Occupational Therapy Activities and Intervention Techniques for Clients With Stroke in Six Rehabilitation Hospitals

Nancy K. Latham, Diane U. Jette, Wendy Coster, Lorie Richards, Randall J. Smout, Roberta A. James, Julie Gassaway, Susan D. Horn

OBJECTIVE. To prospectively monitor occupational therapy activities and intervention techniques used during inpatient stroke rehabilitation in order to provide a description of current clinical practice. METHODS. Data were collected prospectively from 954 clients with stroke receiving occupational therapy
from six U.S. rehabilitation hospitals. Descriptive statistics summarized frequency, intensity, and duration of occupational therapy sessions; proportion of time spent in 16 therapeutic activities; and proportion of those activities that included any of 31 interventions.

RESULTS. Clients received on average 11.8 days (SD = 7.2) of occupational therapy, with each session lasting on average 39.4 min (SD = 16.9). Upper-extremity control (22.9% of treatment time) and dressing (14.2% of treatment time) were the most frequently provided activities. Interventions provided most frequently during upper-extremity control activities were strengthening, motor learning, and postural awareness.

CONCLUSION. Occupational therapy provided reected an integration of treatment approaches. Upperextremity control and basic activities of daily living were the most frequent activities. A small proportion of sessions addressed community integration.
Latham, N. K., Jette, D. U., Coster, W., Richards, L., Smout, R. J., James, R. A., Gassaway, J., & Horn, S. D. (2006). Occupational therapy activities and intervention techniques for clients with stroke in six rehabilitation hospitals. American Journal of Occupational Therapy, 60, 369378.

Nancy K. Latham, PhD, is Research Assistant Professor, Health and Disability Research Institute, Boston University, 53 Bay State Road, Boston, Massachusetts 02215; nlatham@bu.edu Diane U. Jette, DSc, PT, is Professor and Program Director, Physical Therapy Program, Simmons College, Boston, Massachusetts. Wendy Coster, PhD, OTR, is Associate Professor and Program Director, Therapeutic Studies and Occupational Therapy, Boston University, Boston, Massachusetts. Lorie Richards, PhD, OTR, is Research Health Scientist, Veterans Affairs Research Service at the Brain Rehabilitation Research Center, North Florida/South Georgia Department of Veterans Affairs Medical Center, Gainesville, Florida; and Associate Professor, Occupational Therapy Department, University of Florida, Gainesville, Florida. Randall J. Smout, MS, is Senior Analyst, International Severity Information Systems, Inc., Salt Lake City, Utah. Roberta A. James is Data Systems Specialist, International Severity Information Systems, Inc., Salt Lake City, Utah. Julie Gassaway, MS, RN, is Director of Project/Product Development, International Severity Information Systems, Inc., Salt Lake City, Utah. Susan D. Horn, PhD, is Vice President for Research, International Severity Information Systems, Inc., Salt Lake City, Utah.

troke is the third largest cause of death and one of the leading causes of longterm disability in the United States (Centers for Disease Control and Prevention, 2000). Signicant progress has been made in stroke care over the past 30 years and as a result the proportion of people who survive a stroke has increased (Centers for Disease Control and Prevention, 2000). It is now well established that differences in post-stroke care and rehabilitation have a signicant effect on outcome, with one systematic review nding that clients who received organized inpatient care in a stroke unit were more likely to be alive, independent, and living at home 1 year after the stroke (Stroke Unit Trialists Collaboration, 2003). However, despite evidence that post-stroke care inuences outcomes, the ideal activities or approaches to treatment that should be included in stroke rehabilitation are still not well established (Wade & de Jong, 2000). Occupational therapists play an important role in post-stroke rehabilitation. The National Board for Certication in Occupational Therapy (NBCOT) Practice Analysis reported that cerebrovascular accident was the most frequent diagnosis seen by their survey respondents (NBCOT, 2004). Several recent systematic reviews suggest that occupational therapy after a stroke improves the performance of some functional tasks and reduces some impairments (Ma & Trombly, 2002; Steultjens et al., 2003; Trombly & Ma, 2002). However, most trials provide few details about the range of occupational therapy interventions and activities that were used across the rehabilitation episode. Few observational studies exist that describe the nature of occupational therapy interventions currently being used for stroke rehabilitation in the United States. Most studies to date have been conducted in countries outside the United States (Alexander, Bugge, & Hagen, 2001; Ballinger, Ashburn, Low, & Roderick, 1999;
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deWeerdt et al., 2000); have described treatment activities only in terms of duration or frequency (Alexander et al., 2001; Bernhardt, Dewey, Thrift, & Donnan, 2004; Sulch, Perez, Melbourn, & Karla, 2000); or have involved a limited number of clients (Ballinger et al., 1999; deWeerdt et al., 2000). The Practice Analysis (NBCOT, 2004) reports the frequency with which entry-level practitioners use specic interventions, but does not break these down by client condition and surveyed therapists only within the rst 3 years of their practice. Given the limitations of reported studies and a lack of information about how clients with stroke are treated by occupational therapists in the United States, we undertook a study to describe the care provided by occupational therapists for clients with stroke in six hospital-based rehabilitation settings within the United States. Our aim was to describe the occupational therapy plan of care by describing the types of therapeutic activities that therapists used with each client. We dened therapeutic activities as whole tasks that were the focus of a therapy session. In addition, we wished to capture the intervention techniques that the occupational therapists used during each of these activities. We dened intervention techniques as specic treatment approaches used by occupational therapy practitioners to facilitate activities. Finally, we collected data about the duration, frequency, and intensity of occupational therapy sessions, and the personnel who provided them. This information complements and expands information in the NBCOT Practice Analysis (2004), by providing more detailed information about current practice with a specic clinical population by practitioners with a broader range of experience. In addition, it may provide guidance to clinical researchers about important elements of occupational therapy that need to be documented in future studies of rehabilitation outcomes.

al cohort study, a Clinical Practice Improvement approach was used in which detailed client, process, and outcome variables were obtained (Horn, 1997). This study was approved by the institutional review boards at Boston University and at each of the participating hospitals and was classied as exempt because of its observational nature. Nine hundred and fty-four clients met the inclusion criteria, which were a diagnosis code indicating that the person had experienced a stroke (ICD-9-CM of 430438.99), was older than 18 years of age, had a recent stroke (within 1 year of admission) as the reason for admission, and had no interruption in rehabilitation services of greater than 30 days (see Table 1 for client characteristics). The mean age of clients was 66.2 years (SD = 14.2). Men composed 51% of the sample and women 49%. Fiftyseven percent of clients were White, 24% were African American, 4.9% were Asian, and the remaining were of other backgrounds or unknown race. Forty-three percent of clients had left-sided hemiplegia, 43% had right-sided hemiplegia, 10% had bilateral involvement, and the remainder had other types of involvement. A total of 180 occupational therapy staff participated in this study, and of these, 61% were occupational therapists, 38% were occupational therapy assistants, and 1% were students. In the subset of therapists who provided detailed information about their work experience (i.e., 27%), the occupational therapists had an average of 10.3 years of experience (SD = 8.2, range = 132) and the occupational therapy assistants had 8.3 years (SD = 5.6, range = 223). Most occupational therapists or occupational therapy assistants (69%) worked full time (i.e., 40 hr per week). The majority of therapists and assistants had obtained some advanced training in neurology-related or geriatric-related courses in the past 2 years. The most frequently reported

Methods
Subjects As part of the Post-Stroke Rehabilitation Outcomes Project (PSROP), data were collected between March 2001 to August 2003 from consecutive clients with stroke seen at six rehabilitation hospitals in the United States (DeJong et al., 2005). The sites were geographically dispersed (3 in the West, 1 in the Central Mountain region, 1 in the South, and 1 in the East). The facilities were a mixture of freestanding rehabilitation hospitals and rehabilitation units that were linked to acute care hospitals. Physical Medicine and Rehabilitation residents were involved in stroke management in 2 out of 6 of the facilities. For this observation370

Table 1. Client Characteristics

Characteristic Age (years) Mean SD Range Gender % (n) Male Female Race % (n) White African American Asian Other or unknown Impairment % (n) Left hemiplegia Right hemiplegia Bilateral involvement Other N = 954 66 14 1895 51 49 (487) (467)

57.2 (546) 24.0 (229) 4.9 (47) 13.9 (132) 43.6 (416) 43.6 (416) 10.1 (96) 2.7 (26)

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type of training was in neuromuscular interventions (i.e., NDT or neurodevelopmental treatment), in which 59% of respondents said that they had participated during the past 2 years. Instrumentation Forms to record activity and intervention data from each occupational therapy session and denitions for each of these terms were developed with input from occupational therapists involved in care of clients with stroke at each facility participating in the PSROP (DeJong et al., 2004). The data collection forms allowed occupational therapy providers to describe sessions using 16 possible categories of activities. These included Examination/Evaluation and activities to remediate performance skill decits or body structure or function impairments (i.e., Pre-functional, Upper Extremity Control, Sitting Balance/Trunk Control, Transfers, Functional Mobility, Bed Mobility); Activities of Daily Living (ADL: Bathing, Dressing, Grooming, Toileting, Feeding/Eating), and Instrumental Activities of Daily Living (IADL: Home Management, Community Integration, Leisure Performance, Wheelchair Management). Therapists recorded the amount of time spent on each activity with the client in 5-min increments and up to 5 specic intervention techniques (from a list of 31) that they used to facilitate performance of that activity. Options included neuromuscular interventions (7), musculoskeletal interventions (4), cardiopulmonary interventions (2), modality interventions (3), cognitive/perceptual/sensory interventions (4), adaptive and compensatory interventions (4), equipment interventions (i.e., prescription, application, fabrication, and ordering), and education and training interventions (3). Training in the use of assistive devices or equipment during therapy could be recorded under each treatment activity, with a list of 20 devices provided. One category was provided for writing in interventions or equipment not provided on the form. Additional information recorded on each session included: the amount of time spent in evaluation, in cotreatment with other disciplines, and in therapy sessions that included more than one client, as well as which providers gave care during the session, including occupational therapists, occupational therapy assistants, and students (see Figure 1). Procedure One occupational therapist at each site was selected as the lead occupational therapist for this project, and participated in a 90-min train-the-trainer session, which was conducted by project staff. Before this session, each lead occupational therapist received a training manual that contained the occupational therapy intervention documentation
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form, written instructions for completion of the form, and denitions of all terms used on the form. The training manual also contained case studies that provided scenarios of three occupational therapy sessions. A trainers and a trainees copy of each case study were provided. The trainers copy provided instructions and descriptive notes about each case study session, followed by the actual case studies that described an occupational therapy session, including amount of time spent on specic activities and assessments and a completed intervention documentation form. During the train-the-trainer session conducted by project staff with the lead occupational therapists, the project team reviewed the form, instructions, denitions, and care studies in detail. Participants were encouraged to ask questions and discuss possible scenarios that might be raised during their upcoming training sessions with their colleagues at their respective facilities. During each sites internal training sessions (lasting about 60 min), the lead occupational therapy trainer reviewed the intervention documentation form (of which most occupational therapists were familiar because of participation in development efforts), instructions for completing the form, and the denitions of each term used on the form. The trainer then reviewed the rst case scenario with the trainees and described how the intervention documentation form was completed. Individually, trainees then read the second case study and completed the form. The trainer reviewed the second case study with the group and discussed form completion. Trainees then completed the third case scenario and discussed completion of the form. After this training, during the rst month of occupational therapy intervention documentation form use, each sites lead occupational therapist conducted random co-sessions with other therapists. During this time, the lead occupational therapist would observe an occupational therapy session and record it on an intervention documentation form. The therapist providing the treatment session would also complete a form and the two were compared and discussed. The lead occupational therapist continued to serve as a resource person to the other occupational therapists throughout the entire form use period. A member of each sites project team (admitting nurse, medical director, project manager) identied clients to enroll into the study on admission and agged the client chart as being a study patient. Other rehabilitation providers (physicians, therapists [physical, speech, recreational], nurses, social workers) completed their respective project documentation form for each encounter with each enrolled client. Data regarding other client characteristics (e.g., demographics, severity of illness, medications) were collected from clients medical records after their discharge.
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Oc c u p a t i on a l T h e r a p y R e h a b i l i t a t i o n A ct i vi t i e s

Duration of Activity
Enter in 5 minute increments.

Interventions
Enter one intervention code per group of boxes.

ISIS [International Severity Information Systems], Inc., 2003. Reprinted with permission.

Figure 1. Occupational therapy data collection form

Data Analysis Descriptive statistics were used to examine characteristics of clients and characteristics of their episodes of care including length of stay, number of days occupational therapy was provided, number of occupational therapy sessions per day, and intensity of occupational therapy (dened as the number of days occupational therapy was provided divided by the total length of stay). The content of treatment sessions
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was described by determining duration of each session, the proportion of all occupational therapy time spent directed to the activities listed above, and the proportion of those activities that included specic interventions. We examined the proportion of all occupational therapy sessions in which more than one client was treated by a single provider and the proportion of sessions for which occupational therapists, occupational therapy assistants, or students were involved in the care. We also determined combinations of
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activities provided to clients during sessions, the proportion of sessions that included examination or evaluation, and the proportion of clients and families who received an educational intervention.

Results
The mean length of stay for the episode of care was 18.8 days (SD = 10.3, range = 175; see Table 2). Clients received occupational therapy, on average, 11.8 days (SD = 7.2, range = 153) during an episode of care. On days that the clients received occupational therapy, the average number of occupational therapy sessions per day was 1.6 (SD = 0.4, range = 13), and the average time for each session was 39.4 min (SD = 16.9, range = 5240). Seventy percent of the sessions were provided by occupational therapists, 33% by occupational therapy assistants or aides, and 7% by students. The vast majority of the sessions (91%) were provided one-on-one by an occupational therapy provider. Only 5% of sessions consisted of cotreatment with another discipline, and in only 11% of sessions

Table 2. Episode Characteristics

Characteristic Length of rehabilitation hospital stay (days) Mean SD Range Number of days occupational therapy provided Mean SD Range Number of occupational therapy sessions per day Mean SD Range Occupational therapy intensity* Mean SD Range Percentage of total intervention time spent in activity (%) Upper-extremity control Dressing Examination/evaluation Pre-functional Functional mobility Home management Transfer Bathing Grooming Community integration Toileting Sitting balance/trunk control Eating Leisure performance Bed mobility Wheelchair Episodes N = 954 18.8 10.3 175 11.8 7.2 153 1.6 0.4 13 0.64 0.19 0.021.0 22.9 14.2 10.8 9.0 7.1 6.2 6.1 4.6 4.5 3.2 2.8 2.6 2.0 1.9 0.8 0.8

did a group session occur (i.e., more than one client was treated by a single provider). See Table 3. More than 94% of clients had some form of examination or evaluation time recorded, and approximately 7% of sessions included only examination or evaluation. Table 2 gives the percentage time clients spent in each occupational therapy activity. Upper-extremity control (22.9% of total treatment time) and dressing activities (14.2% of total treatment time) were the most frequently used activities, with examination or evaluation (10.8%) and pre-functional activities (9%), the third and fourth most common activities (see Table 3). Upper-extremity control activities were dened as the training or facilitation of normal movement, strength, range of movement, or alignment in the upper extremity. Dressing activities were dened as selecting appropriate clothing and accessories, obtaining clothing from storage area, dressing and undressing in a sequential fashion, and fastening and adjusting clothing, shoes, or personal devices. Pre-functional activities were described as activities that were related to or provided preparation for functional activities. Table 4 provides data on the types of interventions that occupational therapy providers used in each therapeutic activity with their patients. Of a total of 24 types of direct interventions from which providers could choose, 19 interventions were used during at least 5% of the sessions for one or more of the therapeutic activities. All seven educational or equipment provision interventions were used during 5% of sessions for any activity. A wheelchair was the only device used during at least 5% of sessions for any activity. Only 6.5% of patients used a wheelchair during at least one session and it was used primarily in transfer and wheelchair management activities.

Table 3. Session Characteristics

Characteristic Duration of Sessions (min) Mean SD Range Sessions with >1 client % (n) Cotreatment sessions with other healthcare disciplines % (n) Sessions with occupational therapist % (n) Sessions with OTA or aide % (n) Sessions with student % (n) Sessions with >1 occupational therapy provider % (n) Activity combinations during sessions (based on N =18,364) % Evaluation only One activity only Upper-extremity control Dressing Functional mobility Sessions N = 18,359 39.4 16.9 5240 10.8 (1,992) 5 70 32 7 9 (1,006) (12,943) (5,838) (1,234) (1,629)

*Total number of days occupational therapy provided divided by the length of stay in days.

5.6 33.3 16.1 5.5 2.3

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Table 4. Interventions Used To Facilitate Activities

Community Integration % of all sessions that contain intervention 44.5 44.7 42.6 3.6 19.1 2.7 23.6 7.0 10.5 10.6 31.5 7.7 19.4 3.3 2.8 34.9 22.5 11.1 5.6 1.6 1.2 1.5 0.4 30.8 7.9 0.4 4.6 Leisure Performance Home Management Functional Mobility

Upper-Extremity Control

Interventions Neuromuscular Balance training Postural awareness Motor learning PNF NDT Constraint induced therapy Adaptive/Compensatory One-handed skills Energy conservation Environmental adaptation Adaptive equipment Musculoskeletal Strengthening Mobilization/Manual therapy Passive Range of Motion (ROM) Edema control Aerobic exercise Cognitive/Perceptual/Sensory Cognitive therapy Perceptual training Visual training Sensory training Equipment Prescription Application Fabrication Ordering Educational Client education Caregiver education Staff education Devices Used Wheelchair
a

37.6 41.0 42.0 2.6 16.1 1.8 17.1 4.7 5.7 6.9 30.5 9.4 23.8 3.1 3.9 47.7 34.8 24.7 8.0 4.0 2.3 2.4 1.3 34.0 10.6 0.9 3.2

60.5 64.0 43.7 5.7 19.3 3.6 37.2 16.3 28.1 28.2 17.3 3.2 6.4 1.1 2.7 44.6 23.4 8.4 3.1 3.3 1.1 1.6 0.7 30.7 12.7 0.4 7.0

66.1 64.5 54.3 5.4 18.5 3.2 48.8 11.2 14.5 16.7 22.9 4.6 9.4 1.1 2.5 44.5 29.1 11.3 5.1 0.7 1.2 0.8 0.3

62.0 67.9 56.8 7.4 24.6 3.3 47.4 12.7 11.3 11.7 18.8 4.9 9.6 1.4 3.0 49.3 34.2 14.9 5.5 0.6 1.2 1.2 0.3

66.6 64.7 49.6 4.4 22.7 3.8 28.9 12.8 28.6 27.2 22.2 9.7 12.5 3.5 2.6 43.1 27.0 11.6 4.4 2.8 1.5 2.5 1.0 34.0 14.0 0.6 9.1

27.5 48.3 45.5 5.9 14.3 1.6 40.8 10.0 12.7 12.5 14.3 3.8 7.4 1.0 1.8 63.0 40.6 19.6 7.2 0.6 2.8 1.6 0 25.8 8.0 2.1 1.6

76.7 71.2 51.4 1.6 26.5 2.5 29.7 5.5 15.8 18.7 36.6 12.4 22.9 5.5 3.0 30.8 23.7 9.6 5.4 2.5 1.3 2.5 0.3 44.2 12.8 0.5 16.5

73.5 73.9 57.1 1.6 28.6 2.2 40.7 7.1 16.1 16.8 37.9 9.4 24.2 4.2 3.4 35.7 22.7 13.0 4.6 1.4 0.8 2.4 0 42.6 9.5 0.8 16.1

74.8 61.4 45.3 2.3 19.2 3.1 16.2 8.5 13.7 12.3 45.6 9.3 18.6 2.4 5.1 34.3 21.8 11.4 4.8 1.6 0.8 1.5 0.6 40.6 8.3 0.3 6.4

49.0 43.4 37.5 1.9 15.0 2.7 13.6 17.7 18.2 13.0 28.0 4.5 8.2 1.5 3.5 43.6 21.7 12.0 3.8 1.0 0.7 1.5 0.4 43.7 10.8 0.4 2.1

27.8 27.2 24.1 0.8 9.8 1.8 7.5 9.3 13.1 6.1 12.1 2.3 5.0 0.4 2.4 38.8 24.0 14.3 3.4 1.0 0.9 2.0 0.4 60.4 19.2 0.5 2.9

52.4 43.9 39.8 0.3 27.5 1.7 14.6 4.7 10.3 10.0 47.9 5.3 29.8 1.2 3.2 45.6 25.6 14.6 2.9 0 0 2.0 0 43.1 4.7 0.2 2.7

38.7 42.3 51.4 5.4 31.7 4.1 17.8 4.4 7.1 8.3 53.7 16.5 42.5 7.5 3.7 27.5 18.8 10.2 8.0 1.5 1.7 2.1 0.5 34.9 7.6 0.2 4.5

Wheelchair Management 49.7 52.6 55.0 3.3 43.6 2.9 30.7 6.7 20.5 29.2 35.7 20.1 27.0 8.7 7.4 42.1 34.5 15.1 8.7 2.4 2.4 4.9 1.3 60.4 11.1 1.6 26.7

68.9 87.0 46.8 11.8 47.3 2.9 30.0 5.6 4.8 6.0 47.2 12.6 32.7 3.5 3.4 37.4 24.1 10.6 5.0 0.8 1.0 1.3 0.1 36.1 4.1 0.1 2.4

27.3 27.7 4.9 4.5 0.26 0.3 6.6 5.8

Sessions include more than one activity. bPercentages <5% not reported. Note. PNF = proprioceptive neuromuscular facilitation; NDT = neurodevelopmental treatment.

Overall, 97% of patients or their families received some educational intervention and 22.8% of all sessions for all patients included some form of education. Of all the sessions with some form of patient and caregiver education, 28.2% included education related to community integration, 24.2% included education related to home management, and 20.8% included education related to upperextremity control activities. We looked particularly at the interventions used in the most frequent activities cited: upper-extremity control and dressing. Interventions provided most frequently to address upper-extremity control were strengthening (included in 53.7% of sessions for upper-extremity control), motor learning (51.4% of sessions), passive range of motion
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(42.5% of sessions), and postural awareness (42.3% of sessions). In all the sessions that addressed dressing activities, the interventions most frequently provided were balance (included in 66.1% of sessions for dressing activities), postural awareness (64.5% of sessions), motor learning (54.3% of sessions), one-handed skills (48.8% of sessions), and cognitive therapy (44.5% of sessions). These data probably reect the large emphasis placed on regaining sensorimotor skills in this population. A total of 40.2% of therapy time was spent on direct practice of daily life activities, the majority of this time (28.1%) in basic ADL. Clients engaged in the more complex activities of leisure performance, home management, or community integration 12.1% of the time. During
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Sitting Balance

Pre-Functional

Bed Mobility

Grooming

Transfers

Dressing

Toileting

Bathing

Activity

Eating

almost half their time in occupational therapy, clients were engaged in activities that directly targeted remediating performance skill decits or body structure and function impairments (i.e., upper-extremity control, sitting balance, bed mobility, wheelchair, pre-functional, transfers).

Discussion
In this descriptive study of occupational therapy provided to clients during stroke rehabilitation, about 40% of the occupational therapy provided directly targeted life activities (i.e., ADL and IADL), whereas half of the therapy time targeted body function and structure or motor skills that are presumed to underlie functional limitations post-stroke. Upper-extremity tasks and dressing were the most frequently provided activities, and accounted for almost half of the treatment that clients received. Evaluation or examination activities also composed a signicant proportion (10%) of occupational therapy time. In 6% of patients, no evaluation or examination session was documented. It is probable that in many of these cases the therapist did do an evaluation, but the time devoted to this was included under each activity (i.e., a dressing evaluation was recorded under dressing instead of examination or evaluation). When types of activities were compared, there was clearly a greater emphasis on basic ADL, such as dressing, grooming, eating, and toileting than on IADL, such as home maintenance, or on community integration and leisure performance. This focus on more basic activities probably reects the fact that therapy was taking place in a hospital setting with clients who were still in the early rehabilitation phase. In addition, the average length of stay was less than 3 weeks, which could limit the time that is available for more advanced activities. It is interesting to note that, in the Practice Analysis, 65% of therapists reported that dressing was the focus of intervention for more than 25% of their clients (NBCOT, 2004). This percentage was among the ve most frequent interventions listed in that analysis, which covered all practice areas. Occupational therapists reported using a variety of interventions to enable each activity. The most commonly used interventions were neuromuscular interventions, especially balance training, postural awareness, and motor learning; however, adaptive approaches, such as teaching onehanded skills for ADL tasks, were also reported frequently. The therapists were clearly selective in the interventions that they chose to use with each activity, because there was variation in the interventions that were used in each activity. For example, whereas strengthening was used overall in 31.5% of sessions, it was used in more than half (53.7%) of upper-extremity activity sessions but in less than 1/5 (17%)
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of bathing activities. The frequencies for environmental adaptations and use of adaptive equipment also varied by activity, with certain activities (e.g., bathing and toileting) having much higher frequencies than others. These differences likely reect differences in the movement demands of these important hygiene activities, and the extent to which commonly available adaptive equipment such as shower stools may be needed to enable early, safe participation in the activities. There are few current evidence-based guidelines for the provision of intervention to persons with stroke. The Agency for Health Care Policy and Research Guidelines for Post-Stroke Rehabilitation (Gresham et al., 1995) are now outdated and the agency cautions that they should no longer be viewed as guidance for current practice. The most recent update of the National Clinical Guidelines for Stroke published in the United Kingdom (Royal College of Physicians, 2004) includes the general guideline that Emerging evidence is showing advantages of a task-specific training or practice approach over impairment focused approaches. Giving clients the opportunity to practice tasks is a major element in improved outcomes (p. 9). Evidence that supports this general guideline has been presented in two syntheses by Trombly and Ma (Ma & Trombly, 2002; Trombly & Ma, 2002). These authors also present more specic guidelines regarding the conditions under which particular approaches appear to improve outcomes (e.g., that practicing movements with specic goals appears to result in more normalized movement trajectories). However, there is also evidence that some interventions that target body structure and function impairments also contribute to improved rehabilitation outcomes post-stroke. For example, the Royal College of Physicians (2002) guidelines suggest that emerging evidence supports the use of resisted exercise to improve motor function, which suggests that a combination of approaches may lead to successful outcomes. Given these recommendations, it is perhaps noteworthy that a large proportion of occupational therapy time was spent at the body structure and function impairment or performance skill level, and 16% of sessions involved only upper-extremity-control activities. These activities target remediation of performance skill decits and client factors (American Occupational Therapy Association, 2002). A variety of interventions appear to be used in these activities, including balance training (44.5%), motor learning (42.6%), and strengthening (31.5%). Overall, the ndings suggest a shift away from neurofacilitation techniques advocated in the 1960s toward more application of motor control and motor learning approaches. Therapists reported using Brunnstrom techniques (Brunnstrom, 1970) in fewer
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than 2% of sessions, and the percent of sessions in which proprioceptive neuromuscular facilitation (PNF) techniques were used was also low. However, NDT was reported more frequently, with a maximum of 28.6% in bed mobility sessions. A recent analysis of physical therapy intervention with this same sample noted a similar shift in intervention patterns away from facilitation techniques toward application of motor control and motor learning approaches in the context of functional activities (Jette et al., in press). Both cognitive therapy and perceptual training were reported as being used with high frequency during many of the ADL. In the data collection protocol, cognitive therapy is dened as including impulse control, attention, orientation, memory, problem solving, sequencing, social skills, safety, insight, and goal setting, whereas perceptual training includes interventions to address apraxia, neglect, awareness in space, gure ground, and care of sensory impaired body parts (full denitions are available from the rst author of this study). Both of these categories contain a diverse range of approaches, some of which have more supportive evidence than others. Trombly and Ma recommend cognitive approaches such as structured instruction and feedback to improve activity performance (Ma & Trombly, 2002; Trombly & Ma, 2002). Some evidence also supports interventions that involve forced awareness of neglected space (in persons with unilateral neglect), which may be included in the perceptual training category. One limitation of the present study is that we cannot determine more precisely how the reported interventions were applied and the extent to which the applications were consistent with emerging evidence in this area. This applications research would be a valuable area for further investigation. As recommended by current occupational therapy practice guidelines, client education was a signicant intervention component for all activities. As might be expected, this category was the most frequent intervention for sessions that were addressing community integration. Caregiver education was a less frequent intervention for most activities, which is likely explained by the fact that families were not present during the majority of sessions. Nonetheless, caregiver education was a feature of almost 20% of sessions that addressed community integration. Thus, it appears that practitioners are actively engaging both the client and family when discharge with return to community is the focus of treatment. On the downside, only 5% of sessions addressed either community integration or leisure performance. The paucity of time spent in community integration or leisure performance is unfortunate because many persons with stroke have signicant restriction in activities after discharge (Corr & Bayer, 1992) and activity restriction has been shown to be highly related
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to depression (Nieboer et al., 1998; Williamson, 2000; Williamson & Schulz, 1992). Button (2000) found that patients considered that the real rehabilitation was the translation of learning from the rehabilitation context to the home and community context. Although this study provides an initial description of actual occupational therapy practice for persons with stroke, it is important to note several limitations. Most important, we did not have specic information about each clients pattern of impairments, and thus were unable to link the choice of specic interventions to the clients unique prole of difculties. Thus, we were not able to examine variations in practice for persons with similar impairment proles. This study also summarized the activities for all clients across their entire therapy episode. Future analyses might explore whether clients with greater functional abilities or clients who were preparing for discharge participated in more advanced activities. Although the therapists who provided data for this study were trained in the use of data collection forms, and written denitions were provided in the training manual, no specic test of reporting reliability was conducted. Thus, there may have been some degree of misclassication of interventions and activities. However, given the large number of participants and sessions, we do not expect these random errors to have had a large effect on the results. This study provided a broad sketch of current occupational therapy practice for persons with stroke. It suggests an initial framework to describe intervention techniques and activities, from which more rened descriptions may be developed. Without such work to characterize the actual processes of occupational therapy, it will be difcult to conduct more precise examinations of the effectiveness of our services. Such studies are needed in order to identify the specic elements or approaches that lead to better outcomes for persons with stroke.

Conclusion
Occupational therapy provided to clients with stroke at inpatient rehabilitation facilities reected an integration of multiple treatment approaches to facilitate performance of daily activities. The greatest emphasis was on increasing upper-extremity control and improving performance of basic ADL. Most occupational therapy was provided on an individual basis, for an average duration of about 40 min per session, across an average hospital stay of less than 3 weeks. A small proportion of therapy time was spent on leisure and community integration, suggesting the need for occupational therapy services after discharge that address these activities. v
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Acknowledgments
Funding for this project was provided by: The National Institute on Disability & Rehabilitation Research (NIDRR) Grant # H133B990005 establishing the Rehabilitation Research and Training Center on Medical Rehabilitation Outcomes at Sargent College in Boston, Massachusetts, with subcontracts to the Institute for Clinical Outcome Studies in Salt Lake City, Utah; and the NRH Center for Health & Disability Research at the National Rehabilitation Hospital and the MedStar Research Institute in Washington, DC; the U.S. Army & Materiel Command (Cooperative Agreement Award # DAMD17-02-2-0032) establishing the NRH Neuroscience Research Center at the National Rehabilitation Hospital in Washington, DC; the Boston University Aging Research Center; and resources at the North Florida/South Georgia VA Medical Center, Gainesville, Florida. The authors wish to acknowledge the role and contributions of the occupational therapists, occupational therapy assistants, patients, and staff at each of the participating sites in the Post Stroke Rehabilitation Outcomes Project. In particular, the authors wish to acknowledge the contributions of: Alan Jette (Director, Health and Disability Research Institute, Boston University); Brendan Conroy, MD (Stroke Recovery Program, National Rehabilitation Hospital, Washington, DC); Richard Zorowitz, MD (Department of Rehabilitation Medicine, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania); David Ryser, MD (Rehabilitation Department, LDS Hospital, Salt Lake City, Utah); Jeffrey Teraoka, MD (Division of Physical Medicine & Rehabilitation, Stanford University, Palo Alto, California); Frank Wong, MD, and LeeAnn Sims, RN (Rehabilitation Institute of Oregon, Legacy Health Systems, Portland, Oregon); and Murray Brandstater, MD (Loma Linda University Medical Center, Loma Linda, California).

References
Alexander, H., Bugge, C., & Hagen, S. (2001). What is the association between the different components of stroke rehabilitation and health outcomes? Clinical Rehabilitation, 15, 207215. American Occupational Therapy Association. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56, 609639. Ballinger, C., Ashburn, A., Low, J., & Roderick, P. (1999). Unpacking the black box of therapyA pilot study to describe occupational and physiotherapy interventions for people with stroke. Clinical Rehabilitation, 13, 301309. Bernhardt, J., Dewey, H., Thrift, A., & Donnan, G. (2004). Inactive and alone: Physical activity within the rst 14 days of acute stroke unit care. Stroke, 35, 10051009.
The American Journal of Occupational Therapy

Brunnstrom, S. (1970). Movement therapy in hemiplegia: A neurophysiological approach. New York: Harper & Row. Button, C. R. (2000). Living with stroke: A phenomenological study. Journal of Advanced Nursing, 32, 301309. Centers for Disease Control and Prevention. (2000). CDC Fact Book 2000/2001. Atlanta: Author. Corr, S., & Bayer, A. (1992). Poor functional status of stroke patients after hospital discharge: Scope for intervention? British Journal of Occupational Therapy, 55, 383385. DeJong, G., Horn, S. D., Conroy, B., Nichols, D., & Healton, E. B. (2005). Opening the black box of post stroke rehabilitation: Stroke rehabilitation patients, processes and outcomes. Archives of Physical Medicine and Rehabilitation, 86(12), S1S7. DeJong, G., Horn, S. D., Gassaway, J. A., Slavin, M. D., & Dijkers, M. P. (2004). Toward a taxonomy of rehabilitation interventions: Using an inductive approach to examine the black box of rehabilitation. Archives of Physical Medicine and Rehabilitation, 85(4), 678686. deWeerdt, W., Selz, B., Nuyens, G., Staes, F., Swinnen, D., van de Winckel, A., et al. (2000). Time use of stroke patients in an intensive rehabilitation unit: A comparison between a Swiss and Belgian setting. Disability & Rehabilitation, 22(4), 181186. Gresham, G. E., Duncan, P. W., Stason, W. B., Adams, J. H. P., Adelman, A. M., et al. (1995). Post-stroke rehabilitation: Assessment, referral, and patient management. Clinical practice guideline. Rockville, MD: Agency for Health Care Policy and Research (AHCPR), U.S. Department of Health and Human Services. Horn, S. D. (1997). Clinical practice improvement methodology: Implementation and evaluation. Salt Lake City, UT: Faulkner & Gray. Jette, D. U., Latham, N. K., Smout, R. J., Gassaway, J., Slavin, M. D., & Horn, S. D. (2005). Physical therapy interventions for patients with stroke in in-patient rehabilitation facilities. Physical Therapy, 85(3), 238248. Ma, H., & Trombly, C. A. (2002). A synthesis of the effects of occupational therapy for persons with stroke, Part II: Remediation of impairments. American Journal of Occupational Therapy, 56, 260274. National Board for Certication in Occupational Therapy (NBCOT). (2004). National Board for Certication in Occupational Therapy Practice Analysis 2004. Gaithersburg, MD: Author. Nieboer, A. P., Schulz, R., Matthews, K. A., Scheier, M. F., Ormel, J., & Lindenberg, S. M. (1998). Spousal caregivers activity restriction and depression: A model for changes over time. Social Science and Medicine, 47, 13611371. Royal College of Physicians. (2004). National clinical guidelines on stroke. London: Royal College of Physicians. Steultjens, E. M. J., Dekker, J., Bouter, L. M., van de Nes, J. C. M., Cup, E. H. C., & van den Ende, C. H. M. (2003). Occupational therapy for stroke patients: A systematic review. Stroke, 34, 676687. Stroke Unit Trialists Collaboration. (2003). Organised inpatient (stroke unit) care for stroke. Abstract retrieved April 17, 2006, from http://www.cochrane.org/reviews/en/ab000197.html
377

Sulch, D., Perez, I., Melbourn, A., & Karla, L. (2000). Randomized controlled trial of integrated (managed) care pathway for stroke rehabilitation. Stroke, 31(8), 19291934. Trombly, C. A., & Ma, H. (2002). A synthesis of the effects of occupational therapy for persons with stroke, Part I: Restoration of roles, tasks, and activities. American Journal of Occupational Therapy, 56, 250259.

Wade, D. T., & de Jong, B. A. (2000). Recent advances in rehabilitation. British Medical Journal, 320, 13851388. Williamson, G. M. (2000). Extending the activity restriction model of depressed affect: Evidence from a sample of breast cancer patients. Health Psychology, 19, 339347. Williamson, G. M., & Schulz, R. (1992). Pain, activity restriction and symptoms of depression among community-residing elderly adults. Journal of Gerontology, 47, 367372.

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