about SN and its assessments.

Plain-Language Summary: This study gathered baseline information on an underinvestigated topic—occupational therapists’ education, confidence, current practices, barriers, and facilitators when assessing for spatial neglect in adult stroke survivors. The study results also contribute to future research on occupational therapists’ current confidence and knowledge when assessing for spatial neglect.

This study gathered baseline information on an underinvestigated topic—occupational therapists’ education, confidence, current practices, barriers, and facilitators when assessing for spatial neglect in adult stroke survivors.

Importance: Occupational therapy practitioners use yoga in practice to achieve holistic care, and the American Occupational Therapy Association has provided guidance on the use of yoga in occupational therapy. For people with acquired brain injury (ABI), however, it is unknown whether yoga affects occupational performance.

Objective: To explore the perceived impact of an adapted yoga intervention on occupational performance using the Occupational Therapy Practice Framework: Domain and Process (4th ed.; OTPF–4) for participants with ABI.

Design: Qualitative descriptive study using virtual, semistructured interviews. An inductive, holistic, open-coding process, followed by a deductive process to map open codes to the OTPF–4.

Participants: Nine individuals with ABI were recruited from a yoga intervention study.

Results: The theme generated from the data—“Yoga participants with ABI realized that they could still do quite a bit”—was supported by two major categories from the OTPF–4: Occupations and Performance Skills. Participants described improvements in their functional performance (i.e., motor skills, process skills) and how these factors were synergistically connected to their occupational performance (i.e., self-care, leisure).

Conclusions and Relevance: This study provides novel insight into how functional performance improved so participants could “still do things,” such as engaging in occupations. When participants described improved performance skills, they simultaneously described re-engagement with their meaningful occupations. Participants also perceived an improvement in their mind–body connection, which should be further explored in future studies. This study generated original findings about participants’ perceptions of an adapted yoga intervention as they relate to the OTPF–4.

Plain-Language Summary: This study reports individuals’ perceptions of their re-engagement with occupations and changes in occupational performance skills after participating in an adaptive yoga intervention. We highlight the distinct contribution that adaptive yoga—an intervention modality that can be used by occupational therapy practitioners—may have, using the OTPF–4 to connect the participants’ perceptions about their improvements in occupational performance.

This study reports individuals’ perceptions of their re-engagement with occupations and changes in occupational performance skills after participating in an adaptive yoga intervention.

Importance: Reablement is a person-centered and goal-oriented rehabilitative intervention to optimize people’s chances to live independently.

Objective: To investigate the effects of a reablement intervention on performance of instrumental activities of daily living (IADLs) in three aspects (i.e., actual performance, ability, and self-perceived difficulty) for patients with stroke.

Design: A single-blinded, randomized crossover study.

Setting: Participants’ home and community.

Participants: Twenty-seven patients with stroke.

Interventions: Each participant received two interventions (IADL reablement and health education). Each intervention was administered for 6 wk. All participants were randomly assigned to one intervention and then received the other intervention after a 4-wk washout period.

Outcomes and Measures: Outcomes of actual performance and self-perceived difficulty were derived from the Frenchay Activities Index (FAI) and the difficulty dimension of the Participation Measure–3 Domains, 4 Dimensions (PM–3D4D), respectively. Outcomes of ability were measured with the Lawton Instrumental Activities of Daily Living Scale (LIADL) and the Canadian Occupational Performance Measure Performance score (COPM Performance).

Results: No statistically significant differences were found in the three aspects between the IADL reablement and health education (ps = .148–.570). Compared with the health education, the IADL reablement showed better improvements on the FAI, LIADL, COPM Performance, and difficulty dimension of the PM–3D4D with trivial to small effect sizes (ds = 0.17–0.45).

Conclusions and Relevance: Our results reveal that the IADL reablement has the potential to increase the frequency of IADL administration, enhancing the capability to perform IADLs and reducing the self-perceived difficulty of carrying out IADLs.

Plain-Language Summary: The results of this study showed positive outcomes for a reablement intervention that focuses on goal-oriented instrumental activities of daily living for patients with stroke. An IADL reablement intervention may be useful for improving the ability to carry out IADL tasks at home and in the community.

The results of this study showed positive outcomes for a reablement intervention that focuses on goal-oriented instrumental activities of daily living for patients with stroke.

Importance: Although cross-sectional studies have reported the relationships among performance of activities of daily living (ADLs), income satisfaction, and health satisfaction, longitudinal associations in stroke survivors remain unclear.

Objective: To examine the effects of ADL function and income satisfaction on health satisfaction over time in stroke survivors.

Design: Retrospective longitudinal study designs with latent growth curve models (LGMs) to control for time-varying and time-invariant covariates.

Setting: Community.

Participants: A total of 198 stroke survivors.

Outcomes and Measures: Self-reported ADL performance, income satisfaction, and health satisfaction.

Results: The average age of participants was 70.68 yr (SD = 8.09; 107 men, 91 women). Each LGM showed that an increase in ADL score (standardized β = 0.116∼0.296, all ps < .05) and income satisfaction (standardized β = 0.513∼0.726, all ps < .001) positively predicted health satisfaction over time, even after controlling for time-varying annual income, demographics, and behavioral characteristics. The fit results of all LGMs were within the acceptable range: χ²(47) = 66.378, p = .0327; χ²(47) = 57.742, p = .1355; root-mean-square error of approximation, <0.08; comparative fit index and Tucker–Lewis index, >0.90; standardized root-mean-square residual, <0.05.

Conclusions and Relevance: Because ADLs are significant modifiable health satisfaction factors, occupational therapy practitioners would need to focus more closely on ADL training in clinical settings. Furthermore, referring those clients to appropriate vocational rehabilitation to improve their income satisfaction would be necessary.

Plain-Language Summary: This study recognizes the unique challenges and opportunities that arise when stroke survivors are preparing to return to their communities by emphasizing the significance of ADL training and income satisfaction during this stage of recovery. The study suggests that the therapeutic use of ADL training and income satisfaction could increase health satisfaction for stroke survivors. Therefore, comprehensive ADL training, as an occupational therapy intervention, could be crucial for stroke survivors who are preparing to return to their community from a clinical setting. Furthermore, connecting with vocational rehabilitation could also be important for improving income satisfaction for stroke survivors who are preparing to return to a community.

As an occupational therapy intervention, comprehensive ADL training could be crucial for stroke survivors who are preparing to return to their community from a clinical setting.

Importance: Research on the functional and motor performance impact of virtual reality (VR) as an intervention tool for children with cerebral palsy (CP) is limited.

Objective: To understand whether VR is an effective intervention to improve upper extremity (UE) function and motor performance of children diagnosed with CP.

Data Sources: Databases used in the search were EBSCOhost, One Search, PubMed, Cloud Source, CINAHL, SPORTDiscus, and Google Scholar.

Study Selection and Data Collection: Studies published from 2006 to 2021 were included if children had a diagnosis of CP and were age 21 yr or younger, VR was used as an intervention, and measures of UE function and motor performance were used.

Findings: Twenty-one studies were included, and the results provided promising evidence for improvements in areas of UE function, motor performance, and fine motor skills when VR is used as an intervention. To yield noticeable UE improvements in children with CP, VR should be implemented for 30 to 60 min/session and for at least 360 min over more than 3 wk. Additional areas of improvement include gross motor skills, functional mobility, occupational performance, and intrinsic factors.

Conclusions and Relevance: The use of VR as an intervention for children with CP to improve UE function and motor performance is supported. More randomized controlled trials with larger sample sizes focusing on similar outcomes and intervention frequencies are needed to determine the most effective type of VR for use in clinical occupational therapy.

Plain-Language Summary: This systematic review explains how virtual reality (VR) has been used as an intervention with children with cerebral palsy (CP). The review synthesizes the results of 21 research studies of children who had a diagnosis of CP and who were 21 years old or younger. The findings support using VR to improve upper extremity performance, motor performance, and fine motor skills. The findings also show that occupational therapy practitioners should use a VR intervention at a minimum frequency of 30 to 60 minutes per session and for at least 360 minutes over more than 3 weeks to yield noticeable improvements in upper extremity, motor performance, and fine motor skills for children with CP.

This systematic review explains how virtual reality (VR) as an intervention has been used with children with cerebral palsy. The findings include a recommended minimum frequency for VR to be used in occupational therapy to yield noticeable improvements in upper extremity function and motor performance.

Importance: Little is known about how and to what extent persistent concussive symptoms affect occupational performance in adults.

Objective: To evaluate the impact of persistent postconcussive symptoms on occupational performance.

Design: A cross-sectional study design was used in which the occupational performance needs of adults with persistent concussion symptoms were identified by a trained occupational therapist via semistructured interview.

Setting: University research space.

Participants: Adults ages 18 to 60 yr experiencing persistent concussion symptoms.

Outcomes and Measures: Occupational performance was evaluated using the Canadian Occupational Performance Measure. Data were then categorized by two researchers using the Occupational Therapy Practice Framework: Domain and Process (4th ed.).

Results: The most commonly affected occupational performance areas included education and work, social participation, and performance of instrumental activities of daily living.

Conclusions and Relevance: Aligning with prior knowledge of the impact of psychosocial difficulties and higher order cognitive deficits on daily life, performance of complex occupations is heavily affected in adults with persistent concussive symptoms.

Plain-Language Summary: The functional impact of symptoms that adults experience postconcussion becomes apparent as they return to their life occupations. The results of this study showed that adults with persistent concussive symptoms more commonly experienced occupational challenges with participation in education, social activities, and the performance of instrumental activities of daily living, with subtle, important variations in symptoms across adults. Detailed, client-centered evaluation of occupational performance changes postconcussion is an area of potential growth for occupational therapy practice and research.

The study results showed that the most commonly affected occupational performance areas for adults with persistent concussion symptoms included education and work, social participation, and the performance of instrumental activities of daily living.

Importance: Unilateral spatial neglect (neglect) poststroke is disabling. It is critical that people with neglect are identified so that treatment can be provided to maximize independence. However, there is some evidence to suggest that existing assessments may not adequately measure neglect. It is unclear whether assessments also fail to identify people with neglect entirely.

Objective: To determine whether there are stroke survivors who self-report neglect symptoms that are not detected by therapist-rated assessments and to compare self-report and therapist-ratings.

Design: Cross-sectional study.

Setting: U.S. university research center.

Participants: Unilateral stroke survivors (N = 133).

Intervention: Not applicable.

Outcomes and Measures: The Catherine Bergego Scale (CBS) was administered to participants and scored by a trained occupational therapist. The parallel self-evaluation anosognosia form was also administered to participants to self-report and rate neglect symptoms.

Results: Forty-eight participants (36.1%) were classified as without neglect on the basis of therapist-rated total CBS scores, yet 30 (62.5%) of these 48 participants reported symptoms of neglect on the CBS self-evaluation anosognosia form. There was a significant difference (p < .001) between therapist-rated and self-rated total CBS scores.

Conclusions and Relevance: Our results indicate that many stroke survivors report some level of disability associated with neglect yet do not meet the criteria to be classified as having neglect according to a commonly used therapist-rated performance-based measure.

Plain-Language Summary: The findings of this study contribute to the evidence that existing assessments used by occupational therapists to measure performance-based neglect may not always detect neglect symptoms comprehensively in people poststroke. The finding also suggest that we may be missing neglect symptoms entirely. Occupational therapists should consider using various methods to assess for neglect, including patient self-report and comprehensive occupational profiles. Clinicians should also thoroughly screen all clients with stroke for neglect, regardless of lesion location.

The study findings contribute to the evidence that existing assessments used by occupational therapists to measure performance-based neglect may not always detect neglect symptoms comprehensively in people poststroke. The finding also suggest that we may be missing neglect symptoms entirely.

Importance: Complex telehealth interventions can facilitate remote occupational therapy services and improve access for people living with chronic neurological conditions. Understanding the factors that influence the uptake of these technologies is important.

Objective: To explore the fit between electromyography (EMG) biofeedback and telerehabilitation for stroke survivors, optimize EMG biofeedback interventions, and, more broadly, support other efforts to develop complex telerehabilitation interventions.

Design: Pre-implementation mixed-methods analysis of usability and acceptability data collected during a pilot and feasibility study.

Setting: Community.

Participants: Adult stroke survivors with hemiparesis (N = 11; M age = 54 yr).

Intervention: Game-based EMG biofeedback system for arm sensorimotor rehabilitation, delivered via telehealth.

Outcomes and Measures: Post-Study System Usability Questionnaire, an extended Unified Theory of Acceptance and Use of Technology model questionnaire, and semistructured interview. We coded the interview data using questionnaire constructs.

Results: Participants used an EMG biofeedback intervention at home. Quantitative measures show high levels of perceived usability and acceptability, supported by qualitative findings describing specific facilitators and barriers.

Conclusions and Relevance: Pre-implementation studies can improve the design and relevance of complex telehealth interventions. One major conclusion from this study is the influence of therapy providers on acceptability and usability of complex telehealth interventions.

Plain-Language Summary: This study contributes to an emerging body of literature that examines the use of complex telehealth interventions with survivors of neurological injury. The findings highlight the value and support the development and use of complex telehealth interventions, which have the potential to improve remote access to occupational therapy for clients living with chronic neurological conditions. Complex telehealth interventions can open doors for survivors of neurological injury who face barriers to accessing occupational therapy and would benefit from technology-enabled therapy at home.

The study findings highlight the value and support the development and use of complex telehealth interventions, which have the potential to improve remote access to occupational therapy for clients living with chronic neurological conditions.

Importance: Spinal cord stimulation (SCS) is a neuromodulation technique that can improve paresis in individuals with spinal cord injury. SCS is emerging as a technique that can address upper and lower limb hemiparesis. Little is understood about its effectiveness with the poststroke population.

Objective: To summarize the evidence for SCS after stroke and any changes in upper extremity and lower extremity motor function.

Data Sources: PubMed, Web of Science, Embase, and CINAHL. The reviewers used hand searches and reference searches of retrieved articles. There were no limitations regarding publication year.

Study Selection and Data Collection: This review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. The inclusion and exclusion criteria included a broad range of study characteristics. Studies were excluded if the intervention did not meet the definition of SCS intervention, used only animals or healthy participants, did not address upper or lower limb motor function, or examined neurological conditions other than stroke.

Findings: Fourteen articles met the criteria for this review. Seven studies found a significant improvement in motor function in groups receiving SCS.

Conclusions and Relevance: Results indicate that SCS may provide an alternative means to improve motor function in the poststroke population.

Plain-Language Summary: The results of this study show that spinal cord stimulation may provide an alternative way to improve motor function after stroke. Previous neuromodulation methods have targeted the impaired supraspinal circuitry after stroke. Although downregulated, spinal cord circuitry is largely intact and offers new possibilities for motor recovery.

The results of this scoping review show that spinal cord stimulation may provide an alternative way to improve motor function after stroke.

Importance: Transitioning from the hospital to the community poses significant challenges for stroke survivors and their caregivers.

Objective: To examine the feasibility and preliminary effects of a dyad-focused strategy training intervention.

Design: Single-arm trial with data collection at baseline, postintervention, and 3-mo follow-up.

Setting: Rehabilitation settings in Taiwan.

Participants: Sixteen stroke survivor–caregiver dyads.

Interventions: Dyad-focused strategy training was provided to stroke survivor–caregiver dyads twice a week over 6 wk. The training included shared decision-making, goal setting, performance evaluation, strategy development and implementation, and therapeutic guided discovery.

Outcomes and Measures: Feasibility indicators were Goal Attainment Scaling, Dyadic Relationship Scale, Participation Measure–3 Domains, 4 Dimensions, Activity Measure for Post-Acute Care, Montreal Cognitive Assessment, Trail Making Test, Stroop Color and Word Test, Preparedness for Caregiving Scale, and Zarit Burden Interview.

Results: In total, 15 dyads completed all intervention sessions with full attendance. Both stroke survivors and their caregivers demonstrated high engagement and comprehension and reported moderate to high satisfaction with the intervention. From baseline to postintervention, the effects on goal attainment, frequency and perceived difficulty of community participation, executive function, mobility function, and caregiver preparedness were significant and positive.

Conclusions and Relevance: Our study supports the feasibility and preliminary efficacy of dyad-focused strategy training for stroke survivor–caregiver dyads transitioning from the hospital to the community in Taiwan. Our preliminary evidence indicates that dyads who receive strategy training exhibit advancement toward their goals and experience considerable enhancements in their individual outcomes.

Plain-Language Summary: This study addresses the scarcity of interventions catering to both stroke survivors and their caregivers. By demonstrating the feasibility of our dyad-focused intervention, the research offers preliminary evidence that supports the potential advantages of involving both stroke survivors and their caregivers in the intervention process.

This study offers preliminary evidence that supports the potential advantages of involving both stroke survivors and their caregivers in a dyad-focused intervention process.

Importance: Although the cardiopulmonary benefits of aerobic exercise poststroke are well-established, typical stroke rehabilitation does not elicit an aerobic response.

Objective: To characterize heart rate response during upper extremity repetitive task practice (RTP) and determine factors that predict a higher aerobic intensity during RTP.

Design: Secondary analysis of a subset of data from a randomized clinical trial.

Setting: Research laboratory in a large academic medical center.

Participants: Patients with chronic stroke (N = 19).

Intervention: Participants received 90 min of RTP for 24 sessions across 8 wk.

Outcomes and Measures: Aerobic intensity as measured by heart rate reserve (HRR) during RTP.

Results: A total of 2,968 tasks were included in the analysis. Of the tasks performed, approximately 79.5% elicited a very light aerobic response (<30% HRR), 10.2% elicited a light aerobic response (30%–39% HRR), and 10.3% elicited a moderate to vigorous intensity aerobic response (≥40% HRR). Of the tasks that elicited a moderate to vigorous intensity aerobic response, 54.1% were performed in standing, 79.7% were gross motor in nature, and 27.9% had targets at or above shoulder height. Standing position, targets at or above shoulder height, and gross motor tasks predicted higher HRR (all ps < .001).

Conclusions and Relevance: To maximize aerobic intensity during poststroke RTP, therapists should include gross motor tasks trained in standing with targets at or above shoulder height.

Plain-Language Summary: The study characterizes heart rate response in stroke rehabilitation and identifies factors that predict a higher aerobic intensity during upper extremity repetitive task practice. Certain task characteristics were more likely to produce an aerobic response, including gross motor, targets at or above the shoulder, and a standing position. Occupational therapists should include gross motor tasks trained in standing with targets at or above shoulder height to maximize aerobic intensity during poststroke repetitive task practice. Monitoring heart rate may improve awareness of aerobic response to training.

The study findings show that occupational therapists should include gross motor tasks trained in standing with targets at or above shoulder height to maximize aerobic intensity during poststroke repetitive task practice.

Importance: Current interventions are limited in improving use of the more-affected upper limb in real-world daily occupations and functional independence poststroke. A comprehensive understanding of the factors influencing real-world upper limb use is required to develop interventions to improve functional independence poststroke.

Objective: To systematically review the factors that influence real-world use of the more-affected upper limb poststroke.

Data Sources: We searched MEDLINE, Embase, PsycINFO, and the Physiotherapy Evidence Database for English-language articles from 2012 to 2023.

Study Selection and Data Collection: Of 774 studies, we included 33 studies that had participants at least age 18 yr who exhibited upper limb impairments poststroke, objectively measured real-world upper limb use using a movement sensor, and measured factors affecting upper limb use. Two reviewers independently screened the abstracts.

Findings: The results were categorized by International Classification of Functioning, Disability and Health domains. Prominent factors were upper limb impairment; motor ability; functional independence; task type; hand dominance; stroke-related factors, including time since stroke; and perception of use of the more-affected upper limb.

Conclusions and Relevance: Existing interventions primarily focus on upper limb impairments and motor ability. Our findings suggest that interventions should also incorporate other factors: task type (unilateral vs. bilateral), hand dominance, self-efficacy, and perception of more-affected limb use as active ingredients in improving real-world use of the more-affected upper limb poststroke. We also provide recommendations to use behavioral activation theory in designing an occupation-focused intervention to augment self-efficacy and confidence in use of the more-affected upper limb in daily occupations.

Plain-Language Summary: In order to develop interventions to improve functional independence poststroke, occupational therapy practitioners must have a comprehensive understanding of the factors that influence real-world more-affected upper limb use. The study findings provide a set of distinct factors that practitioners can target separately or in combination to improve real-world use of the more-affected upper limb poststroke.

The study findings identify factors that occupational therapy practitioners can target separately or in combination to improve real-world use of the more-affected upper limb poststroke.

Health professionals across all care delivery settings, including occupational therapy practitioners, are experiencing high levels of moral distress. The mental, emotional, and physical consequences of unresolved moral distress are resulting in burnout, decreased quality of care, and poor patient outcomes. Moral resilience is a teachable and learnable skill that can nullify some of the adverse consequences of moral distress. To ensure quality care outcomes and improve the well-being of individual occupational therapy practitioners and the profession, it is essential that occupational therapy practitioners be provided with the education, training, resources, and strategies needed to address moral distress, foster moral resilience, and cultivate the skills necessary to cope with ethical tensions. In this column, we call the profession to action to address the phenomenon of moral distress as it relates to occupational therapy practitioner well-being. We also discuss resources and strategies for addressing ethical tensions and building moral resilience in occupational therapy practice.

The authors assert a call to action for the profession to address the moral distress related to the well-being of practitioners and discuss resources and strategies for building moral resilience in occupational therapy practice.

Evidence Connection articles provide a clinical application of systematic reviews developed in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Project. Each article in this series summarizes the evidence from published reviews on a given topic and presents an application of the evidence to a related clinical case. Evidence Connection articles illustrate how the research evidence from the reviews can be used to inform and guide clinical decision-making. In this Evidence Connection article, we provide a case report of a caregiver of a patient who had experienced a stroke. The occupational therapy evaluation and intervention process is described.

This Evidence Connection article provides a case report for a caregiver of a patient who had experienced a stroke and describes the occupational therapy evaluation and intervention process.