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The Occupational Therapy Practice Guidelines for Adults With Stroke provide evidence-based recommendations to support occupational therapy practitioners in improving the performance and participation of stroke survivors and their caregivers in daily activities. The guidelines are based on systematic reviews of 168 studies, highlighting effective interventions such as mirror therapy and task-oriented training. These guidelines aim to enhance understanding of occupational therapy's role in stroke rehabilitation and are intended for practitioners, policymakers, and healthcare professionals.

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Occupational Therapy Practice Guidelines for Adults With Stroke

Article in American Journal of Occupational Therapy · October 2023

DOI: 10.5014/ajot.2023.077501

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Practice Guidelines

Occupational Therapy Practice

Guidelines for Adults With Stroke

Importance: Stroke is a leading cause of disability. Occupational therapy practitioners ensure maximum
participation and performance in valued occupations for stroke survivors and their caregivers.

Objective: These Practice Guidelines are meant to support occupational therapy practitioners’ clinical decision
making when working with people after stroke and their caregivers.

Method: Clinical recommendations were reviewed from three systematic review questions on interventions to
improve performance and participation in daily activities and occupations and from one question on maintaining
the caregiving role for caregivers of people after stroke.

Results: The systematic reviews included 168 studies, 24 Level 1a, 90 Level 1b, and 54 Level 2b. These studies
were used as the basis for the clinical recommendations in these Practice Guidelines and have strong or moderate
supporting evidence.

Conclusions and Recommendations: Interventions with strong strength of evidence for improving performance in
activities of daily living and functional mobility include mirror therapy, task-oriented training, mental imagery, balance
training, self-management strategies, and a multidisciplinary three-stages-of-care rehabilitation program. Constraint-
induced therapy has strong strength of evidence for improving performance of instrumental activities of daily living.
Moderate strength of evidence supported cognitive–behavioral therapy (CBT) to address balance self-efficacy, long-
term group intervention to improve mobility in the community, and a wearable upper extremity sensory device paired
with training games in inpatient rehabilitation to improve social participation. Practitioners should incorporate
problem-solving therapy in combination with CBT or with education and a family support organizer program.

What This Article Adds: These Practice Guidelines provide a summary of strong and moderate evidence for
effective interventions for people with stroke and for their caregivers.
Hildebrand, M. W., Geller, D., & Profﬁtt, R. (2023). Practice Guidelines—Occupational therapy practice guidelines for adults with stroke. American
Journal of Occupational Therapy, 77, 7705397010. https://doi.org/10.5014/ajot.2023.077501

stroke, also known as a cerebrovascular accident Certain factors and health conditions can increase
A (CVA) or a brain attack, occurs when the brain
is deprived of oxygen as a result of blockage (ische-
the risk of stroke: hypertension; smoking; diabetes;
diet; physical inactivity; obesity; hyperlipidemia; heart
mic) or rupture of blood vessels (hemorrhagic) disease; sickle cell disease flare-ups; kidney and liver
within or leading to the brain. In the United States, disease; sleep disorders; and psychosocial factors, such
it is a leading cause of long-term disability or death as depression, psychological distress, and loneliness.
(Centers for Disease Control and Prevention [CDC], These risks may be mitigated with health management
2022b). The yearly incidence of stroke is approxi- strategies (American Occupational Therapy Associa-
mately 795,000, of which 77% are new strokes and tion [AOTA], 2020; American Stroke Association
23% are recurrent strokes. In 2018, the prevalence of [ASA], 2021; Tsao et al., 2022). However, nonmodifi-
stroke, or the number of adults older than age 20 yr able factors also increase the risk of stroke, such as
who had a stroke, was estimated to be 2.7%, or age; family history; race; gender; and prior occurrence
7.6 million Americans, and it is projected to increase of a stroke, transient ischemic attack, or myocardial
to 3.9% of the U.S. population by 2030. Globally, the infarction (ASA, 2021). A stroke may occur at any
prevalence of stroke in 2020 was 89.13 million, and age—one in seven strokes occurs in people ages 15 to
the incidence of stroke per year was 11.71 million 49 yr—but the chance of having a stroke doubles every
(Tsao et al., 2022). 10 yr after age 55 (CDC, 2022c). Regarding race and
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 1
ethnicity, statistics show that Black, Hispanic, and In- and visual deficits. Cerebellar strokes may result in
digenous Americans have a higher incidence of stroke ataxia, ataxic dysarthria, and poor postural control.
than non-Hispanic White or Asian Americans. In the Strokes in the brainstem may cause coma, dysphagia,
United States, females have 55,000 more strokes each diplopia, vertigo, or quadriparesis (Johns Hopkins
year and an overall higher lifetime risk of stroke than Medicine, 2022).
males. The intersectionality of age, gender, and race In 2017, the caregiving that family and friends pro-
increases the risk of stroke among Black and Hispanic vided to all adults in need of assistance with daily
women older than age 70 compared with White activities in the United States was valued at about
women (Tsao et al., 2022). In addition, it must be $470 billion per year (Reinhard et al., 2019). Stroke is
noted that socioeconomic status and racial disparities one of the conditions that most often require caregiv-
often play a significant role in stroke outcomes. Socio- ing. The ASA emphasizes the vital role that informal

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economically deprived populations are less likely to caregivers play as members of the stroke rehabilitation
receive effective management of stroke risk factors and team (Collinson & De La Torre, 2017; Winstein et al.,
equity in and access to good quality poststroke care 2016). Moreover, the Occupational Therapy Practice
(Marshall et al., 2015). Ikeme et al. (2022) found that Framework: Domain and Practice (4th ed.; OTPF–4;
a greater proportion of White patients than of racial AOTA, 2020) states that caregiving is a co-occupation
minorities used emergency medical services, arrived and that considering caregivers as clients is essential.
within 3 hr from the onset of stroke symptoms, and Informal caregivers may assist with activities of daily
received tissue-type plasminogen activator (tPA) or living (ADLs), instrumental activities of daily living
mechanical thrombectomy, thus negatively affecting (IADLs), and medical tasks, such as administering med-
stroke outcomes for Black, Hispanic, Asian, and Native ication and supervising home exercise programs
American patients. (Reinhard et al., 2019). The effects of caregiving on the
Other aspects of one’s environment may also create caregiver can be positive or negative. Positive effects
a greater risk of having a stroke and of having poorer include feeling good about oneself and becoming closer
stroke outcomes. For example, people in rural areas of to the person who has had a stroke. However, caregiv-
the United States experience poorer outcomes post- ing’s negative effects are most often reported and
stroke than those in urban areas. This has been include harm to employment, finances, and mental
hypothesized to be a result of the lack of equal access health (depression, anxiety, stress, and burden or
to evidence-based acute stroke care (Hammond et al., strain), as well as physical health challenges (injury or
2020). In addition, exposure to environmental degra- cardiovascular changes; Collinson & De La Torre, 2017;
dation such as air pollution increases stroke risk Loh et al., 2017; Schulz & Eden, 2016). When the care-
worldwide (Tsao et al., 2022). giver experiences negative effects, the person who has
Diagnosis of acute stroke is based on the patient’s had a stroke has a poorer outcome (Bakas et al., 2014).
history, clinical presentation, identifying signs and Across the continuum of care, stroke patients and
symptoms of stroke, a physical examination of stroke caregivers require a sustained and coordinated effort
severity with the commonly used NIH Stroke Scale from a multidisciplinary rehabilitation team, of which
(National Institute of Neurological Disorders and occupational therapy is a vital part (Winstein et al.,
Stroke, 2011), and cerebrovascular imaging (Choi 2016). In stroke rehabilitation, occupational therapy
et al., 2022; Powers et al., 2019). Diagnosing the type practitioners implement the process that supports en-
and location of the stroke is essential to ensure the gagement and participation in occupations and health
best medical intervention and client outcomes. For in- for both the adult with stroke and their caregiver
stance, a person with an acute ischemic stroke may (AOTA, 2020). Because the effects of a stroke are
require tPA to remove blockage and decrease brain highly variable, assessment and intervention are client
damage (Powers et al., 2019), and one with an acute centered and based on holistic occupational therapy
hemorrhagic stroke may require medication or surgery models of practice (e.g., the Person–Environment–
to control bleeding (Unnithan et al., 2022). Occupation model; Law et al., 1996).
The effects of a stroke vary greatly and depend on Multiple frames of reference grounded in these
the location, severity, and type of stroke. In the cere- holistic models guide stroke intervention. The biome-
brum, left hemisphere strokes are thought to be more chanical frame of reference is used to remediate
common than right hemisphere strokes (Portegies limitations in range of motion, strength, and endur-
et al., 2015). Left hemisphere strokes may result in ance caused by stroke (Grice, 2021). For impaired
right-sided hemiplegia or hemiparesis, contralateral motor function, a motor control and motor learning
sensory impairments, apraxia, and communication dif- frame of reference focused on task-oriented interven-
ficulties, such as aphasia, and right hemisphere strokes tions improves motor performance and function
may result in left-sided hemiplegia or hemiparesis, (Nilsen & Gillen, 2021). Alternatively, for residual im-
contralateral sensory impairments, unilateral spatial or pairments after stroke that may be considered chronic
body neglect, and spatial dysfunction (Johns Hopkins or permanent, the occupational therapy practitioner
Medicine, 2022). A stroke in either hemisphere may focuses on compensatory or adaptive techniques, using
cause dysphagia, cognitive impairments, depression, the rehabilitation frame of reference (Winstead, 2021).
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 2
In all poststroke care settings, occupational therapy practice to improve performance and participa-
treatment of the person with stroke or the caregiver tion in ADLs for adult stroke survivors?
includes any or all of the intervention approaches enu- 2. What is the evidence for the effectiveness of inter-
merated in the OTPF–4: remediation, maintenance, ventions within the scope of occupational therapy
compensation, prevention, and health promotion practice to improve performance and participa-
(AOTA, 2020). Stroke is not only an acute event but is tion in IADLs among adult stroke survivors?
also classified by the CDC (2022a) as a chronic disease 3. What is the evidence for the effectiveness of inter-
if the impairments caused by the stroke limit ADLs or ventions within the scope of occupational therapy
require medical attention for more than 1 yr. Thus, practice to improve the performance of and par-
the occupational therapy stroke intervention changes ticipation in education, volunteering, social par-
from a focus on remediation to one on compensation, ticipation, work, and leisure among adults

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health promotion, and prevention to reduce modifi- poststroke?
able stroke risk factors. 4. What is the evidence for the effectiveness of inter-
These practice guidelines update the previous Occu- ventions within the scope of occupational therapy
pational Therapy Practice Guidelines for Adults With practice for caregivers of people with stroke to facili-
Stroke (Wolf & Nilsen, 2015) that were based on three tate maintaining participation in the caregiver role?
systematic reviews addressing interventions within
the scope of practice of occupational therapy to im-
prove cognition, motor, and psychological and Goals of These Practice Guidelines
emotional impairments and one systematic review that Through these Practice Guidelines, AOTA aims to
examined the evidence for activity- and occupation- help occupational therapy practitioners, as well as
based interventions to improve occupation and social the people who manage, reimburse, or set policy re-
participation after stroke. In keeping with the philoso- garding occupational therapy services, understand
phy of occupational therapy and the International occupational therapy’s contribution in providing
Classification of Functioning, Disability, and Health for services to people with stroke and their care part-
Children and Youth (World Health Organization, ners. These guidelines can also serve as a reference
2007) and the evolution of the literature since the last for health care professionals, health care facility
practice guidelines, the primary focus of these guide- managers, education professionals, education and
lines has shifted from impairment to occupational health care regulators, third-party payers, managed
performance and participation. Therefore, the focus care organizations, and those who conduct research
here is solely on ADLs, IADLs, and participation out- to advance the care of people with stroke.
come measures, not impairment outcome measures These Practice Guidelines were commissioned,
(e.g., Modified Ashworth Scale [Bohannon & Smith, edited, and endorsed by AOTA without external fund-
1987], Fugl-Meyer Assessment [Fugl-Meyer et al., ing being sought or obtained. They were financially
1975; Gladstone et al., 2002]) or upper limb function supported entirely by AOTA and developed without
(e.g., Action Research Arm Test [Lyle, 1981], Wolf any involvement of industry. All authors of the sys-
Motor Function Test [Wolf et al., 2005]). These prac- tematic reviews completed conflict-of-interest
tice guidelines incorporate information from three disclosure forms, with no conflicts noted. AOTA re-
systematic review questions on improving stroke survi- views practice guidelines, and updates them as needed,
vors’ occupational performance and participation in every 5 yr to keep the recommendations on each topic
ADLs (Geller, Goldberg, et al., 2023a, 2023b; Geller, current according to criteria established by ECRI
Winterbottom, et al., 2023; Goldberg et al., 2023a, (2020). Guidelines topics are evaluated by a multidisci-
2023b; Winterbottom, Geller, et al., 2023; Winterbot- plinary advisory group consisting of AOTA members,
tom, Goldberg, et al., 2023); IADLs (Kotler et al., 2023; nonmember content experts, and external stakehold-
Mahoney et al., 2023); and education, work, volunteer- ers. These Practice Guidelines were reviewed and
ing, leisure, and social participation (Proffitt et al., revised on the basis of feedback from a group of
2022). In addition, the practice guidelines include find- content experts on people with stroke that included
ings from one systematic review question on practitioners, researchers, educators, practitioners, and
interventions for caregivers that facilitate maintaining policy experts. Reviewers who agreed to be identified
their caregiving role (Mack & Hildebrand, 2023), a are listed in the Acknowledgments.
category that was not in the previous practice guide- These Practice Guidelines report the findings from
lines for adults with stroke. systematic reviews of published scientific research on
focused topic-specific questions. The systematic re-
views were conducted according to the Cochrane
Systematic Review Questions Collaboration methodology (Higgins et al., 2019) and
These Practice Guidelines are based on the following are reported according to the Preferred Reporting
four questions: Items for Systematic Reviews and Meta-Analyses
1. What is the evidence for the effectiveness of inter- (PRISMA) guidelines for conducting systematic re-
ventions within the scope of occupational therapy views (Moher et al., 2009). The process included
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 3
䊏 protocol and question development with input The recommendations for these Practice Guidelines
from a multidisciplinary advisory group that also were evaluated and finalized by AOTA staff, the
included consumers and information end users, AOTA research methodologist, and the systematic re-
䊏 a literature search conducted by a medical review and Practice Guidelines authors. AOTA uses the
search librarian, and grading methodology provided by the U.S. Preventive
䊏 team evaluation of literature and a synthesis of Services Task Force (2018) for clinical recommenda-
ﬁndings (see Appendix Table A.2). tions. The clinical recommendations pertaining to
Interventions that were described in sources other each review, along with the studies’ level of evidence
than the published literature and that did not meet the and supporting details, are presented in Tables 1 to 4.
inclusion criteria were excluded from the reviews. For the purposes of these Practice Guidelines, we
Occupational therapy practitioners should not report only recommendations graded A, B, and D, the

Canada Setting: Inpatient rehabilitation

Delivery method: Individual

Dose: 15–40 min, 3–6 days/wk, for 2–12 wk

Improvement: In 5 studies (N 5 158), participants in the intervention

group showed significant improvements in FM compared with the
control group (small effect size). Two studies (N 5 63) found that the
intervention group had statistically significant improvements in FM
compared with the control group.
1a Yang et al. (2018) Participants: N 5 1,685 people with stroke (recovery time not noted)
Meta-analysis
Setting: Rehabilitation (specific site not reported)
China
Intervention: 37 trials of MT of the affected upper limb alone or combined
with e-stimulation versus control group

Delivery method: Individual

Dose: Varied, not reported

Improvement: 20 studies (N 5 934; 2 studies used MT 1 e-stim) found

significant improvements in ADLs in the intervention group compared with
the control group (moderate to large effect size).
1b Hsieh et al. (2018) Participants: N 5 12 adults with subacute and chronic stroke
RCT
Setting: Home based
Taiwan
Intervention: MT followed by home-based versus hospital functional task
training (grooming, meal preparation, bathroom transfer)

Delivery method: Individual

Dose: 30–45 min MT followed by 45–60 min functional training 2×/wk for
a total of 12 training sessions

Improvement: A statistically significant improvement (sit to stand) was seen

in FM in favor of home-based MT versus clinic-based MT.
MI and TOT for FM
A: Strong Recommendation: Practitioners should consider the use of MI, using video, audio, or images of
specific movements or tasks, as an adjunct to TOT for adults with stroke at all stages of recovery to
improve FM in the short term (dose: <6 wk; 12–40 5- to 30-min sessions over 4–6 wk).
1a Guerra et al. (2017) Population: N 5 995 adults with acute, subacute, and chronic stroke
Meta-analysis (majority, acute or subacute)

Brazil Setting: Not reported

(Continued)

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 5
Table 1. Clinical Recommendations for Interventions to Improve ADL and FM Outcomes (Cont.)
Grade/Evidence Level Citation Intervention Details
Intervention: 32 trials of MI of specific movements or tasks, including
audiotapes, films, or images related to the movement plus routine treatment

Delivery method: Individual

Dose: The number of sessions ranged from 12 to 40, with the most
common being 12. Duration ranged from 5 to 30 min per session for either
4 or 6 wk.

Improvement: 4 studies (N 5 116) found significant improvements in FM in

Delivery method: Individual

Dose: 5–30 min (most common 15 min) for 2–8 wk (most common 6 wk)

Improvement: 2 studies (N 5 54) found that short-term FM interventions

<6 wk resulted in significant improvements in FM in the intervention group
compared with the control group (large effect size).
Balance Training for ADLs and FM
A: Strong Recommendation: Practitioners should consider providing balance training to improve ADLs (inpatient
rehabilitation setting) and FM (inpatient rehabilitation and other settings) for adults with subacute
and chronic stroke (dose: 2–62 hr; e.g., 1 hr conventional therapy with 15-min balance intervention,
5×/wk for 5 wk)
1a van Duijnhoven et al. Population: N 5 430 adults with chronic stroke
Meta-analysis (2016)
Setting: Not reported
Netherlands
Intervention: 43 trials (36 trials for meta-analysis) of balance, functional
weight shifting training, or both; gait training; multisensory training; high-
intensity aerobic training; other training

Delivery method: Not reported

Dose: 1.9–61.7 hr (details not reported)

Improvement: A significant improvement was found in FM in 28 trials

(N 5 985).
1b Cabanas-Valdés Participants: N 5 80 adults with subacute stroke; follow-up, N 5 79
RCT et al. (2016, 2017
[3-mo follow-up]) Setting: Inpatient rehabilitation
Spain
Intervention: Core stability exercises 15 min/day plus conventional therapy
(PT facilitation, stretching, passive mobilization, ROM, walking, OT, and
nursing)

Delivery method: Individual

Dose: Conventional therapy for 1 hr, 5 days/wk, for 5 wk (25 sessions) plus
an additional 15 min of core stability exercises per session (total of 31 hr)

Improvement: Significant improvement was seen in ADLs and FM. FM was

still significantly improved after 3 mo.
(Continued)

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 6
Table 1. Clinical Recommendations for Interventions to Improve ADL and FM Outcomes (Cont.)
Grade/Evidence Level Citation Intervention Details
Three-Stage Multidisciplinary Rehabilitation Program for ADLs and FM
A: Strong Recommendation: Practitioners should consider providing 3 stages of care—from hospital, to
inpatient rehabilitation, to home or community—for people poststroke across the continuum from
onset through 6 mo (dose Stage 1, 45 min/day, 5× wk, for 1 mo; Stage 2, 45 min/day, 5×/wk,
Months 2 and 3; Stage 3, 45 min/day, 5×/wk, Months 4–6)
1b Bai et al. (2012) Population: N 5 364 adults with hemiplegia after acute ICH in an inpatient
RCT emergency or neurology unit

China Setting: Inpatient hospital (Stage 1), rehabilitation center (Stage 2), and

Intervention: Early rehabilitation group received routine internal medical

intervention 1 3-stage rehabilitation program (PT and OT with emphasis on
ADL training). Stage 1 focused on basic ADLs for 1st mo poststroke; Stage 2
focused on balance and walking 2–3 mo poststroke; and Stage 3 focused on
ADLs and motor function 4–6 mo poststroke. Control group received routine
internal medicine intervention only and no rehabilitation intervention.

Delivery method: Individual, in person

Dose: Stage 1, 45 min/day, 5× wk, for 1 mo; unspecified for Stages 2

(2 and 3 mo postonset) and 3 (4-, 5-, and 6-mo postonset).

Improvement: ADL performance improved.

1b Bai et al. (2014) Population: N 5 165 adults (age range 5 40–80 yr) stabilized for 1 wk
RCT after 1st stroke in inpatient hospital

China Setting: Inpatient hospital (Stage 1), rehabilitation center (Stage 2), home
based (Stage 3)

Intervention: Received standard care in hospital 1 3-stage rehabilitation

protocol. Stage 1 (1st mo poststroke in inpatient hospital) included passive
movement, positioning of limbs, active movement, sitting, standing, balance
training. Stage 2 (2–3 mo poststroke in rehabilitation center) included
PROM, strengthening, walking and balance training, stairs, and active
exercise related to ADLs for the upper limbs. Stage 3 (4–6 mo poststroke
home-based rehab) included ADL training supervised by caregivers with
therapy every 2 wk in the home.

Delivery method: Individual, in person

Dose: Stage 1, 45 min/day, 5 days/wk (1st mo poststroke); Stage 2, 45 min

2×/day, 5 days/wk (2–3 mo poststroke); Stage 3, every 2 wk

Improvement: ADL performance improved.

Stroke Self-Management Interventions for ADLs
A: Strong Recommendation: Practitioners should consider providing a health management intervention for
stroke self-management, using a mixture of group, individual, and telephone follow-up, to improve
ADL performance of adults poststroke, during inpatient or outpatient rehabilitation (dose: 20- to
60-min sessions, 1–5×/wk, with telephone follow-up for 6–13 wk)
1b Sit et al. (2016) Population: N 5 210 adults with first-time stroke scheduled for ambulatory
RCT stroke rehabilitation

China Setting: Outpatient rehabilitation

Intervention: Usual care 1 HEISS included self-management skills, self-

efficacy activities, and goal setting and action planning with workbook. Part 1
included 6 weekly small groups from Wk 3 to Wk 8 for self-efficacy and
(Continued)

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 7
Table 1. Clinical Recommendations for Interventions to Improve ADL and FM Outcomes (Cont.)
Grade/Evidence Level Citation Intervention Details
self-management skills. Part 2 involved home-based biweekly telephone calls
from Wk 9 to Wk 13 to encourage positive change and help with problem-
solving skills. Control group received usual-care ambulatory stroke
rehabilitation.

Delivery method: Group and telephone follow-up

Dose: 6 weekly 1-hr small groups (Wk 3–8), biweekly phone calls
(Wk 9–13)

China Setting: Inpatient rehabilitation

Intervention: Usual care 1 PCSMEI: 5 daily sessions (self-management

knowledge and skills; self-management goals; information on individuated health
needs, such as stroke risk factors; self-health monitoring; advice; problem
solving), small-group session (talk with each other regarding stroke management),
and 4 weekly telephone follow-ups postdischarge (assess patients’ self-
management skills and behaviors). Control group received usual care.

Delivery method: Individual and group, with telephone follow-up postdischarge

Dose: Five 20-min daily sessions in 1st wk, 1 60-min small-group session in
2nd wk, 1 discharge session, 4 20- to 30-min weekly telephone follow-ups

Improvement: Intervention group had significant improvement in basic ADL

outcomes at 3 mo postintervention compared with the control group.
CBT Intervention for ADLs
B: Moderate Recommendation: Practitioners could consider providing group or individual CBT, inpatient or in the
community, for adults with depression poststroke to improve ADL performance (dose: 3–40 wk total,
3–40 sessions total)
1a Wang et al. (2018) Population: Adults with poststroke depression. 23 RCTs (N 5 1,972) were
Meta-analysis included in the systematic review (N 5 753 participants from 7 meta-
analyses of ADL outcomes)
China and Australia
Setting: Not reported

Intervention: CBT alone or CBT with antidepressants. Control group received

placebo or same antidepressants as CBT group.

Delivery method: Group and individual treatment with community and

inpatient participants

Dose: Treatment duration ranged from 3 to 40 wk (M 5 9.5, Mdn 5 8).

Number of CBT sessions ranged from 3 to 40 (M 5 13.5, Mdn 5 14.3).
Session length not specified.

Improvement: Significantly improved ADL outcomes for the intervention

group compared with the control group (moderate to large effect size).
Unilateral Spatial Neglect Intervention for ADLs
B: Moderate Recommendation: Practitioners could consider providing activity-based interventions (e.g., computer-
based training for visual scanning training and optokinetic stimulation, mental practice, MT, voluntary
trunk rotation, vestibular rehabilitation) for adults with unilateral spatial neglect poststroke to improve
ADL performance (dose: 5–30 sessions, 2–10×/wk, 1 hr 45 min to 30 hr, for 4 days–5 wk)
(Continued)

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 8
Table 1. Clinical Recommendations for Interventions to Improve ADL and FM Outcomes (Cont.)
Grade/Evidence Level Citation Intervention Details
1a K. P. Y. Liu et al. Population: Individuals with USN or hemianopsia after stroke. 20 RCTs
Meta-analysis (2019) (N 5 594 participants), 5 activity-based intervention studies (N 5 156
participants), and 4 combined activity–nonactivity intervention studies
Australia (N 5 105 participants) included in meta-analysis of ADL outcomes.

Setting: Hospital, rehabilitation center, research center

Intervention:
1. Activity-based interventions: computer-based training for visual scanning
training and optokinetic stimulation, mental practice, MT, voluntary trunk

Delivery method: Individual

Dose: Ranged from 5 to 30 sessions, 2–10×/wk for 1 hr 45 min to

30 hr, for 4 days–5 wk

Improvement: Only activity-based interventions had a moderate effect on

improving ADL outcomes for people with USN.
Recreational Interventions for ADLs and FM
B: Moderate Recommendation: Practitioners could consider using recreational interventions such as music,
horseback riding, and other creative arts activities to improve ADL performance of adults poststroke
(dose: 90- to 240-min sessions, 2×/wk, for 4–12 wk)
1b Bunketorp-K€all et al. Population: N 5 123 participants with stroke with hemispheric symptoms
3-arm RCT (2017, 2019)
Setting: Community
Sweden
Intervention:
1. R-MT used rhythm, music, color, and movement. Participants performed
rhythmic movements with their hands and feet while listening to music.
2. H-RT included preparing the horse for riding, completion of tailored
exercises (balance, trunk rotation, goal-oriented movement, cognition) while
the horse was moving, and relaxation and body awareness.
3. Control group received R-MT after 1-yr delay.

Delivery method: Group

Dose:
R-MT: 2 90-min sessions/wk for 12 wk
H-RT: 2 240-min sessions/wk for 12 wk

Improvement: R-MT and H-RT groups improved significantly compared with

the control group in ADL performance over 3 time points—postintervention,
3 mo, and 6 mo. The H-RT group also had significantly improved balance
and FM compared with the other 2 groups.
1b Kongkasuwan et al. Participants: N 5 118 stroke patients in a hospital inpatient rehabilitation
RCT (2016) unit (ages ≥50 yr).

Thailand Setting: Inpatient rehabilitation

Intervention: Creative art intervention in addition to physical therapy.

(Continued)

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 9
Table 1. Clinical Recommendations for Interventions to Improve ADL and FM Outcomes (Cont.)
Grade/Evidence Level Citation Intervention Details
Intervention included meditation with music, warm-up activity, main activity,
and group singing activity and a group-healing circle. Control group
received conventional PT only.

Delivery method: Group

Dose: Intervention group received creative arts therapy in addition to PT

2×/wk for 4 wk (8 1.5- to 2-hr sessions).

Improvement: The intervention group improved significantly in ADL

Delivery method: Individual

Dose: Varied; 20–90 min/session, 3–6 days/wk, for 3–8 wk

Improvement: Significant improvements in ADLs in the intervention group

compared with the control group (4 studies; N 5 226; moderate to large effect
size). Significant improvement in FM (8 trials; N 5 220) in the intervention
group compared with the control group (moderate to large effect size).
Tai Chi for ADLs and FM
B: Moderate Recommendation: Practitioners could consider providing or recommending Tai Chi for adults with
subacute or chronic stroke to improve ADL and FM outcomes in inpatient (or other) settings (dose:
15–60 min, 5×/wk, for 2–12 wk)
1a Lyu et al. (2018) Population: N 5 1,293 (21 trials); stage of stroke varied
Meta-analysis
Setting: Not reported
China
Intervention: All types of Tai Chi

Delivery method: Not reported

Dose: Not reported

Improvement: Significant improvement in the intervention group over the

control group in ADLs (2 studies; N 5 166) and in FM (2 studies, Tai Chi
vs. conventional rehabilitation; 4 studies, Tai Chi 1 conventional
rehabilitation vs. conventional rehabilitation alone).
1b Chen et al. (2019) Population: N 5 72 adults with subacute stroke
RCT
Setting: Inpatient rehabilitation
Taiwan
Intervention: Mind–body interactive exercise program (Chan-Chuang qigong
exercise: lifting ball posture, holding tree trunk posture, pressing ball
posture, and pushing posture and calm breathing and relaxation)

Delivery method: Individual

Dose: ≥15 min/day for 10 days

(Continued)
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 10
Table 1. Clinical Recommendations for Interventions to Improve ADL and FM Outcomes (Cont.)
Grade/Evidence Level Citation Intervention Details
Improvement: Significant improvement in ADL outcomes among the
intervention group compared with the control group.
1b Xie et al. (2018) Population: N 5 72 adults with chronic stroke
RCT
Setting: Community setting
China
Intervention: Tai-Chi Yunshou exercise plus health education

Delivery method: Individual

Improvement: None.
Aquatic Therapy or Hydrotherapy for ADLs and FM
B: Moderate Recommendation: Practitioners could consider providing hydrotherapy in an outpatient or community
setting for adults with subacute or chronic stroke to improve ADL and FM outcomes (dose: 2–5
30- to 60-min sessions/wk for 2–8 wk).
1a Chae et al. (2020) Population: N 5 325 adults with subacute or chronic stroke (11 trials)
Meta-analysis
Setting: Interactive therapy lab and recreation room
Korea
Intervention: Hydrotherapy (exercise performed underwater)

Delivery method: Not reported

Dose: 2–5 30- to 60-min sessions/wk for 2–8 wk

Improvement: Significant improvement in the intervention group over the

control in ADLs (2 studies; N 5 166) and FM (2 studies, hydrotherapy vs.
conventional; 4 studies, hydrotherapy 1 conventional vs. conventional alone).
OT-Provided ADL Interventions
B: Moderate Recommendation: Practitioners could consider using OT ADL training strategies (remediation,
adaptation, technology, environmental modification) to improve ADL performance of people
poststroke at all stages of recovery (dose unspecified).
1a Chae et al. (2020) Population: N 5 325 adults with subacute or chronic stroke (11 trials)
Meta-analysis
Setting: Interactive therapy lab and recreation room
Korea
Intervention: Hydrotherapy (exercise performed underwater)

Delivery method: Not reported

Dose: 2–5 30- to 60-min sessions/wk for 2–8 wk

Improvement: Significant improvement in the intervention group over the

control group in ADLs (N 5 166): FM improvement from 2 studies that
used hydrotherapy vs. conventional rehabilitation and from 4 studies that
used hydrotherapy 1 conventional rehabilitation vs. conventional
rehabilitation alone.
Home-Based Exercise and ADL Interventions for ADLs
B: Moderate Recommendation: Practitioners could consider providing a home-based audiovisual program,
including exercises and performing ADLs (food preparation, dressing, mobility) for people at the
subacute stage poststroke (dose: 1-hr session 1×/wk for 6 mo)
1b Chaiyawat & Population: N 5 60 individuals with MCA stroke living at home
RCT Kulkantrakorn (2012)
Setting: Home
(Continued)

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 11
Table 1. Clinical Recommendations for Interventions to Improve ADL and FM Outcomes (Cont.)
Grade/Evidence Level Citation Intervention Details
Thailand Intervention: Home-based individualized audiovisual program consisting of
passive, active, and resistive exercises and ADLs, such as preparing a drink,
using a key in a lock, donning and doffing shoes, using cane or wheelchair.

Delivery method: Individual, in person

Dose: 1-hr session 1×/mo for 6 mo

Improvement: ADL performance improved.

ADL Training Before Discharge Home

Delivery method: Individual, in person

Dose: During inpatient stay, 60-min session of exercise and ADL training
1–3×/wk. After discharge, received 60-min session of rehabilitation training
1–5 days/wk for 4 wk.

Improvement: ADL and FM performance improved.

Home-Based ADL Training and Education
B: Moderate Recommendation: Practitioners could consider providing home-based ADL training and education to
improve ADL performance for people poststroke discharged from acute care (2-hr sessions, 1×/wk,
for 6 wk)
1b Sahelbalzamani Population: N 5 80 adults (age range 5 40–70 yr) with hemiplegia
RCT et al. (2009) poststroke

Iran Setting: Home health after discharge from acute care

Intervention: Education (skill and booklet) in individual hygiene, bathing,

nutrition, toileting, grooming, dressing, bowel and bladder control, mobility,
wheelchair use, transferring to and from chair to bed.

Delivery method: Individual, in person

Dose: 2-hr session 1×/wk for 6 wk

Improvement: Participants improved in all areas of ADLs except for bowel

and bladder management.
VR Interventions for ADLs
B: Moderate Recommendation: Practitioners could consider using technology to improve ADL performance of
people ≥3 mo poststroke in a variety of settings (inpatient rehabilitation, outpatient; dose: 30 min/day,
3 days/wk, for 4 wk; total hours of treatment: <5 hr [n 5 13]; 6–10 hr [n 5 25]; 11–20 hr
[n 5 26]; >21 [n 5 7]; 1 study had a low-intensity group [4 hr] and a high-intensity group [10 hr]).
(Continued)

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 12
Table 1. Clinical Recommendations for Interventions to Improve ADL and FM Outcomes (Cont.)
Grade/Evidence Level Citation Intervention Details
1a Laver et al. (2017) Population: N 5 2,470 (across 72 trials; varies by study) stroke patients
Systematic review with in a variety of settings, at a variety of stages poststroke, participating in VR
meta-analysis intervention

United States and Setting: Varied

Canada
Intervention: Five intervention approaches using VR (varies by study) were used:
activity retraining (n 5 4); upper limb training (n 5 35); lower limb, balance,
and gait training (n 5 23); global motor function training (n 5 10);
cognitive–perceptual training (n 5 1). 22 studies used commercially available

Delivery method: Varied by study

Dose: Varied. Total hours of treatment: <5 hr (n 5 13); 6–10 hr (n 5 25);

11–20 hr (n 5 26); >21 hr (n 5 7); 1 study had a low-intensity group (4 hr)
and a high-intensity group (10 hr).

Improvement: Pooled analysis from 10 trials with 466 participants found

statistically significant findings favoring the impact of VR on ADL performance.
1b Lin et al. (2015) Population: N 5 33 ≥3 mo poststroke, with the ability to flex and extend
RCT the paretic arm and hand

Taipei Setting: Inpatient rehabilitation

Intervention: Bilateral isometric handgrip force training while seated at an

LCD screen in which the individual gradually increased or decreased their
grip to track the trajectory of the targeted force

Delivery method: Individual, in person

Dose: 30 min/day, 3 days/wk, for 4 wk

Improvement: Statistically significant improvements in favor of the

intervention for ADL performance compared with the control.
Preparatory Methods: Early Mobilization for ADLs
B: Moderate Recommendation: Practitioners could consider providing mobilization, within the 1st 24 hr after
stroke onset, during acute care, to improve ADL performance (dose: 5–30 min, 2×/day, for
7–14 days, depending on discharge).
1b Chippala & Sharma Participants: N 5 86 (age >18 yr) with acute stroke, admitted within 24 hr
RCT (2016) of symptom onset

India Setting: Acute care inpatient

Intervention: Upright and out-of-bed activities started as soon as practical

after recruitment and determined by patient’s tolerance

Delivery method: Individual

Dose: 5–30 min, 2×/day, for 7 days or until discharge (whichever was
sooner)

Improvement: Significant improvement in ADL performance at discharge as

well as at 3-mo follow-up, in favor of the intervention compared with usual
care.
(Continued)

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 13
Table 1. Clinical Recommendations for Interventions to Improve ADL and FM Outcomes (Cont.)
Grade/Evidence Level Citation Intervention Details
Preparatory Methods: PROM for ADLs
B: Moderate Recommendation: Practitioners could consider providing PROM for acute stroke patients in intensive
care to improve self-care performance (dose: 15 min, 2×/day, 5 days/wk for 4 wk)
1b Kim et al. (2014) Population: N 5 37 acute stroke patients with muscle strength <Grade 3.
RCT
Setting: Neuroscience intensive care unit
Korea
Intervention: PROM performed with bilateral upper extremities

Dose: 15-min session 2×/day, 5 days/wk, for 4 wk

Improvement: Significant improvement in self-care for the intervention group

compared with the usual-care control group.
Preparatory Methods: Sensory Retraining for ADLs
B: Moderate Recommendation: Practitioners could consider providing various types of sensory retraining to
improve ADL performance for leg somatosensory impairment for people in inpatient rehabilitation
(dose: varies per study; 20- to 45-min sessions, 2–5×/wk, for 2–9 wk)
1a Chia et al. (2019) Population: N 5 430 adults age ≥18 yr with leg somatosensory impairment
Systematic review with after stroke
meta-analysis
Setting: Eight of 16 studies were set in inpatient rehabilitation
Numerous countries (9)
Intervention: Varies per study; compelled body weight shift (N 5 2 studies);
assisted movement with enhanced sensation 1 EMG feedback (N 5 1 study);
Nintendo Wii (N 5 1 study); underwater unstable surface (N 5 1 study);
education and proprioception training on affected foot (1 study); proprioception,
localization, vibration, pressure discrimination, and TENS 1 NDT (N 5 1
study); AROM and PROM of affected leg (N 5 1 study); motor imagery 1
proprioceptive training (N 5 1 study); education, detection, localization,
discrimination, and proprioception of the affected big toe and ankle (N 5 1
study); aerobic deep-water walking (N 5 1 study); treadmill training with eyes
closed (N 5 1 study); hardness discrimination perceptual learning exercises
(N 5 1 study); TENS using sock electrode on affected foot (N 5 2 studies)

Delivery method: Individual, in person

Dose: Varies per study; 20- to 45-min sessions, 2–5×/wk, for 2–9 wk

Improvement: Significant improvement in ADL performance and balance in the

intervention group compared with the control group.

Note: All studies included had statistically signiﬁcant positive outcomes related to the interventions discussed. ADL/ADLs 5 activities of
daily living; AO 5 action observation; AROM 5 active range of motion; CAREN = Computer-Assisted Rehabilitation Environment; CBT 5
cognitive–behavioral therapy; EMG 5 electromyography; e-stim 5 electrical stimulation; FM 5 functional mobility; HEISS 5 Health
Empowerment Intervention for Stroke Self-Management; H-RT 5 horse-riding therapy; ICH 5 intracerebral hemorrhage; IREX 5
Immersion Rehabilitation Exercise; MCA 5 middle cerebral artery; Mdn 5 median; MI 5 mental imagery; MT 5 mirror therapy;
NDT 5 neurodevelopmental treatment; OT 5 occupational therapy; PCSMEI 5 Patient-Centered Self-Management Empowerment
Intervention; PROM 5 passive range of motion; PT 5 physical therapy; RCT 5 randomized controlled trial; R-MT 5 rhythm and
music therapy; ROM 5 range of motion; TENS 5 transcutaneous electrical nerve stimulation; TOT 5 task-oriented training; USN 5
unilateral spatial neglect; VR 5 virtual reality.

1. Exactly what intervention do I need to provide? 2. How well do the conditions in which I will
*What types of client outcomes am I looking provide the intervention match those in the
for? studies?
*Do the studies I’ve located provide enough * What are the demographic characteristics
detail on the intervention so that I know what (e.g., age, gender, diagnosis, comorbidities) of
to do and how to do it? the participants in the studies?

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 14
Table 2. Clinical Recommendations for Interventions to Improve IADL Outcomes
Grade/Evidence Level Citation Intervention Details
CIT Interventions
A: Strong Recommendation: Practitioners should consider providing CIT alone or in combination with other
interventions (self-regulation, trunk restraint, robotic therapy) during inpatient rehabilitation to improve
IADL performance and mobility after stroke (dose: 1–2-hr sessions, 5×/wk, 2–4 wk).
1b Liu et al. (2016) Participants: N 5 86, stroke onset <3 mo
RCT
Setting: Inpatient rehabilitation
China
Intervention: Self-regulatory and mCIMT: restraint of the nonimpaired

Delivery method: Individual, in person

Dose: 10 1-hr sessions, 5×/wk, for 2 wk

Improvement: IADL performance improved.

1b Wu et al. (2012) Participants: N 5 57, >6 mo after stroke
RCT
Setting: Rehabilitation hospital
Taiwan
Intervention: dCIT with TR training of the affected UE included shaping
skills and repetitive practice of functional tasks; TR harness secured the
trunk to the back of the chair; the unaffected hand was restrained in a
mitt for 6 hr/day for 3 wk.

Delivery method: Individual, in person

Dose: 2-hr sessions, 5×/wk, for 3 wk

Improvement: Participation in IADL tasks and outdoor activities.

2b Hsieh et al. (2016) Participants: N 5 34, >6 mo poststroke
RCT
Setting: Rehabilitation hospital
Taiwan
Intervention: For the first 2 wk, participants in RT 1 mCIT group
received RT, using the same treatment principles as those in the RT
group. RT was followed by 2 wk of a form of mCIT with reduced
training and restraint time compared with the original CIT. Treatment
components included repetitive training of the affected UE in functional
tasks with behavior shaping. A mitt was used to restrict the unaffected
hand for 6 hr/day. Some strategies of transfer package applied to
facilitate the use of the affected UE included behavioral contract, home
diary, and problem-solving mentoring.

Delivery method: Individual, in person

Dose: 90- to 105-min session, 5×/wk, for 4 wk

Improvement: Independence in IADLs improved.

2b Lin et al. (2009) Participants: N 5 32, >6 mo poststroke
RCT
Setting: Rehabilitation setting
Taiwan
Intervention: Included functional training of the affected limb. Shaping,
adaptive, and repetitive practice of functional tasks included dialing a
phone number, reaching forward to move a jar from one place to
(Continued)

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 15
Table 2. Clinical Recommendations for Interventions to Improve IADL Outcomes (Cont.)
Grade/Evidence Level Citation Intervention Details
another, picking up a cup and drinking from it, and other activities
similar to those performed on a daily basis.

Delivery method: Individual, in person

Dose: 2-hr session, 5×/wk, for 3 wk

Improvement: Functional mobility improved.

Medication Management

Delivery method: Individual, remote

Dose: Text for every dose, and health information texts 2×/wk for 8 wk

Improvement: Medication adherence improved.

2b O’Carroll et al. (2013) Participants: N 5 62, discharged home on preventive stroke medicine
Pilot RCT
Setting: Home based
Scotland
Intervention: Two-session intervention aimed at increasing adherence by
(1) introducing a plan linked to environmental cues (implementation
intentions) to help establish a better medication-taking routine (habit)
and (2) eliciting and modifying any mistaken patient beliefs regarding
medication or stroke.

Delivery method: Individual, in person

Dose: 2 brief sessions, 2 wk apart, for 3 mo, with assessment after

both sessions.

Improvement: Medication adherence improved.

Driving Intervention
B: Moderate Recommendation: Practitioners could consider the use of driving simulation interventions to improve
driving performance of people living at home poststroke (dose: 1-hr sessions, 3×/wk, for 5 wk)
1b Devos et al. (2009) Participants: N 5 83 subacute participants (age 5 <75 yr)
RCT
Setting: Rehabilitation clinic
Belgium
Intervention: Simulator-based driving training; trained in a stationary full-
bodied Ford Fiesta 1.8 with automatic gear transmission and all of its
original mechanical parts. Life-size computer-generated images were
projected onto a flat screen with a horizontal visual angle of 45 . Tailor-
made, interactive driving scenarios were developed using the Scenario
Definition Language from STISIM Drive System (Version 1.03; Systems
(Continued)

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 16
Table 2. Clinical Recommendations for Interventions to Improve IADL Outcomes (Cont.)
Grade/Evidence Level Citation Intervention Details
Technology Inc., Hawthorne, CA).

Delivery method: Individual, in person

Dose: 1-hr sessions, 3×/wk, for 5 wk

Improvement: On-road performance improved at conclusion of intervention

and 6 mo later. Anticipation and perception of signs, visual behavior and
communication, quality of traffic participation, and left-turn performance
improved at conclusion of the intervention.

Hong Kong Setting: Subacute hospital and home based

Intervention: HEISS. Part 1: 6 weekly small-group sessions from Wk 3 to

Wk 8 in parallel with the ambulatory rehabilitation schedule (usual care).
Groups focused on personal goal setting and action planning, self-
efficacy activities to develop self-management skills, and articulating
participants’ health needs with their personal resources for goal
attainment. Part 2: Home-based implementation during Wk 9–13 with
biweekly telephone follow-up calls to the participants.

Delivery method: Group (with individual home follow-up), in person

Dose: 1 60-min, small-group session/wk and home-based

implementation with short biweekly telephone follow-up call for 6 wk

Improvement: IADL performance improved at 1 wk, 3 mo, and 6 mo

postintervention.

Note. CIT 5 constraint-induced therapy; dCIT 5 distributed constraint-induced therapy; HEISS 5 Health Empowerment Intervention for
Stroke Self-management; IADL/IADLs 5 instrumental activities of daily living; mCIMT 5 modiﬁed constraint-induced movement therapy;
RCT 5 randomized controlled trial; RT 5 robotic therapy; TR 5 trunk restraint; UE 5 upper extremity.

*In which setting (e.g., inpatient, home, com- To modify or adapt evidence-based interventions in
munity, school) did the studies take place? practice, practitioners must plan and proactively think
*Do any contextual factors (e.g., resources, policies) through the changes they need to make to fit the in-
that are different from those in the studies inﬂu- tervention to the client and the practice setting. In
ence my ability to provide the intervention? addition, they must document how and why they altered
3. How ﬂexible is the intervention, and how much the researched intervention so others in their setting
can I modify or adapt it? know how to implement the intervention and why the
*If my setting or client population differs from changes were made. If an intervention must be adapted
those of the studies, can I modify or adapt the extensively, it may not be the right fit for the situation.
intervention without changing its integrity? If extensive adaptations to the intervention are necessary,
*If I modify or adapt the intervention, what the intervention is probably not right for the client or
client characteristics (e.g., comorbidities) do I setting. If the practitioner finds that the intervention
need to consider? does not suit the client, they should not use that inter-
*Can I be proactive and plan how to modify or vention. Clinical interventions should be as similar as
adapt the intervention before I start imple-
possible to the interventions used in the research.
menting it?
*
Can I make minimal changes to the intervention,
such as reordering the content of the sessions, or Case Studies and Evigraphs
does the need for substantial changes indicate The case studies presented in these Practice Guidelines
that I should select another intervention? illustrate how occupational therapy practitioners can
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 17
Table 3. Clinical Recommendations for Interventions to Improve Social Participation
Grade/Evidence Level Citation Intervention Details
Occupation-Based Interventions for Social Participation Outcomes
B: Moderate Recommendation: Practitioners could provide multimodal stroke education (e.g., written material,
lectures) with supportive follow-up (telephone, internet) to improve social participation outcomes for
adults after stroke (1 session before discharge and multiple phone and home follow-up (6 mo) or
mix of group training 1 hr, 2×/wk, and home training 1.5 hr, 5×/wk, for 3 mo).
1b Geng et al. (2019) Participants: N 5 60; age ≥60 yr; first stroke, either hemorrhagic or
RCT ischemic; ability to communicate; cognitive competence with Mini-
Mental State Examination score ≥20; slight to moderate level of
China disability; and scheduled to discharge from hospital to home

Intervention: Routine stroke education before hospital discharge,

telephone follow-up call 1 wk postdischarge, and routine check-up with
their doctor postdischarge. TC nurses visited participants’ homes
weekly and conducted weekly telephone follow-up calls to assess
patients’ and caregivers’ needs 1–3 mo after discharge.

Delivery method: Individual

Dose: TC intervention included 30-min education by a neurologist and

nurse practitioner on recovering after stroke 1 day before discharge.
Multiple home and telephone follow-ups postdischarge.

Improvement: Improvements were seen in social participation, lasting

≤6 mo postdischarge.
2b Ru et al. (2017) Participants: N 5 964 (age <75 yr); diagnosis of stroke confirmed with
Pilot RCT CT and MRI; unilateral limb dysfunction; absence of serious cardiac
conditions; absence of prior sensory aphasia, severe mental disorder,
China or cognitive impairment.

Setting: Community based

Intervention: Comprehensive stroke rehabilitation education protocol

consisting of textbooks, brochures, flyers, bulletins, seminars, lectures,
and health advisory activities. Participants were grouped according to
functional limitations (abilities). Rhyming words were used to help
patients coordinate and control movements.

Delivery method: Group

Dose: Group training 2×/wk for 1 hr and home-based training 5×/wk

for 1.5 hr, both over the course of 3 mo.

Improvement: Social participation improved.

Impairment-Based Interventions to Improve Social Participation
B: Moderate Recommendation: Practitioners could use standard OT plus the RAPAEL® Smart Glove (Neofect,
Watertown, MA) with sensor device and training games to improve participation for adults poststroke
in the inpatient rehabilitation setting (dose: 5×/wk for 4 wk).
1b Shin et al. (2016) Participants: N 5 46 poststroke with minimal cognitive impairments
RCT
Setting: Inpatient rehabilitation
Korea
Intervention: Standard OT (ROM, strengthening, ADLs), plus RAPAEL
Smart Glove with sensor device and software application. Participants
played training games involving the forearm, wrist, hand, and fingers.
Games used an algorithm to adjust difficulty level and ROM.

Delivery method: Individual

(Continued)
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 18
Table 3. Clinical Recommendations for Interventions to Improve Social Participation (Cont.)
Grade/Evidence Level Citation Intervention Details
Dose: Standard OT (30 min 5 days/wk for 4 wk) 1 additional 30 min
with RAPAEL glove (5 days/wk for 4 wk)

Improvement: Activity participation significantly improved

B: Moderate Recommendation: Practitioners could provide group CBT (45 min) addressing balance self-efficacy
and task-oriented balance training (45 min) to improve community integration for adults poststroke
(dose: 90-min sessions 2×/wk for 8 wk)
1b K. P. Y. Liu et al. (2019) Participants: N 5 89 with single stroke in previous 1–6 yr, ability to
RCT walk 10 m independently

Intervention: 45 min of group-based CBT with the purpose of improving

balance self-efficacy and 45 min of task-oriented balance training

Delivery method: Group

Dose: 90-min session 2×/wk for 8 wk

Improvement: Social participation and community integration improved.

Decreased fear of falling was also noted.
B: Moderate Recommendation: Practitioners could provide a long-term (6-mo) group intervention in a community
setting that includes walking and strength and balance exercises to improve social participation for
adults poststroke (dose: 1 hr/day 3 days/wk for 6 mo)
1b Stuart et al. (2009) Participants: N 5 92. Chronic phase of stroke recovery (>9 mo
RCT poststroke), mild to moderate hemiparetic gait, age >39 yr, no aphasia
with inability to follow 2-step commands
Italy
Setting: Community based

Intervention: Stroke program, group classes of 9–13 people for 6 mo.

Program included walking, strength, and balance training exercises.

Delivery method: Group, community based

Dose: 1 hr/day 3 days/wk for 6 mo

Improvement: Social participation significantly improved.

Note. ADLs 5 activities of daily living; CBT 5 cognitive–behavioral therapy; CT 5 computerized tomography; MRI 5 magnetic resonance
imaging; OT 5 occupational therapy; RCT 5 randomized controlled trial; ROM 5 range of motion; TC 5 transitional care.

translate evidence from the systematic reviews to their interventions that strongly align with or are supportive
professional practice when collaborating with people of these factors in the context of the client’s occupa-
with stroke. Each case study highlights interventions tional profile. It is important to note that the evigraphs
that are supported by evidence and expert opinion. in these Practice Guidelines present simplified examples
Included with the case studies are decision-making ev- of the decision-making processes occupational therapy
idence graphics (evigraphs; Figures 1–4) developed by practitioners might use to address their specific clients’
the authors and AOTA staff on the basis of the clinical goals in relation to the setting.
recommendations. Evigraphs are presented in relation
to clinical recommendations for improving ADLs and
functional mobility (Figure 1), IADLs (Figure 2), social Case Study 1: Michelle
participation (Figure 3), and participation in the care- Occupational Profile
giver role (Figure 4). Michelle is a 55-yr-old woman who sustained an ische-
Evigraphs based on clinical recommendations were mic left cerebrovascular accident (CVA) of the internal
developed to assist practitioners with clinical decision carotid artery. She has a past medical history of hyper-
making. Practitioners must consider each potential in- tension, diabetes, and depression. One week ago, while
tervention in relation to the client’s individual goals, cooking dinner in her apartment, she felt dizzy, weak,
interests, habits, routines, and environment and choose and unable to keep her balance. Michelle’s wife, Chloe,
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 19
Table 4. Clinical Recommendations for Interventions to Improve Participation in the Caregiver Role
Grade/Evidence Level Citation Intervention Details
Combined Problem-Solving and Other CBT Techniques
A: Strong Recommendation: Practitioners should consider providing problem-solving therapy skills training
and other CBT techniques (modeling, reinforcement, stress management, reframing negative
thoughts) to improve caregiver depression, health, and satisfaction (dose: 1–2 in-person sessions
[home or during inpatient stay] and telephone follow-up for 3–12 mo)
1b Pfeiffer et al. (2014) Participants: N 5 122 caregivers
RCT
Setting: Home
Germany, United States

Delivery method: In person, in home, and then telephone

follow-up

Dose: 1 home visit postdischarge, 9 weekly telephone

calls over 3 mo, 1 additional home visit, and then
9 monthly telephone sessions for ≤12 mo

Improvement: At 3 mo, caregivers had significantly lower

depression, fewer physical complaints, and higher
satisfaction with leisure time compared with
preintervention; at 12 mo, they continued to have
significantly lower depression and fewer health
symptoms.
1b King et al. (2012) Participants: N 5 255 caregivers
RCT
Setting: Inpatient and home
United States
Intervention: Combined problem-solving training; skills
training; and the CBT techniques of stress management,
relaxation training, reframing negative thoughts, and
mood rating

Delivery method: In person, inpatient, with home-based

telephone follow-up

Dose: First 2 sessions (length not reported) were in-

person, inpatient, and Sessions 3–7 were conducted by
telephone over 3 mo.

Improvement: Significantly lower depression, life change,

and health symptoms at 3 mo (but no statistically
significant differences between groups by 6 mo
postdischarge).
Combined Problem-Solving and Stroke Education
A: Strong Recommendation: Practitioners should consider using stroke education in addition to problem-
solving skills training, during or immediately after discharge from inpatient care, with long-term
follow-up (3–6 mo), to improve caregiver outcomes (satisfaction, burden; dose: in-person and
remote sessions or remote-only [phone] sessions, weekly or biweekly for 2–6 mo)
1b Cheng et al. (2018) Participants: N 5 128 caregiver–patient dyads
RCT
Setting: Inpatient predischarge and home postdischarge
Hong Kong
Intervention: Problem-solving therapy skills training to
improve cognitive and behavioral skills for addressing
consequences of stroke and stroke education in
(Continued)

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 20
Table 4. Clinical Recommendations for Interventions to Improve Participation in the Caregiver Role (Cont.)
Grade/Evidence Level Citation Intervention Details
caregiving techniques and stroke information

Delivery method: In person and telephone follow-up

Dose: 2 in-person education sessions during inpatient

stay, 6 biweekly postdischarge telephone sessions over 3 mo

Improvement: The intervention group had significantly

improved caregiving competence, problem-solving coping
abilities, and satisfaction with perceived social support

Delivery method: In person during inpatient stay, and

telephone follow-up

Dose: 4 face-to-face, daily 1-hr inpatient sessions, with

telephone follow-up for 2 mo

Improvement: Family caregiver burden was significantly less

at both 2 wk and 2 mo after the intervention.
1b Perrin et al. (2010) Participants: N 5 61 caregiver–patient dyads
RCT
Setting: Inpatient and home
United States
Intervention: Stroke education (effects, prevention, and
recovery) and problem-solving therapy skills training

Delivery method: Face-to-face training and stroke

education before discharge and problem-solving
intervention via videophone calls each week

Dose: 1 1-hr inpatient, in-person session, 4 weekly

telephone follow-up sessions for 2 mo

Improvement: There was a significant decrease in

caregiver strain at both the 1- and 3-mo follow-up
assessments.
2b Bishop et al. (2014) Participants: N 5 49 caregiver–patient dyads
Pilot RCT
Setting: Home
United States
Intervention: Assist the stroke survivor and caregiver to
identify and address problems. Stroke-related education
and packets of information and resources were provided
as references for problems that were identified.

Delivery method: Telephone

Dose: 13 calls with caregiver over 6 mo, starting

(Continued)
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 21
Table 4. Clinical Recommendations for Interventions to Improve Participation in the Caregiver Role (Cont.)
Grade/Evidence Level Citation Intervention Details
postdischarge from inpatient rehabilitation

Improvement: Caregivers self-reported significantly higher

scores on family functioning, their own functional
independence (i.e., caregivers’ ADLs while caring for the
stroke survivor), and criticism of self at 3 mo and 6 mo
postdischarge.
FSO
A: Strong Recommendation: Practitioners should consider providing tailored, long-term (9-mo) support (case

Delivery method: Support before hospital discharge and

postdischarge home visits and telephone calls

Dose: Variable, as needed for 9 mo

Improvement: Significant improvement in caregiver

knowledge at both 4 and 9 mo (not mood or strain).
1a Mant et al. (2000) Participants: N 5 267 caregivers
Systematic review
Setting: Inpatient and home
United Kingdom
Intervention: The FSO was available to provide education
and support before discharge, at home, and via telephone,
as well as acting as a liaison with other services.

Delivery method: Support before hospital discharge and

postdischarge home visits and telephone calls

Dose: Variable, as needed for 9 mo

Improvement: Statistically significant improvement in the

intervention group in social activity level, QOL, and other
measures pertaining to maintenance of participation in the
caregiving role at 6 mo.
Problem-Solving Only
B: Moderate Recommendation: Practitioners could consider providing in-person problem-solving therapy skills
training and long-term telephone follow-up (3 mo), during inpatient care, immediately after
discharge, or both (1 3-hr in-person session, weekly in Mo 1, biweekly in Mo 2, and once in
Mo 3 postdischarge).
2b Grant et al. (2002) Participants: N 5 74 caregivers
Pilot RCT
Setting: Home
United States
Intervention: In-home problem-solving therapy skills
training session
(Continued)

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 22
Table 4. Clinical Recommendations for Interventions to Improve Participation in the Caregiver Role (Cont.)
Grade/Evidence Level Citation Intervention Details
Delivery method: In-person in-home and telephone follow-
up

Dose: Initial 3-hr meeting; telephone sessions weekly for

1st mo, biweekly for the 2nd mo, and once in the 3rd mo

Improvement: Significant improvement was seen in

vitality, mental health, role limitations, social problem-
solving skills, negative orientation, greater caregiver
preparedness, and depression at 13 wk postdischarge.

Delivery method: In-person, inpatient setting with home-

based telephone follow-up

Dose: 3-hr inpatient training, followed up with telephone

sessions weekly in 1st mo, biweekly in 2nd mo, and once
in 3rd mo

Improvement: Significantly better problem-solving skills and

caregiver preparedness at 2 and 5 wk postdischarge from
hospital but not at 13 wk.
Home-Based Interventions
B: Moderate Recommendation: Practitioners could consider providing long-term (6-mo) home visit interventions
that include education, ADL training, community resources, stress management, problem-solving
and coping strategies to improve caregiver health status, and mobilizing family support and
acquiring social support (dose: as needed over 6 mo, average 16 visits, 70-min session).
1b Ostwald et al. (2014) Participants: N 5 159 caregiver–patient dyads
RCT
Setting: Home
United States
Intervention: Support and education, including topics such as
ADL training with the stroke survivor, community resources
education, written stroke information, stress management,
problem-solving strategies, and coping strategies

Delivery method: Home visit

Dose: Average 16 70-min visits over 6 mo.

Improvement: Significant improvements in self-reported

health status at 6 mo and measures of mobilizing family
support and acquiring social support at 12 mo.
Telephone Group Education
B: Moderate Recommendation: Practitioners could consider providing long-term (2-mo) telephone-delivered
group education sessions to caregivers to improve perceived competence and burden (8 1-hr
sessions over 2 mo).
1b Hartke & King (2003) Participants: N 5 88 caregivers
RCT
Setting: Home
United States
Intervention: Psychoeducational telephone support group
combined with the use of home stress management
(Continued)

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 23
Table 4. Clinical Recommendations for Interventions to Improve Participation in the Caregiver Role (Cont.)
Grade/Evidence Level Citation Intervention Details
techniques. Provision of educational material in a manual,
and home use of a relaxation tape.

Delivery method: Group, telephone

Dose: 8 weekly 1-hr sessions

Improvement: Significant improvement in caregiver sense

of competence and burden.

Delivery method: Individual or group

Dose: 8 weekly 1-hr sessions

Improvement: Caregivers in both types of intervention

delivery (group or individual) had significantly better
confidence in their knowledge and increased use of
coping strategies than the control group 1 mo after
program completion. At 6-mo follow-up, both intervention
groups when combined had statistically significant better
knowledge of patient care, coping strategies, and social
support than the control group.
2b Wilz & Barskova (2007) Participants: N 5 89 caregiver–patient dyads
Pilot RCT
Setting: Home
Germany
Intervention: Stroke education, rehabilitation technique
information, expressing emotions, practicing cognitive
restructuring, problem solving, relaxation techniques, and
receiving professional support

Delivery method: Individual home based

Dose: 15 structured 1-hr sessions 2×/mo over 8 mo

Improvement: Statistically significant improvements in

psychological, social, and environmental QOL and
improved caregiver depression levels. The caregiver
outcomes were best for those caregivers whose spouse
also took part.
Skills Training Before Discharge and Home Follow-Up
B: Moderate Recommendation: Practitioners could consider providing inpatient skills training (transfers, ADLs,
communication, pressure ulcer prevention) for caregivers during the patient’s inpatient stay with in-
person home follow-up postdischarge to improve caregiver burden, QOL, anxiety, and depression
(3–4 30- to 45-min session and 1 home visit).
(Continued)

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 24
Table 4. Clinical Recommendations for Interventions to Improve Participation in the Caregiver Role (Cont.)
Grade/Evidence Level Citation Intervention Details
1b Kalra et al. (2004) Participants: N 5 300 caregiver–patient dyads
RCT
Setting: Inpatient and home
England
Intervention: Multiple training sessions (e.g., transfers, ADLs,
communication, prevention of pressure ulcers) in hospital
before discharge with a single at-home follow-up visit

Delivery method: Individual (inpatient and home

postdischarge)

Improvement: Significant improvement in caregiver burden,

QOL, anxiety, and depression.
Inpatient, Home, and Follow-Up Phone Call Intervention
B: Moderate Recommendation: Providers could consider providing educational and discharge support from
inpatient to home to improve caregiver preparation, social functioning, and QOL (4–5 30-min
inpatient sessions, 1 45-min telephone call, 30-min home visit at 1 wk and 1 mo postdischarge)
1b Shyu et al. (2008, 2010 [follow-up]) Population: N 5 158 caregiver–patient dyads
RCT
Setting: Inpatient and home
Taiwan
Intervention: Provision of health education, referral
services, and discharge planning education

Delivery method: Hospital before discharge combined with

a single telephone call and 2 home visits

Dose: 4–5 30-min visits during hospitalization, combined

with a single 30- to 45-min telephone visit at 1 wk
postdischarge and 30-min home visits at 1 wk and 1 mo
postdischarge

Improvement: Statistically significant improvements in

caregiver preparation scores, both self-rated and as rated
by a nurse. At follow-up, there was statistically significant
improvement in the intervention group, but only in social
functioning of the caregiver at 3 mo and quality of care
provided at 6 mo.

Note. ADL/ADLs 5 activities of daily living; CBT 5 cognitive–behavioral therapy; FSO 5 family support organizer; QOL 5 quality of life;
RCT 5 randomized controlled trial.

helped her to the couch and realized she was slurring Jasmine, who is in high school. They have a shower–
her words. Chloe called 911, and Michelle was rushed bath combo with shower curtains and a three-in-one
to the emergency room. A computerized tomography commode from Chloe’s earlier hip replacement. Mi-
scan showed a blockage of the left internal carotid ar- chelle works full time as an assistant manager of a
tery, and tPA was administered. She was admitted to retail shoe store and commutes by bus, and her wife
the acute care neurological unit, medically stabilized, works as a teacher. Michelle had difficulty with bed
and discharged to inpatient rehabilitation after 1 wk. mobility, transfers, and basic ADLs, such as dressing
Michelle presented with right-sided weakness and and bathing; however, she was able to groom and feed
expressive aphasia. She had difficulty communicating herself with set-up. Michelle’s family and friends were
and became easily frustrated, but she could follow very supportive and able to assist. Michelle enjoys cook-
two-step commands and accurately answer yes-and-no ing, reading, and painting. Michelle’s goal is to take care
questions. Michelle lives in a two-bedroom apartment of herself. Chloe reported that household duties were
in a building with an elevator and two steps to enter. shared; she performed the cleaning and laundry, and
She lives with her wife Chloe and 17-yr-old daughter Michelle performed money management and meal
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 25
Figure 1. Evidence-based interventions to improve ADLs and functional mobility after stroke.

Note. Practitioners should remain mindful of the continuum of care in the rehabilitation process and anticipate client needs when making de-
cisions and recommendations regarding intervention planning, future therapy, and discharge disposition. As always, intervention planning
should be collaborative and based on the client’s goals, interests, and functional abilities, and activities should be graded to maximize partici-
pation. See Table 1 for individual study information. Not all interventions from Table 1 are included. See Table 1 and the individual studies for
intervention-specific information; the shaded area of the table indicates interventions to support occupations. ADL 5 activities of daily living;
CBT 5 cognitive–behavioral therapy; FM 5 functional mobility; IRF 5 inpatient rehabilitation facility; ITSO 5 interventions to support occupa-
tions (preparatory activities); OP 5 outpatient; OT 5 occupational therapist; PROM 5 passive range of motion.

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 26
Figure 2. Evidence-based interventions to improve IADLs after stroke.

preparation. Because Chloe has arthritis and a busy conversation, and use gestures and visual aids. Table 5
schedule as a teacher and parent, she reported being summarizes the results of Michelle’s initial assessment.
worried about caring for Michelle at home. She stated Michelle’s treatment goals were as follows:
that it is very important that Michelle be able to perform 1. Michelle will perform bathing with supervision
medication management and other self-care tasks. with use of shower chair and grab bars using
adaptive techniques in 2 wk.
2. Michelle will perform toilet transfer, toileting,
Occupational Therapy Initial Evaluation and and dressing independently with use of adaptive
Findings equipment in 2 wk.
The occupational therapist at the inpatient rehabilita- 3. Michelle will improve her ability to use her right
tion facility completed a comprehensive initial upper extremity from use as an independent sta-
evaluation, including an occupational profile (AOTA, bilizer to use as a gross assist as per the FUEL to
2021), clinical assessments, the Inpatient Rehabilitation increase independence in ADLs in 2 wk.
Facility Patient Assessment Instrument (Centers for 4. With Chloe, Michelle will prepare a simple meal
Medicare & Medicaid Services, 2022) to determine the with minimal assistance using adaptive techni-
amount of assistance needed for self-care, the Cana- ques and equipment in 2 wk.
dian Occupational Performance Measure (COPM; Law 5. Michelle will manage medications independently
et al., 2019) to identify and prioritize everyday issues, using a medication organizer and smartphone cues
and the Functional Upper Extremity Levels (FUEL; in 2 wk.
Van Lew et al., 2015) to determine the functional abil-
ity of Michelle’s right upper extremity. The physical Occupational Therapy Interventions
therapist stated that Michelle required minimal assis- A multidisciplinary approach in an urban public reha-
tance for ambulation with a hemiwalker. The speech- bilitation hospital was used to develop Michelle’s
language pathologist recommended that the occupa- comprehensive plan, which included occupational
tional therapy practitioner speak slowly, provide time therapy, physical therapy, social work, speech therapy,
for Michelle to process and answer questions, encourage nursing, psychology, and physiatry. She was in the
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 27
Figure 3. Evidence-based interventions to improve social participation after stroke.

rehabilitation unit for 2.5 wk and received occupa- healthy individuals performing range-of-motion exer-
tional therapy 1.0 hr/day, 6 days/wk. cises and functional reaching and grasping movements
䊏
Action observation (AO) with task-oriented followed by task practice. For instance, Michelle would
training was selected to address ADLs and func- watch a video of an individual reaching for a cup on a
tional mobility (Peng et al., 2019). table and then practice the movement with assistance.
䊏 Self-regulatory modiﬁed constraint-induced move- AO was implemented in the morning for 20 min
ment therapy (SR–mCIMT) intervention was se- 3 days/wk (Peng et al., 2019), and Michelle and Chloe
lected to address IADLs such as meal preparation were trained in this method to perform the task in the
and medication management (Liu et al., 2016). evenings for 30 min 3–5 days/wk for 2 wk.
䊏
Self-management interventions, in collaboration
with physical therapy, were used to address
Self-Regulatory Modified Constraint-Induced
stroke management and prevention of further
Movement Therapy
strokes (Chen et al., 2018).
The occupational therapist included SR–mCIMT (Liu
䊏 Stroke education, skills training, and problem-
et al., 2016) for Michelle to improve IADLs, such as meal
solving therapy before discharge were selected for
prep, and health management occupations, for example,
Michelle and Chloe to improve Michelle’s ADL
medication management. The intervention consisted of
performance and quality of life and to reduce
1-hr sessions with the unaffected hand restrained with a
Chloe’s caregiver burden (Deyhoul et al., 2020).
mitt, thus forcing use of the affected hand during ADL
and IADL activities. However, for safety, the mitt was re-
Action Observation and Task-Oriented Training moved for transfers and ambulation. The first 5 days
After reviewing the clinical assessment of the affected focused on ADLs such as brushing teeth, upper and lower
upper extremity, the occupational therapist selected body dressing, toilet transfer, and bathing, and the re-
AO followed by task-oriented practice (Peng et al., maining 5 days focused on using a phone, preparing a
2019) to improve Michelle’s upper extremity function simple meal, folding laundry, putting clothing on hangers,
and ADLs. The occupational therapy practitioner sweeping the floor, and washing dishes. The focus of each
explained to Michelle and Chloe that AO is a multi- session was to have Michelle reflect on her abilities and
sensory approach that can be used with Michelle’s deficits in performing the tasks while using problem-
affected upper extremity and performed in therapy solving strategies, which included identifying the problem,
sessions, as well as in the evenings to increase repeti- generating solutions, implementing one solution, and
tion. Michelle and Chloe agreed to try AO. The evaluating the results to achieve task independence. The
intervention consisted of Michelle watching videos of occupational therapist provided guidance throughout the
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 28
Figure 4. Evidence-based interventions to support participation in the caregiver role.

session and used communication strategies recom- (Chen et al., 2018) for Michelle, which was designed
mended by the speech-language pathologist to facilitate to improve her self-efficacy regarding stroke knowl-
Michelle’s learning. Michelle’s unaffected arm was also edge and management, as well as ADL skills, through
restrained for an additional 3 hr a day with supervision of five individual sessions, one group session, and phone-
the nurse and family (Liu et al., 2016). Michelle and Chloe call follow-up. The individual sessions were held bed-
were taught that they could use the mitt in the evening side in the morning with Michelle and occurred on for
while performing the AO intervention. 20 min inpatient Days 3 to 7. These sessions included
ADL training, stroke education (e.g., risk factors), self-
health monitoring, complication prevention, goal set-
Patient-Centered Self-Management ting, and the creation of action plans regarding stroke
Empowerment Intervention management and rehabilitation through discussion
The occupational therapist included the patient- and written material. A 60-min group session with six
centered self-management empowerment intervention stroke patients was held on Day 7. The group session
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 29
Table 5. Occupational Therapy Evaluation Results for Michelle
Assessment Results
COPM (Law et al., 2019) Occupation: Performance (range 5 1–10), Satisfaction (range 5 1–10)
Bathing: Performance 2/10, Satisfaction 1/10
Dressing: Performance 2/10, Satisfaction1/10
Toileting and toilet transfer: Performance 2/10, Satisfaction 1/10
Preparing simple meal: Performance 1/10, Satisfaction 1/10
Medication management: Performance 1/10, Satisfaction 1/10
IRF–PAI (Centers for Medicare The IRF–PAI is a standardized assessment scored on a scale ranging from 1 to 6 (1 5
& Medicaid Services, 2022) dependent, 2 5 maximal assist, 3 5 moderate assist, 4 5 supervision or touching assist,
5 5 set-up or clean-up assist, 6 5 independent). Michelle’s self-care scores were as follows:
eating 5 5, oral hygiene 5 5, toileting hygiene 5 3, shower or bathe self 5 3, upper body

mal release; no finger individuation

䊏 Sensation: Impaired light touch in hand

䊏
Pain: Reported pain is 3 out of 10 pain with shoulder flexion and external rotation at
end-range PROM
Sitting balance: Good
Standing balance: Fair

Note. AROM 5 active range of motion; COPM 5 Canadian Occupational Performance Measure; FUEL 5 Functional Upper Extremity Levels;
IRF–PAI 5 Inpatient Rehabilitation Facility Patient Assessment Instrument; PROM 5 passive range of motion; WFL 5 within functional limits.

included watching a 20-min video regarding self- focused on strategies to increase performance of ADLs
management poststroke, and the remaining 40 min and IADLs through lectures, skills training (e.g., trans-
was dedicated to group members sharing their experi- fers, bathing, one-handed dressing strategies, adaptive
ences poststroke and the skills learned in their meal prep equipment), educational slide shows, discus-
individual sessions (Chen et al., 2018). The occupa- sions, and questions. The objective of the third day
tional therapist collaborated with psychology and
was to increase self-efficacy through problem-solving
nursing professionals to develop these individual ses-
therapy training. This included techniques to cope
sions and the group session, with speech therapy to
assist with Michelle’s communication in the group. with problems caused by the stroke by identifying a
problem, generating solution alternatives, analyzing
the solutions, implementing one, and evaluating the
Skills Training Before Discharge results. On the fourth day, Chloe was provided with
The occupational therapist incorporated several indi- stroke education handouts and stroke patient care
vidually tailored training sessions for both Michelle booklets, and competence was assessed by having her
and Chloe to increase Michelle’s ability to perform provide a verbal summary of the information and
ADLs and to reduce Chloe’s caregiving burden before training content to Jasmine, their daughter. Even
discharge (Deyhoul et al., 2020). The occupational though Chloe demonstrated competence with the
therapist collaborated with the physical therapist re- stroke education material, Jasmine was asked to re-
garding gait facilitation and with the speech-language mind Chloe about the stroke topics in the first week
pathologist regarding communication. The interven- after discharge at home. In addition, weekly phone
tion consisted of four 60-min sessions/day before calls from one of the rehabilitation team members
discharge. The objective of the first 2 days was to pro- were provided for 2 mo to address home safety and
vide stroke education and prevention and caregiving
fall prevention (Deyhoul et al., 2020).
strategies for Michelle and Chloe. Stroke education in-
cluded the following: stroke symptoms; ischemic
versus hemorrhagic strokes; risk factors such as hyper- Outcomes
tension and diabetes; stroke prevention methods such Table 6 summarizes Michelle’s results on discharge
as diet, diabetes, and hypertension monitoring and outcome measures.
control; treatment such as AO and CIMT; and stroke 䊏
Michelle attended all occupational therapy ses-
complications. Stroke caregiving training for Chloe sions and was consistent with her evening
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 30
Table 6. Occupational Therapy Discharge Results for Michelle
Assessment Results
COPM (Law et al., 2019) Occupation: Performance (range 5 1–10), Satisfaction (range 5
1–10)
Bathing: Performance 6/10, Satisfaction 6/10
Dressing: Performance 7/10, Satisfaction 6/10
Toileting and toilet transfer: Performance 7/10, Satisfaction 7/10
Preparing simple meal: Performance 5/10, Satisfaction 5/10
Medication management: Performance 7/10, Satisfaction 7/10
IRF–PAI (Centers for Medicare & Medicaid Services, 2022) The IRF–PAI is a standardized assessment scored on a scale
ranging from 1 to 6 (1 5 dependent, 2 5 maximal assist, 3 5
moderate assist, 4 5 supervision or touching assist, 5 5 set-up

䊏 Pain: Reported pain is 0 out of 10 pain with shoulder flexion

and external rotation at end-range PROM

Sitting balance: Good
Standing balance: Good

exercise program, including AO, task practice, hours in the evening while participating in home-
and SR–mCIMT. work given by all the therapists.
䊏 Michelle improved on all outcome measures and 䊏 Chloe reported that she was happy with the
met her goals. She improved in feeding, groom- home discharge plan for Michelle, although she
ing, dressing, toileting, and bathing with adap- was anxious about her ability to cope with many
tive equipment and one-handed techniques. facets of her life now, which included care of Mi-
䊏 Michelle continues to require supervision for chelle. However, she reported feeling more con-
bathing while seated in a shower chair for safety. fident with helping Michelle as needed and
䊏 Michelle is able to use her affected upper ex- addressing problems as they came up at home
tremity as a gross assist during functional tasks, using the problem-solving methods that she
such grasping a soda can with her affected hand learned from the occupational therapist. They
and opening it with her unaffected hand. How- both reported wanting some home care assis-
ever, she continues to have difficulty with open- tance and occupational and physical therapy
ing her affected hand and finger individuation. home health visits.
䊏
Michelle is able to independently manage her 䊏 Chloe stated that she would continue to use the
medication using a medication sorter and re- stress management techniques she learned and
minder alarms set on her smartphone. would follow the recommendations of the occu-
䊏 Michelle requires minimal assistance for simple pational therapy practitioner to participate in
meal preparation, such as managing tight con- the caregiver stroke support group and seek
tainers and cutting vegetables. treatment from a social worker or psychologist
䊏 Michelle reported feeling more confident in her for further cognitive–behavioral therapy strate-
ability to go home and is looking forward to re- gies to address anxiety.
turning to work in the near future because she was 䊏 Michelle was discharged home with a shower
able to tolerate 3 hr of therapy a day plus additional chair and grab bars for the bath and shower and
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 31
will use her commode over the toilet and at bed- 2005). These findings were included in a referral to a
side as needed. Michelle will receive home care local driving rehabilitation center that has a certified
2×/wk for 3 hr for IADLs, home management, driver rehabilitation specialist (CDRS®) on staff. The
and community reentry. physical therapist in the outpatient clinic administered
and reported the results of the 6-Minute Walk Test
(Dunn et al., 2015). The occupational therapist also
Case Study 2: James asked Juanita to complete the Caregiver Self-Assessment
Occupational Profile Questionnaire (Epstein-Lubow et al., 2010) to determine
James is a 70-yr-old man who experienced a right mid- whether she should be further evaluated for any signifi-
dle cerebral artery (MCA) occlusion ischemic stroke 18 cant levels of burden, depression, and burnout. Last, the
mo ago. James was hospitalized and then progressed to occupational therapist asked Juanita and James to com-
inpatient rehabilitation for 3 wk before returning home

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plete the Safe at Home Checklist (Rebuilding Together,
under the care of his wife, Juanita. James completed 19 n.d.) to identify any potential environmental safety haz-
sessions of outpatient occupational therapy and physi- ards. Table 7 summarizes the results of James’s initial
cal therapy to address weakness on his left side and assessment.
functional mobility. His last session was about 1 yr No home safety hazards were identified. The driv-
ago, and he was recently referred by his neurologist for ing evaluation found no cognitive or visual deficits
additional occupational and physical therapy in a com- that affected James’s ability to drive. However, slow
munity-based setting. Over the past year, James has reaction time resulting from anxiety affected his per-
returned to some of his valued occupations, such as formance. The CDRS recommended participation in a
gardening (modified) and watching high school and driving rehab program using a driving simulator and
college sports on television. James continues to struggle training with a spinner knob for one-handed driving
with a few daily tasks, such as showering and bathing given James’s limited left upper extremity active range
and meal preparation. He reports that he “feels stuck of motion. The physical therapist reported that the re-
and a burden” because he is reliant on Juanita and sults of the 6-Minute Walk Test showed that James
other family members to drive him and assist him with was significantly impaired in walking speed and en-
daily tasks. James and Juanita live in a small rural town durance (350 m or 382 yd with one 30-s seated rest
and have been very active in their local community break using his straight cane). James reported low con-
since their children were small. He has experienced fidence in his community mobility because of fatigue.
two falls, early after his discharge home; neither were Juanita reported caregiver strain and burnout and re-
injurious. Since then, he has been extremely cautious. vealed that she struggles with finding time alone
James has stopped attending local games because of his because James is at home most of the day.
slower walking speed and difficulty navigating stadium On the basis of James’s assessment results, the oc-
bleachers with his straight cane. He states that he cupational therapist, James, and Juanita developed the
spends about 3 hr/week in social activities, most of following long-term treatment goals:
which are coordinated by Juanita. James, Juanita, and 䊏
James will shower independently by discharge,
their extended family have planned a summer trip to a managing all parts of the shower, including the
large theme park, and James is concerned about his showerhead and bath products.
ability to tolerate the long days at the theme park on 䊏 James will drive himself in his own car between
foot. Juanita says James complains of being tired after home and known local destinations (e.g., gro-
15 min of moderate activity. cery store, high school) by discharge.
䊏 James will increase time spent in valued social
activities by 25% at 3 mo and by 50% at 9 mo.
Occupational Therapy Initial Evaluation and 䊏
James and Juanita will identify and implement
Findings three strategies for Juanita to increase the per-
On the basis of James’s primary complaints of reduced
centage of time spent alone and mentally unbur-
social interactions as a result of his functional mobility
dened from her caregiving role by 9 mo.
and feeling like a burden because of his difficulties 䊏 James will increase his conﬁdence in functional
performing ADLs and IADLs, the occupational thera-
mobility in unfamiliar environments and iden-
pist administered the COPM (Law et al., 2019) to
tify and implement strategies to decrease fatigue
further develop an occupational profile. Additionally,
during community mobility by discharge.
the occupational therapist had James perform some of
the identified areas of the COPM while Juanita videore-
corded and rated his performance using the Performance Occupational Therapy Interventions
Quality Rating System (PQRS; Martini et al., 2015). James participated in occupational therapy in a multi-
The occupational therapist screened James for cognitive disciplinary center with a specialty in neurological
and visual deficits that might affect his ability to drive disorders. He initially attended therapy 5×/wk for
using basic visuomotor screening (Gillen & Hreha, 2 wk and then 2×/wk for 6 wk. The occupational ther-
2021), the Snellen eye chart (Hetherington, 1954), and apist recommended a constraint-induced therapy
the Montreal Cognitive Assessment (Nasreddine et al., (CIT; task-oriented) approach to the intervention for
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 32
Table 7. Occupational Therapy Evaluation Results for James
Assessment Results
COPM (Law et al., 2019) and PQRS Managing showerhead and cleaning products during shower: COPM Performance,
(Martini et al., 2015) 2/10; COPM Satisfaction, 1/10; PQRS, 2/10
Flipping burgers and picking up hot dogs on the grill: COPM Performance, 3/10;
COPM Satisfaction, 1/10; PQRS, 3/10
Driving self to high school sports and local hardware store for gardening supplies:
COPM Performance, 1/10; COPM Satisfaction, 1/10; PQRS, not rated
Functional mobility in unfamiliar environments and uneven terrain: COPM
Performance, 4/10; COPM Satisfaction, 4; PQRS, 2/10
Attending local high school sports and interacting with friends: COPM
Performance, 4/10; COPM Satisfaction, 2/10; PQRS, not rated

䊏 Saccades—Normal

䊏 Gaze stabilization—Normal

䊏 Convergence—Normal

AROM screen Cervical: WFL

Right upper extremity: WNL
Left upper extremity:
䊏
Shoulder: 90 in all directions
䊏 Elbow: WFL, hypertonic

䊏 Wrist: 30 flexion, 10 extension

䊏
Hand: flexion, WFL (hypertonic); very limited extension due to tone
Modified Ashworth Scale (spasticity; Shoulder flexors: 0/4
Bohannon & Smith, 1987) Elbow flexors: 11/4
Wrist flexors: 2/4
Finger flexors: 2/4
Caregiver Self-Assessment Questionnaire Total score: 13/16
(Epstein-Lubow et al., 2010) Current level of stress: 7/10
Current health compared with last year: 4/10

Note. AROM 5 active range of motion; COPM 5 Canadian Occupational Performance Measure; MoCA 5 Montreal Cognitive Assessment;
PQRS 5 Performance Quality Rating Scale; WFL 5 within functional limits; WNL 5 within normal limits.

the first 2 wk. After the CIT protocol and the evidence James and Juanita, selected a CIT approach to address
supporting it were explained to them, James and James’s concerns with being able to cook and grill for
Juanita agreed to try it. During the follow-along phase his family and manage all components of taking a
of CIT in the latter 6 wk, James attended group-based shower (Lin et al., 2009; Liu et al., 2016). The occupa-
cognitive–behavioral therapy (CBT) paired with task- tional therapy practitioner followed the dosing in Liu
oriented training for balance and functional mobility et al. (2016) and Lin et al. (2009), scheduling 1-hr ses-
led by an occupational therapy assistant and a licensed sions 5 days/wk for 2 wk. James wore a mitt on his
physical therapy assistant. James’s occupational thera- right hand during the in-clinic sessions and for up to
pist was not a CDRS, so he was referred to a local 4 hr per day. He recorded his performance of several
driving rehabilitation center. Juanita attended most daily tasks on his homework sheet and committed to
outpatient sessions with James, and the occupational intensive individual practice and problem solving for
therapist integrated CBT methods and a problem- up to 2 additional hr/day. The occupational therapist
solving approach for both James and Juanita into the completed an activity analysis of showering and grill-
sessions. Last, the occupational therapist recom- ing (based on PQRS ratings of videos) and used the
mended that Juanita attend the local stroke support findings to tailor the shaping tasks for James. For ex-
group and connected her with a clinical psychologist ample, James had difficulty with supination while
who specialized in CBT methods. using the heavy grill spatula to flip hamburgers. For a
shaping task, James started with the task of sliding his
Constraint-Induced Therapy hand under the page of a board book to turn it. He
After reviewing the ADL and IADL evigraphs (Figures progressed to turning over playing cards and then
1–2), the occupational therapist, in collaboration with pancakes using a light spatula. The occupational
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 33
therapist also integrated problem solving into the ses- and challenging his reaction time. James has weakness
sions to provide James with strategies to use in other on the left side, so the occupational therapist trained
areas of occupational performance. Specifically, the James in using a spinner knob attached to the steering
occupational therapist taught James to use the self- wheel. The occupational therapist also included train-
regulation strategy to self-identify problems and solu- ing in the other components of driving, such as
tions and practice adapted tasks. For example, James starting the car, shifting, and fastening a seatbelt with
would often become frustrated when he was unable to hemiparesis.
open various bottles during his shower. Using a self-
regulation strategy, James was able to identify that his
Caregiver: Cognitive–Behavioral Techniques and
current approach to opening a bottle of shampoo was
Problem Solving
not working and to try a different strategy. If the new
At the recommendation of James’s usual occupational

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strategy did not work, he would be able to reflect on
therapy practitioner, Juanita began attending the local
what was different, what worked and what did not,
caregiver stroke support group that met once a month
and try something different.
via videoconference. The occupational therapy practi-
tioner also continued to use problem-solving training
Group-Based Cognitive–Behavioral Therapy and with Juanita via phone calls. The sessions focused on
Task-Oriented Training giving her the strategies to define problems, brain-
Starting in Wk 3, James attended a group class 2×/wk storm solutions, try solutions, and then reflect on how
for 6 wk via videoconferencing (T. W. Liu et al., the solution worked (Pfeiffer et al., 2014). Juanita iden-
2019). The group was co-led by an occupational ther- tified a thought pattern similar to James’s, in that she
apy assistant trained in CBT techniques and a physical felt anxious leaving him alone, which contributed to
therapy assistant. Each class was 90 min long. The first burnout. Juanita and the occupational therapist brain-
half of the class was led by the occupational therapy stormed a few solutions, such as reframing her
assistant and focused on CBT with the purpose of im- anxious thought with a positive one and practicing
proving balance self-efficacy. The two main strategies breathing techniques to calm her anxiety. Juanita also
were cognitive restructuring and behavior modifica- decided that she and James would keep their cell
tion. Cognitive restructuring has four steps, including phones with them at all times in case of an emergency.
identification of automatic thoughts. This addresses Juanita scheduled an appointment with a clinical psy-
maladaptive thoughts that can influence a person’s chologist for additional therapy to address her anxiety
balance performance. Behavior modification strategies and depression related to caregiving.
include helping participants identify potential risks
and develop behavioral strategies to help them increase
Outcomes
their activity levels. James discovered that he was
At the end of 8 wk of outpatient rehabilitation, James
somewhat fearful of walking alone because he was of-
met several of his goals. James can shower indepen-
ten scolded by nursing staff in inpatient rehabilitation
dently, reducing the burden on Juanita. James and
whenever he tried to get up and walk on his own. He
Juanita have had several conversations about Juanita’s
developed a new mantra, “my legs are strong,” and set
caregiver role and worked together to restructure the
a timer on his phone to prompt him to get up every
guest bedroom in their house to be a quiet space for
hour and take a walk. The second half of the class was
Juanita to do yoga, sew, and have alone time. Addi-
led by the physical therapy assistant and included
tionally, James’s confidence in his ability to walk
strengthening and balance exercises in addition to task
outside has increased, and he now walks with a friend
practice. All exercises and tasks were customized for
to the town diner three times a week. This gives Jua-
individual participants and group discussion, and par-
nita time alone in the house. Because of her problem-
ticipants were encouraged to reassure one another. For
solving training, Juanita has noticed that she is more
James, there was an additional focus on endurance
confident in her ability to cope with future problems
during balance exercises and strengthening.
and worries less about James’s safety. She also practi-
ces strategies to reframe her anxious thoughts and to
Driving Rehabilitation calm herself with relaxation techniques. James and
James attended driving rehabilitation at a local center Juanita have started taking their elementary-age grand-
that had a driving simulator for both testing and driv- children to a local farm to pick fruit and to fish in a
ing training (Devos et al., 2009). The system included pond to further increase James’s confidence in his mo-
a life-sized car and surround screens. Scenarios and bility on uneven surfaces, such as his garden, and to
difficulty settings could be programmed by the occu- increase his activity tolerance. James plans to plant a
pational therapist, who was a CDRS. James began small salad garden next spring. He has started imple-
driving rehabilitation in Wk 3, attending a 1-hr menting strategies from CIT into meal preparation in
session, 1×/wk, for 8 wk. The CDRS focused on the kitchen and using the grill. He still requires some
improving James’s confidence behind the wheel, grad- assistance with flipping hamburgers because of tone in
ually increasing the complexity of driving scenarios his left forearm, limiting supination; however, he
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 34
reports that he finds the tasks more enjoyable and even questions for the systematic reviews were developed
agreed to help serve hot dogs at the local high school with an intentional focus on occupation-based out-
sports department fundraiser. James has attended two comes. Improvement in these outcomes is the goal of
of the past five high school football games and plans to occupational therapy, so the systematic reviews targeted
attend some basketball games in the coming season. studies reporting occupation-based interventions and
James is still in driving rehabilitation and plans to take outcomes. Additionally, the guidelines provide materi-
his driving test in 2 mo. He has been practicing driving als to help practitioners see how the research findings
on short, simple routes with his CDRS. Table 8 sum- might be translated to the practice setting.
marizes James’s results on discharge outcome The stroke intervention literature is relatively abun-
measures. dant in the areas of research on ADLs and caregivers
of people with stroke. The systematic review for ADL

Strengths Limitations: Gaps in the Evidence

At every step of the process, the review authors fol- Gaps in knowledge exist when the information in the
lowed best-practice methodology to the best of their literature about an intervention is insufficient, impre-
ability, including getting input at all stages from practi- cise, inconsistent, or biased (Robinson et al., 2011).
tioners, researchers, consumers, and experts in the Gaps also exist when the literature is not sufficient to
areas included in the reviews. The clinical recommen- answer a clinical question.
dations are based on findings from the systematic Lack of research supporting specific interventions
reviews. It is worth noting that the systematic reviews does not mean practitioners should not use those in-
on which these practice guidelines are based include terventions. When providing occupational therapy
available research published since the previous reviews services to clients, practitioners considering specific in-
(2012–2019), or, in the case of the question regarding terventions when there is not enough evidence to
caregivers of people with stroke, an even greater period support evidence-based practice should use expert
of time because this question had not been addressed knowledge and their own training and experience to
in the previous reviews (i.e., 1999–2019). The review guide practice. In this section, we pinpoint important

Table 8. Occupational Therapy Discharge Results for James

Assessment Results
COPM (Law et al., 2019) and PQRS Managing showerhead and bath products during shower: COPM
(Martini et al., 2015) Performance, 9/10; COPM Satisfaction, 10/10; PQRS, 8/10
Flipping burgers and picking up hot dogs on the grill: COPM
Performance, 7/10; COPM Satisfaction, 5/10; PQRS, 6/10
Driving self to high school sports and local hardware store for gardening supplies:
COPM Performance, 5/10; COPM Satisfaction, 5/10; PQRS, not rated
Functional mobility in unfamiliar environments and uneven terrain: COPM
Performance, 7/10; COPM Satisfaction, 4/10; PQRS, 7/10
Attending local high school sports and interacting with friends: COPM
Performance, 8/10; COPM Satisfaction, 8/10; PQRS, not rated
Caregiver Self-Assessment Questionnaire Total score: 6/16
(Epstein-Lubow et al., 2010) Current level of stress: 2/10
Current health compared with last year: 4/10

Note. COPM 5 Canadian Occupational Performance Measure; PQRS 5 Performance Quality Rating Scale.

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 35
gaps in evidence for interventions and approaches topics have stronger evidence (e.g., Level 1b) but only
practitioners may consider using, as appropriate. within a specific substroke population. Additional gaps
Occupational therapy practitioners need to think include a lack of research participant diversity, limited
about the elements of evidence-based practice as use of participation as a primary outcome measure,
they evaluate these guidelines, considering gaps in the and a focus on changes in impairment rather than
literature related to their clinical practice. Practitioners changes in occupational performance. Despite these
should consider the following questions when they gaps, occupational therapy practitioners should con-
identify these gaps (Gutenbrunner & Nugraha, 2020): tinue to use comprehensive, client-centered, and
1. What evidence exists? functional assessments and interventions and are
*
What are the best practices associated with urged to collaborate with researchers to provide evi-
providing services to this client population? dence for these important topics.

Gaps in the Literature Participation Outcome Measures

Gaps in stroke rehabilitation research with respect to As a construct, social participation was generally as-
the role of occupational therapy can be attributed to sessed through a component of a broader assessment
several factors. Some topics have minimal research or tool, such as the 36-item Short Form Survey (SF–36;
lower level evidence (e.g., Level 3b), whereas other Hays et al., 1993) or the Stroke Impact Scale (Mulder
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 36
& Nijland, 2016). Additionally, most assessment tools Visuospatial and Neurobehavioral Impairments
that include questions related to social participation Related to ADLs, IADLs, and Social Participation
have a narrow and limited scope. Social participation Occupational therapy practitioners should address
is multifaceted and includes physical abilities as well as stroke clients’ visuospatial (e.g., hemianopsia, diplopia)
emotional and social considerations; thus, changes in a and neurobehavioral impairments (e.g., ideational
client’s participation in everyday social activities do not apraxia, motor apraxia, neglect) because these impair-
occur rapidly (Tipnis et al., 2023). Occupational thera- ments can negatively affect occupations, occupational
pists are encouraged to assess the social participation of performance, and quality of life (Gillen & Hreha, 2021).
each client who has had a stroke and to consider using They should perform a comprehensive assessment of
more robust measures of social participation, such as the client’s abilities, limitations, and functional goals
the PROMIS® Social Function measures (Cella et al., and implement a comprehensive client-centered treat-

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2010) or the Assessment of Life Habits (Fougeyrollas ment plan. The minimal research in this area has shown
et al., 2002). Future research should consider a focus on improvements, but findings are limited to gains at the
social participation as a primary outcome and design impairment level or consist of low-level research related
studies that include appropriate time scales for assess- to ADL outcomes (Gillen, 2009; Gillen & Hreha, 2021).
ment (≥1 yr pre–post). Thus, higher levels of research are needed to address
Similarly, few stroke caregiver studies included visuospatial and neurobehavioral interventions to
outcome measures of the caregivers’ occupational per- improve occupational performance in ADLs, IADLs,
formance or participation. Most caregiver intervention leisure, and work.
outcomes were impairment based and measured self-
reported burden, strain, or coping (e.g., Caregiving
Burden Scale; Elmstahl et al., 1996); depression or anxi- Additional Implications for
ety (e.g., Center for Epidemiological Studies–Depression Occupational Therapy
scale (Radloff, 1977); or quality of life (e.g., SF–36; Rand To complement the clinical recommendations pro-
Corporation). A few studies measured caregivers’ vided in Tables 1 to 4, the sections that follow describe
knowledge of care techniques and their performance of general implications for occupational therapy with
caregiving skills. For example, Mant et al. (2000, 2005) people with stroke and their care partners, based on
included the Frenchay Activities Index (Schuling et al., stroke-related evidence and best-practice occupational
1993) to determine how the intervention affected care- therapy principles.
givers’ social activity level. Given the large number of
caregivers of people with stroke, their significance as a
stroke team member, and the effect of caregiver perfor- Occupation-Based Assessment and Intervention
mance on the stroke patient’s outcomes, practitioners Occupational therapy practitioners and researchers
must consider caregivers’ occupational performance should focus on occupation-based rather than impair-
and participation in addition to their caregiving capa- ment-based assessments and interventions. Occupation-
bilities. Future research should also include outcome based intervention can be integrated into stroke rehabili-
measures that determine whether caregiver interven- tation in two ways: occupation as ends or occupation as
tions improve performance and participation in means. Occupation as ends refers to tasks or activities
caregiving skills and in caregivers’ valued occupations. that a client needs to or wants to perform, for example,
practicing dressing so that the client will be able to dress
in the morning before work. Occupation as means refers
Modifiable Risk Factors: Health Promotion and to using occupations to improve client factors or perfor-
Prevention mance skills, such as using the Nintendo Wii to improve
The OTPF–4 (AOTA, 2020) designates health manage- eye–hand coordination or hand strength. Occupations
ment as an occupation within the domain of practice are the hallmark of the occupational therapy profession
and defines aspects that should be addressed in inter- and should be the focus of occupational therapy practi-
vention, such as social and emotional health promotion, tioners and researchers.
communication with health care providers; physical
activity; and management of symptoms, conditions,
medications, nutrition, and personal care devices. Occu- Interventions That Clients Perform Outside of
pational therapy practitioners should collaborate with Therapy Sessions
interprofessional teams to assess and treat these compo- For individuals poststroke, the context of activity and
nents of health management in people with stroke to repetition are important to recovery, specifically to
prevent another stroke, to prevent disabilities or promote neuroplastic changes (Hara, 2015; Rahayu
complications resulting from stroke, and to support et al., 2020; Singh et al., 2021), making it critical for
participation in other occupations (AOTA, 2020; Tsao occupational therapy practitioners to train clients in
et al., 2022). Researchers should also consider investi- therapeutic interventions, such as AO, mirror therapy,
gating the efficacy of health promotion and prevention or CIT, that can be performed independently outside
interventions for the performance of the occupations of formal therapy sessions (i.e., in the home or in the
that make up health management. evening in the rehabilitation hospital). These
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 37
approaches are low cost and easy to administer, pro- Summary
vide opportunities for increased practice and These Practice Guidelines summarize the current evi-
neuroplastic changes, and subsequently lead to in- dence to inform occupational therapy practitioners’
creased occupational performance. clinical decision making when collaborating on inter-
ventions with clients with stroke, their caregivers, and
interdisciplinary team members. Included are evi-
Remote Service Delivery Models
dence-based interventions to address occupational
Interventions performed by telephone or telephone
performance in ADLs, IADLs, and social participation
follow-up after discharge were found to have strong or
for clients who have had a stroke and interventions for
moderate evidence for improving ADLs (Chen et al.,
their caregivers to maintain the caregiving role. On the
2018; Sit et al., 2016), IADLs (Sit et al., 2016), and so-
basis of the findings of the systematic reviews, occupa-
cial participation (Geng et al., 2019) of people with

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tional therapy practitioners have many choices of
stroke. Telephone interventions were widely used with
evidence-based interventions to offer their clients with
caregivers of people with stroke. Much research found
stroke and their caregivers and on which to collaborate
strong and moderate levels of evidence for providing
with interprofessional team members. These Practice
telephone interventions and follow-up postdischarge
Guidelines also provide two practical case examples
in CBT and problem-solving training, education, and
and evigraphs to guide evidence-based decision mak-
support to caregivers (Bishop et al., 2014; Cheng et al.,
ing and intervention planning. Although much
2018; Deyhoul et al., 2020; Hartke & King, 2003; King
research was found, particularly with respect to ADLs,
et al., 2012; Kuo et al., 2016; Lincoln et al., 2003; Mant the Practice Guidelines identify gaps in the research
et al., 2000; Perrin et al., 2010; Pfeiffer et al., 2014; that are based on expert opinion and the evidence.
Shyu et al., 2008). Occupational therapy practitioners Occupational therapy practitioners have an integral
should consider offering interventions that would be role to play in all practice settings in which people with
appropriate to deliver remotely, such as education or stroke are treated, from acute care to community
support. This may ease the burden and stress caused programming. They are unique members of the rehabil-
by in-person therapy sessions for both the person with itation team because of their holistic consideration of
stroke who may have multiple impairments and the the many factors that influence occupational perfor-
caregiver who has limited time and energy. mance and participation. Practitioners should use the
evidence in these Practice Guidelines, along with their
Caregiving as a Co-Occupation professional experience and reasoning and the preferen-
Not only is the caregiver an important stroke team ces of the client and family. Delivering evidence-based
member, but they should also be considered as clients and innovative care to people with stroke and their care-
and, consequently, should be a focus of interventions givers in traditional and nontraditional settings is
for performing caregiving tasks and maintaining their challenging, but the profession must continue to evolve,
own occupational participation and quality of life with practitioners implementing best practice as evidence
(AOTA, 2020). Research has shown that caregivers changes and advances, to ensure that occupational ther-
who are physically and emotionally well provide better apy educational programs prepare future practitioners
care, resulting in better outcomes for the care recipient for best practice, and to grow a body of research
who has had a stroke (Bakas et al., 2014). However, grounded in occupation.
studies have found that the time therapists spend with
caregivers of people with stroke is short, and the topics Acknowledgments
addressed are limited (Lawson et al., 2015). Occupa- The authors acknowledge and thank the following
tional therapy practitioners should be familiar with a individuals for their participation in the content re-
variety of caregiver assessments and follow the recom- view and development of this publication:
mendations for best practice in interventions for
caregivers in these Practice Guidelines. Practice Guideline Series Editor
Susan Cahill, PhD, OTR/L, FAOTA, Director of Evidence-
Based Practice, American Occupational Therapy Associa-
Psychotherapeutic Interventions tion, North Bethesda, MD
CBT, problem-solving therapy, self-management tech-
niques, and empowerment coaching were found to be Contributing Practice Guideline Editor
effective tools in improving ADLs and IADLs in peo- Deborah Lieberman, MHSA, OTR/L, FAOTA, Former
ple with stroke and in improving caregivers’ quality of Vice President, Practice Improvement, American
life and ability to perform caregiving tasks (Grant Occupational Therapy Association, North Bethesda,
MD
et al., 2002; T. W. Liu et al., 2019; Pfeiffer et al., 2014;
Sit et al., 2016; Wang et al., 2018). As with any unfa- Practice Guideline Editor and Research Methodologist
miliar technique, occupational therapy practitioners Elizabeth G. Hunter, PhD, OTR/L, Assistant Professor,
should consider seeking additional training to imple- Graduate Center for Gerontology, College of Public
ment them skillfully. Health, University of Kentucky, Lexington
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 38
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Systematic Review Authors
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Anna Boone, PhD, MOT; Daniel Geller, EdD, MPH,
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OTR/L; Glen Gillen, EdD, OTR/L, FAOTA; Carly Gold- 10.1177/0269215517701804
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Appendix: Overview of the Systematic 䊏Publication dates as follows: Question 1, Janu-

Review Methods and Findings ary 1, 2012–December 31, 2019; Questions 2–3,
The systematic reviews completed for these Practice January 1, 2009–December 31, 2019; Question
Guidelines were conducted according to the Cochrane 4, January 1, 1999–December 31, 2019
Collaboration methodology (Higgins et al., 2019) and
䊏Levels 1a, 1b, 2a, 2b, and 3a evidence, and Level
are reported in a manner consistent with the Preferred 3b evidence if no higher-level studies are available
(see “Levels of Evidence” section)
Reporting Items for Systematic Reviews and Meta- 䊏Interventions within the scope of occupational
Analyses guidelines (Moher et al., 2009).
therapy practice
䊏Participants who were adults ages >18 yr
Review Questions 䊏Participants after stroke, as well as caregivers of
1. What is the evidence for the effectiveness of inter- adults with stroke.
ventions within the scope of occupational therapy Exclusion criteria were as follows:
practice to improve performance and participa- 䊏Dissertations, theses, presentations, and
tion in activities of daily living (ADLs) for adult proceedings
stroke survivors? 䊏Published outside the date range of the reviews
2. What is the evidence for the effectiveness of inter- 䊏Level 4 or 5 evidence
ventions within the scope of occupational therapy
䊏Interventions outside of scope of occupational
practice to improve performance and participa- therapy practice
tion in instrumental activities of daily living
䊏Average age of participants <18 yr.
(IADLs) among adult stroke survivors? The following databases were searched:
3. What is the evidence for the effectiveness of inter-
䊏MEDLINE
ventions within the scope of occupational therapy
䊏PsycINFO
practice to improve the performance of and par-
䊏CINAHL
䊏OTseeker
ticipation in education, work, volunteering, lei- 䊏
Cochrane databases
sure, and on social participation among adult 䊏Hand search as needed.
stroke survivors?
4. What is the evidence for the effectiveness of inter-
ventions within the scope of occupational therapy Levels of Evidence
practice for caregivers of people who have had a Each article evaluated in the reviews was assigned a
stroke that facilitate maintaining participation in level of evidence using the Oxford Centre for
the caregiver role? Evidence-Based Medicine (2009) framework:
䊏 Level 1a: Systematic review of homogeneous
randomized controlled trials (RCTs; e.g., similar
Inclusion and Exclusion Criteria, population, intervention) with or without meta-
Databases Searched, and Search analysis
Terms 䊏 Level 1b: Well-designed individual RCT (not a pi-
Table A.1 summarizes the search strategies for these lot or feasibility study with a small sample size)
systematic reviews. Inclusion criteria were as follows: 䊏
Level 2a: Systematic review of cohort studies
䊏Peer-reviewed journal articles 䊏
Level 2b: Individual prospective cohort study,
䊏Publication in English (unless review authors low-quality RCT (e.g., <80% follow-up or low
were able to translate) number of participants, pilot or feasibility

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 44
Table A.1. Search Strategy for Systematic Review Questions
Category Key Search Terms
Diagnosis and stroke, cerebrovascular accident, cerebrovascular disorders, hemiparesis, hemiplegia
conditions
Study and trial designs best practices, case control, case report, case series, clinical guidelines, clinical trial, cohort,
comparative study, controlled clinical trial, cross over, cross-sectional, double-blind, evaluation
study, evidence-based, evidence synthesis, feasibility study, follow-up, intervention, longitudinal,
main outcome measure, meta-analysis, multicenter study, observational study, outcome and
process assessment, practice guidelines, prospective, random allocation, randomized controlled
trials, single subject design, standard of care, systematic literature review, systematic review,
treatment outcome

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 45
Table A.1. Search Strategy for Systematic Review Questions (Cont.)
Category Key Search Terms
political, productive activities, reading, recreation, relationships, retired senior volunteer program
(RSVP), retirement, retirement planning, retirement preparation, return to work, senior center,
smartphone use, social activity, social adjustment, social capital, social environment, social
interaction, social isolation, socialization, socializing, social participation, social skills, social
support, sports, travel, volunteer, volunteer exploration, volunteerism, volunteer participation,
volunteer work, wage earner, work, work role, work transition, worker, writing
Question 4: Caregiver caregiver, caregiver appraisal, caregiver burden, caregiver burnout, caregiver confidence, caregiver
burden depression, caregiver education, caregiver participation, caregiver perception, caregiver quality of life,
caregivers, caregiver strategies, caregiver stress, caregiver support, caregiver training, caregiver upset,

Note. ADL 5 activities of daily living; BADL 5 basic activities of daily living; EMG 5 electromyography; IADL 5 instrumental activities of
daily living; Q 5 question.

study), ecological study, or two-group non- consultation with a third party (an American Occu-
randomized study pational Therapy Association Evidence-Based Pro-
䊏
Level 3a: Systematic review of case–control studies gram team member) until consensus was reached.
䊏 Level 3b: Individual retrospective case–control The review teams then obtained and reviewed the
study, one-group nonrandomized pretest–post- full-text articles to determine inclusion or exclusion.
test study, or cohort study They extracted data from the included studies in an
䊏 Level 4: Case series (or low-quality cohort or evidence table that summarized each study’s meth-
case–control study) ods, risk-of-bias evaluation, participants, interven-
䊏 Level 5: Expert opinion without explicit critical tion setting, intervention and control conditions,
appraisal. outcome measures, and results.

Article Screening and Data Extraction Quality of the Evidence and Risk of
A medical librarian conducted the searches and re- Bias
moved duplicates; review teams (of at least two au- Two members of the review teams independently
thors) independently screened titles and abstracts assigned quality ratings to each study and collabo-
based on the inclusion criteria. Reviewers resolved rated to reach consensus. The review teams evalu-
any differences by discussion and, if necessary, ated the risk of bias on the basis of study design

Table A.2. Strength of Evidence (Level of Certainty) Designations

Level Description
Strong 䊏 Two or more Level 1a or 1b studies
䊏 The available evidence usually includes consistent results from well-designed, well-conducted studies. The find-
ings are strong, and they are unlikely to be strongly called into question by the results of future studies.
Moderate 䊏 At least 1 Level 1a or 1b high-quality study or multiple moderate-quality studies (e.g., Level 2a or 2b,
Level 3a or 3b).
䊏 The available evidence is sufficient to determine the effects on health outcomes, but confidence in the es-
timate is constrained by such factors as
*
number, size, or quality of individual studies and
* inconsistency of findings across individual studies.

䊏 As more information (other research findings) becomes available, the magnitude or direction of the ob-
served effect could change, and this change may be large enough to alter the conclusion related to the
usefulness of the intervention.
Low 䊏 Small number of low-level studies, flaws in the studies, etc.
䊏
The available evidence is insufficient to assess effects on health and other outcomes of relevance to occu-
pational therapy. Evidence is insufficient because of
* limited number or size of studies,

* important flaws in study design or methods,

* inconsistency of findings across individual studies, and

* lack of information on important health outcomes.

䊏 More information may allow estimation of effects on health and other outcomes of relevance to occupa-
tional therapy.

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 46
Table A.3. Number of Articles Included in the Systematic Reviews, by Topic
Level of Evidence
Review Question Topic 1a 1b 2b Total
ADLs 24 42 0 66
IADL 0 9 10 19
Education, work, leisure, volunteering, social participation 0 17 32 49
Caregiver 0 22 12 34
Total 24 90 54 168

Note. None of the studies included in these reviews reported adverse events or harms related to the interventions evaluated. ADLs 5 activi-

(controlled or noncontrolled trial). For studies that guidelines.) Citations for the systematic review articles
included a control group (randomized or non- and systematic review briefs are as follows:
randomized), they used the Cochrane tool (Higgins
et al., 2016); for noncontrolled trials, they used a Geller, D., Goldberg, C., Winterbottom, L., Nilsen, D. M., Mahoney, D.,
tool developed by the National Heart, Lung, and & Gillen, G. (2023a). Systematic Review Briefs—Task oriented
Blood Institute (2014). training interventions for adults with stroke to improve ADL and
functional mobility performance (2012–2019). American Journal of
Occupational Therapy, 77(Suppl. 1), 7710393050. https://doi.org/
Strength of Evidence 10.5014/ajot.2023.77S10005
Each systematic review team grouped the evidence Geller, D., Goldberg, C., Winterbottom, L., Nilsen, D. M., Mahoney, D., &
into themes and determined the strength of the evi- Gillen, G. (2023b). Systematic Review Brief—Task-oriented training with
cognitive strategies for adults with stroke to improve ADL and/or functional
dence for each theme. The strength-of-evidence desig-
mobility performance (2012–2019). American Journal of Occupational
nations are outlined in Table A.2 and are based on
Therapy, 77(Suppl. 1), 7710393030. https://doi.org/10.5014/
U.S. Preventive Services Task Force (2018) guidelines.
ajot.2022.77S10003
Strength-of-evidence designations are a synthesis of Geller, D., Winterbottom, L., Goldberg, C., Nilsen, D. M., Mahoney, D., &
number of studies, level of evidence, quality of evi- Gillen, G. (2023). Systematic Review Briefs—Exercise for adults with
dence (risk of bias), and findings of the studies (e.g., stroke to improve ADL and/or functional mobility performance
significance). Synthesizing these four elements of the (2012–2019). American Journal of Occupational Therapy, 77(Suppl. 1),
evidence enabled the review authors to determine the 7710393040. https://doi.org/10.5014/ajot.2023.77S10004
level of certainty that the interventions discussed in Goldberg, C., Winterbottom, L., Geller, D., Nilsen, D. M., Mahoney, D.,
the articles resulted in the outcomes shown. & Gillen, G. (2023a). Systematic Review Brief—Preparatory
interventions to support ADL performance for adults with stroke
(2012–2019). American Journal of Occupational Therapy, 77(Suppl.
Overview of Search Results 1), 7710393010. https://doi.org/10.5014/ajot.2023.77S10001
The searches located 82,357 citations and abstracts for Goldberg, C., Winterbottom, L., Geller, D., Nilsen, D. M., Mahoney, D.,
Questions 1–3 and 2,976 for Question 4. The research & Gillen, G. (2023b). Systematic Review Brief—Technology-related
methodologist completed the first step of eliminating interventions to improve performance in activities of daily living for
adults with stroke (2012–2019). American Journal of Occupational
references on the basis of title, removing duplicates and
Therapy, 77(Suppl. 1), 7710393020. 10.5014/ajot.2022.77S10002
studies clearly not within the parameters of the review
Kotler, J. M., Mahoney, D., Nilsen, D. M., & Gillen, G. (2023). Systematic
(e.g., date of publication, population, intervention). This
Review Brief—Effectiveness of occupational therapy interventions to
step reduced the number of citations to 9,411 (Questions improve performance and participation in instrumental activities of
1–3) and 547 (Question 4), which were given to the re- daily living (IADL) among adult stroke survivors (2009–2019).
view teams. American Journal of Occupational Therapy, 77(Suppl. 1), 7710393090.
Teams of two or more reviewers with expertise in https://doi.org/10.5014/ajot.2023.77S10009
the content areas carried out the systematic reviews. Mack, A., & Hildebrand, M. (2023). Interventions for caregivers of people who
The review teams completed the next step of eliminat- have had a stroke: A systematic review. American Journal of Occupational
ing references on the basis of the abstracts, retrieved Therapy, 77, 7701205180. https://doi.org/10.5014/ajot.2023.050012
the full-text versions of potential articles, and deter- Mahoney, D., Kotler, J. M., Nilsen, D. M., & Gillen, G. (2023). Systematic
mined final inclusion in the reviews on the basis of the Review Brief—Effectiveness of task-oriented approaches and
occupation-based activities to improve performance and participation
inclusion and exclusion criteria.
in instrumental activities of daily living (IADL) among adult stroke
A total of 168 studies were included in the systematic
survivors (2009–2019). American Journal of Occupational Therapy,
reviews—24 Level 1a, 90 Level 1b, and 54 Level 2b stud- 77(Suppl. 1), 7710393080. https://doi.org/10.5014/ajot.2023.77S10008
ies—and served as the basis for the clinical recommen- Proffitt, R., Boone, A., Hunter, E. G., Schaffer, O., Strickland, M., Wood,
dations. Table A.3 lists the number of articles included L., & Wolf, T. J. (2022). Interventions to improve social participation,
in each review and their levels of evidence. (Note that work, and leisure among adults poststroke: A systematic review.
some articles addressed multiple outcomes of interest American Journal of Occupational Therapy, 76, 7605205120. https://
and are discussed in more than one section of these doi.org/10.5014/ajot.2022.049305

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 47
Winterbottom, L., Geller, D., Goldberg, C., Nilsen, D. M., Mahoney, D., & Winterbottom, L., Goldberg, C., Geller, D., Nilsen, D. M., Mahoney, D.,
Gillen, G. (2023). Systematic Review Brief—Occupational therapy and & Gillen, G. (2023). Systematic Review Brief—Behavioral
activities of daily living interventions to improve performance in interventions to improve performance in activities of daily living for
activities of daily living for adults with stroke (2012–2019). American adults with stroke (2012–2019). American Journal of Occupational
Journal of Occupational Therapy, 77(Suppl. 1), 7710393070. https://doi. Therapy, 77(Suppl. 1), 7710393060. https://doi.org/10.5014/
org/10.5014/ajot.2023.77S10007 ajot.2023.77S10006

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY SEPTEMBER/OCTOBER 2023, VOLUME 77, NUMBER 5 48
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