Effectiveness of Occupation-Based Interventions to

Improve Areas of Occupation and Social Participation

After Stroke: An Evidence-Based Review

Timothy J. Wolf, Adrianna Chuh, Tracy Floyd, Karen McInnis,

Elizabeth Williams

MeSH TERMS This evidence-based review examined the evidence supporting the use of occupation-based interventions to
 activities of daily living improve areas of occupation and social participation poststroke. A total of 39 studies met the inclusion criteria
and were critically evaluated. Most of the literature targeted activity of daily living (ADL)–based interventions and
 evaluation studies as topic
collectively provided strong evidence for the use of occupation-based interventions to improve ADL perfor-
 human activities mance. The evidence related to instrumental ADLs was much more disparate, with limited evidence to support
 social participation the use of virtual reality interventions and emerging evidence to support driver education programs to improve
 stroke occupational performance poststroke. Only 6 studies addressed leisure, social participation, or rest and sleep,
with sufficient evidence to support only leisure-based interventions. The implications of this review for
research, education, and practice in occupational therapy are also discussed.

Wolf, T. J., Chuh, A., Floyd, T., McInnis, K., & Williams, E. (2015). Effectiveness of occupation-based interventions to
improve areas of occupation and social participation after stroke: An evidence-based review. American Journal of
Occupational Therapy, 69, 6901180060. http://dx.doi.org/10.5014/ajot.2015.012195

Timothy J. Wolf, OTD, MSCI, OTR/L, is Assistant

Professor, Program in Occupational Therapy and
Department of Neurology, School of Medicine,
O ccupational therapy practitioners can help people with stroke improve their
occupational performance and social participation using many different
intervention strategies, including but not limited to remediation or development
Washington University, St. Louis, MO; wolft@wustl.edu
of skills, use of compensatory strategies, activity modifications, and environmental
Adrianna Chuh, MSOT, is Graduate Student, Program accommodations. The foundation of any of these approaches is helping clients
in Occupational Therapy, School of Medicine, Washington
University, St. Louis, MO.
engage in occupations, using occupation-based interventions, occupation-based
interventions, or both. The objective of this evidence-based review was to identify,
Tracy Floyd, MS, OTR/L, is Battalion Rehab Manager, evaluate, and synthesize the literature related to the focused question, What is the
U.S. Army, Warrior Transition Battalion, Fort Belvoir, VA..
evidence for the effectiveness of activity- and occupation-based interventions to
Karen McInnis, MSOT, is Graduate Student, Program improve areas of occupation and social participation after stroke?
in Occupational Therapy, School of Medicine, Washington
University, St. Louis, MO.
Background Literature and Statement of Problem
Elizabeth Williams, MSOT, is Graduate Student,
Strokes vary in severity and subsequent functional impact depending on the
Program in Occupational Therapy, School of Medicine,
Washington University, St. Louis, MO. extent of the neurological damage and potential recovery. After a stroke, many
survivors experience some form of functional impairment that will require a
period of rehabilitation. For those with mild impairment, rehabilitation can be
accomplished through a brief period of inpatient rehabilitation or through home-
based or outpatient programs (Teasell, Foley, Bhogal, Chakravertty, & Bluvol,
2005). Chronic symptoms may include hemiparesis, balance deficits, mobility
challenges, visual changes, sensory loss, cognitive deficits, speech disruption,
fatigue, and sensory processing problems (Jørgensen et al., 1995).
Any or all of these deficits may require ongoing assistance and in some cases
require institutionalized care (Kelly-Hayes et al., 2003). Occupational therapy is

The American Journal of Occupational Therapy 6901180060p1

an essential component in the rehabilitation of patients Stroke” in this issue (Arbesman, Lieberman, & Berlanstein,
after stroke (Langhorne & Pollock, 2002). Stroke care 2015). This article includes all of the specific search terms
may be provided in the acute care, rehabilitation, home and search methods for this evidence-based review. Also,
health, outpatient, and specialty clinic settings in which the results of this evidence-based review have been published
occupational therapists work (Krug & McCormack, as a Critically Appraised Topic available on the AOTA
2009). The complex nature of stroke symptoms and the website (Wolf, Chuh, McInnis, & Williams, 2014).
diversity of the stroke population require occupational The initial search yielded a total of 83 abstracts that
therapy practitioners to have a strong knowledge base of were forwarded to the research team. All 83 abstracts were
best-practice methods to support people after stroke. reviewed by at least two members of the research team, and
Occupational therapy focuses on assisting people to the team then met to discuss whether they fit with the
engage in daily life activities that they find meaningful focused question. Five abstracts were eliminated, and the
(American Occupational Therapy Association [AOTA], remaining 78 abstracts were reviewed by at least two
2014). In 1997, Law, Polatajko, Baptiste, and Townsend members of the research team to determine whether they
defined occupation as every activity people do to occupy fit the focused question of this study. The final selection
themselves—including activities of daily living (ADLs), for inclusion in this review was determined by the research
enjoying life, and social participation—that has meaning team in collaboration with representatives from AOTA.
and value to them. For the purposes of this review, occupation-
based interventions are defined as activities that support Results
performance in the following areas of occupation: ADLs,
instrumental activities of daily living (IADLs), rest and This evidence-based review included 39 studies: 26 Level I
sleep, education, work, play, leisure, and social participa- studies, 4 Level II studies, and 9 Level III studies. The articles
tion (AOTA, 2014). were then clustered into the five areas of occupation based on
Occupational therapy practitioners across all settings can the Occupational Therapy Practice Framework: Domain and
help stroke survivors improve their occupational perfor- Process (see AOTA, 2014): ADLs, IADLs, leisure, social
mance through multiple approaches. At times, practitioners participation, and rest and sleep. If necessary, the articles
use a skills remediation, or bottom-up, approach in which were then further classified within each area of occupation
specific sensory and motor deficits are addressed with a by the treatment setting in which the study was conducted:
goal of general function return across occupations. At other inpatient, outpatient, home health, and community. Sum-
times, practitioners may use an occupation-based, or top- maries of selected Level I articles determined to be of par-
down, approach that emphasizes looking at all components ticular interest to the field of occupational therapy are
of an individual, determining how they relate, and de- provided in Supplemental Table 1 (available online at http://
veloping a holistic view of the patient that is considered in all otjournal.net; navigate to this article, and click on “Supple-
aspects of treatment (Baum & Christiansen, 2005). The mental”). The full evidence table is available in the Oc-
purpose of this evidence-based review was to provide oc- cupational Therapy Practice Guidelines for Adults With Stroke
cupational therapy practitioners with the current evidence (Wolf & Nilsen, 2015).
supporting the use of occupation-based interventions to
Activities of Daily Living
improve areas of occupation and social participation after
stroke. Skill remediation–based interventions, although a Of the 39 articles included in this evidence-based review,
relevant part of occupational therapy treatment of stroke 21 addressed ADL performance. We examined the results
patients, were not considered in this evidence-based review. of 10 Level I randomized controlled trials (RCTs), 5 Level
I systematic reviews, 2 Level II non-RCTs, and 4 Level III
studies. We further classified the studies by the area of
Method for Conducting the practice in which they were conducted.
Evidence-Based Review Interventions in Inpatient Settings. Seven studies pro-
This evidence-based review was completed in collaboration viding Level I (3 studies), Level II (2 studies), and Level III
with AOTA as part of an evidence-based review project on (2 studies) evidence evaluated the use of occupation-based
interventions for adults with stroke. This review included peer- interventions to improve ADL performance in an in-
reviewed articles published between 2003 and March 2012. patient setting. Haslam and Beaulieu (2007) found limited
Detailed information about the methodology for the entire evidence to support the use of functional (task training)
literature review can be found in the article “Method for over remedial (not activity-based) interventions to improve
the Evidence-Based Reviews on Occupational Therapy and ADL performance. They compared the repetitive practice

6901180060p2 January/February 2015, Volume 69, Number 1

of functional daily tasks, incorporating compensatory donner. No significant difference in ADL performance was
strategies and adaptations, with the use of remedial skill found between the two interventions.
building intended to carry over to functional tasks. Haslam Finally, Gustafsson and McKenna (2010) compared
and Beaulieu concluded that although more research has two rehabilitation units in two different facilities. Unit A
supported functional training than remedial interventions, had occupational therapy assistants on staff who supple-
the results are inconclusive because of limitations of the mented individual therapy by offering occupation-based
studies and the small number of articles included (N 5 11) groups, including daily breakfast preparation, daily life skills
in their systematic review. Abizanda et al. (2011) found no groups, and weekly community shopping. Unit B had in-
difference between occupational therapy intervention (ADL dividual therapies and usual care with a weekly recreational
retraining with family involvement) coupled with conven- cooking group. When metrics from Unit A and Unit B were
tional treatment (medicine and physical therapy) and con- compared, no significant differences in self-efficacy and well-
ventional treatment alone. being were found between the occupation-based group
A small study (N 5 4) by Mew (2010) found in- program and standard care (Gustafsson & McKenna, 2010).
sufficient evidence that Bobath-based normal movement Evidence generally supports the use of occupation-
interventions to normalize tone and avoid abnormal move- based interventions to improve ADL performance in the
ments were associated with better motor recovery and that inpatient setting. Although several of the studies did not
functional interventions, such as the use of environmental support the use of occupation-based interventions over the
adaptation, adaptive equipment, or compensatory strategies control condition, most of these studies lacked methodo-
when performing ADLs, were associated with greater in- logical rigor in terms of an adequate sample, appropriate
dependence in ADLs. comparison group, or a sensitive outcome measure that
Sonoda, Saitoh, Nagai, Kawakita, and Kanada (2004) could adequately measure change.
compared the Full-time Integrated Treatment (FIT) re- Interventions in Outpatient Settings. Four Level I studies, 1
habilitation program (high-intensity dose of occupational Level II study, and 1 Level III study evaluated occupation-
and physical therapy in 40-min sessions 7 days/wk) with based interventions targeting improvement in ADL per-
the standard care model (lower intensity gait and exercise formance in an outpatient setting. Hershkovitz, Beloosesky,
related to ADL performance with occupational and physical Brill, and Gottlieb (2004) found significant improvements
therapy in 40-min sessions 5 days/wk). This Level II study in functional independence within participants from
demonstrated support for FIT high-intensity-dose occupa- admission to discharge in a day rehabilitation program;
tional and physical therapy in improving ADL functioning however, the article did not provide specifics about the
at discharge compared with standard care. program.
Teasell et al. (2005) described a Level III pre–post Bode, Heinemann, Zahara, and Lovell (2007) com-
study of an interdisciplinary rehabilitation program (oc- pared ADL performance outcomes after participation in
cupational therapist, physical therapist, speech–language either a day rehabilitation or an outpatient program
pathologist, social worker, dietitian, and members of the poststroke. Results of the study indicated that most day
medical team) that also included therapeutic recreation rehabilitation patients received more units of occupa-
and a rehabilitation specialist at a specialized stroke re- tional therapy than physical therapy, and outpatients re-
habilitation unit for highly involved stroke patients in ceived more units of physical therapy than occupational
England. The role of therapeutic recreation was to facilitate therapy. The differences in ADL performance between the
carryover of skills learned in other therapies while par- day rehabilitation and outpatient programs were signifi-
ticipating in leisure activities. The rehabilitation specialist cant (Bode et al., 2007). For people who received day
played a supporting role that allowed participants addi- rehabilitation, more intense therapy was associated with
tional opportunities for practice. Family members also greater life satisfaction and improved mobility and activity
participated in a support group as a part of the program. level. Those who received more intense outpatient therapy
The results of the study revealed that participants showed experienced poorer health and had a lower activity level.
greater independence in ADLs and improved FIM
Guidetti, Andersson, Andersson, Tham, and Van
scores from admission to discharge (Teasell et al., 2005). Koch (2010) evaluated the effect of a client-centered self-
Mount et al. (2007) compared an errorless learning care intervention against that of a traditional self-care
intervention and a trial-and-error learning intervention for intervention over a 3-mo period in three different clinics.
people with memory deficit poststroke. Participants were The client-centered group used a structured protocol that
randomly assigned into intervention groups and learned two allowed participants to set self-care goals with the treating
tasks: wheelchair transfer and sock donning using a sock occupational therapist. Once goals were identified, clients

The American Journal of Occupational Therapy 6901180060p3

were responsible for the use of a training diary that allowed improve ADL in the home health setting. Chieu and Man
them to take responsibility for the goals while also com- (2004) compared the efficacy of home-based ADL assis-
municating them to others in this format. The traditional tive technology training with traditional ADL assistive
self-care group received the self-care training program at its technology training. The treatment group received two to
respective clinic. No significant differences in ADL per- three home-based training sessions regarding their pre-
formance were found between the two groups. In 2011, scribed bathing assistive technology (instruction, demon-
Guidetti and Ytterberg used the same client-centered self- stration, question–answer, assessment of fit). Treatment and
care protocol described in the 2010 study, collecting results control groups both received usual care or training in use of
at 3, 6, 9, and 12 mo postintervention, and compared the prescribed bathing device before inpatient discharge.
these results with the standard self-care training on ADL This training occurred in the inpatient setting for 95% of
performance. They found no differences between the participants. Both groups were assessed preintervention and
client-centered intervention and standard self-care train- at 3 mo postintervention. The authors found that home-
ing on ADL performance. based assistive technology training resulted in higher rates of
Katz et al. (2005) compared the effect of two virtual assistive technology use than standard training.
reality (VR) interventions on ADL performance. The ex- Sahebalzamani, Aliloo, and Shakibi (2009) examined
perimental group completed a computer-based, occupation- the impact of self-care education on hemiplegic stroke
centered street-crossing training, and the control group survivors. Both the control and the experimental groups
completed a skills training computer-based visual scanning completed an ADL scale on discharge and then again 45
activity. Both interventions were conducted for 12 sessions days after discharge. The experimental group received
(for a total of 9 hr) over the course of 4 wk. Both groups education on hygiene, bathing, nutrition, toileting,
improved from pre- to posttest on the ADL checklist used. grooming, dressing, bowel and bladder control, mobility,
Despite the improvement noted, Katz et al. found no sig- and transfers on discharge. The experimental group fol-
nificant difference in ADL performance between the ex- lowed the program for six to eight sessions over the 45
perimental and control groups. days before reassessment. Sahebalzamani et al. found that
Schmid et al. (2012) compared the efficacy of yoga- the self-care education improved ADL performance in
based rehabilitation on balance, balance self-efficacy, and the experimental group compared with the control group.
fear of falling. Participants were randomized into three In contrast, Askim, Rohweder, Lydersen, and Indredavik
groups: group yoga, yoga plus (group yoga and at-home (2004) compared the effect of ordinary service with an
yoga and a relaxation recording), and control (wait-list, early supported discharge program in three rural com-
usual-care intervention). The group yoga interventions munities. The ordinary service group received treatment
were completed in 1-hr sessions biweekly for 8 wk. Although combined with further follow-up organized by either
balance improved clinically with the yoga intervention, a rehabilitation clinic or a primary health care system
Schmid et al. found no statistically significant differences after discharge from inpatient care. The supported early
between the yoga groups and the control group on quality discharge program was a home-based rehabilitation pro-
of life or level of disability. gram coordinated by a mobile stroke team comprising a
Overall, the evidence from these studies to support nurse, physiotherapist, occupational therapist, and consul-
occupation-based interventions to improve ADL perfor- ting physician in conjunction with primary health care
mance in the outpatient setting is limited. Limitations of system services available in the community on discharge.
the studies include poor description of the intervention, The mobile team provided intervention for 4 wk post-
mixed results in terms of the effect of the occupation-based discharge through phone contact and home visits. In cases
intervention, and small sample sizes to evaluate the effect. in which multiple patients were in the same community,
Interventions in Home Health Settings. The strongest families were invited to a meeting to receive education on
evidence to support the use of occupation-based in- issues with stroke care and to share personal experiences.
tervention in the home health setting comes from three Askim et al. found no differences in functional gains be-
Level I systematic reviews that reported that ADL-specific tween individuals who were discharged early with a home
home-based interventions are associated with higher levels program versus standard care. Overall, a significant amount
of ADL independence and decreased odds of death and of evidence supports the use of occupation-based inter-
other negative outcomes (Legg & Langhorne, 2004; Legg ventions to improve ADL performance in people with
et al., 2007; Legg, Drummond, & Langhorne, 2009). stroke in the home health setting.
In addition to these systematic reviews, 2 Level I RCTs Interventions in Community Settings. Wilkins, Jung,
also found support for occupation-based interventions to Wishart, Edwards, and Norton (2003) found that

6901180060p4 January/February 2015, Volume 69, Number 1

occupational therapy education and functional training use of VR to improve various skills deemed essential for
programs, particularly short-term community-based inter- safe street crossing (i.e., reaction time for safe street
ventions focused on specific performance issues, are effective crossing). Specifically, they found a significant improve-
in improving ADL performance in older adults with stroke. ment in reaction time, need for visual and auditory cueing,
In a Level I RCT, Harrington et al. (2010) compared and success in street crossing compared with the two
the efficacy of a community-based education and exer- control groups; however, the description of the com-
cise program for stroke survivors with that of traditional parison intervention was very limited.
care. The experimental group received the community- Rand, Weiss, and Katz (2009) found insufficient
based program in addition to standard care, and the evidence to support the use of a VR program to improve
control group received only standard care. Harrington executive functioning and multitasking within shopping
et al. found that an exercise and education interven- tasks in a small study using the Multiple Errands Test as
tion did not improve quality of life or community re- an outcome measure. Participants completed ten 60-min
integration at 12 mo compared with standard care. The sessions with an occupational therapist using a VR system
intervention condition in this study was very broad over a 3-wk period. Participants interacted with a virtual
based, and the rate of attrition was very high. environment on a video screen. In each session, partici-
Overall, evidence supports occupation-based interven- pants used VMall for 45 min and other multitasking VR
tions in the community setting; however, larger scale powered programs for 15 min. Although the data were trending in
studies are needed to confirm the use of occupation-based a positive direction, the sample was too small to detect
interventions in this setting with people with stroke. a difference (N 5 4). Overall, these studies provide limited
evidence to support the use of VR interventions to improve
Instrumental Activities of Daily Living occupational performance.
The remaining IADL-focused studies included in this
Twelve studies included in this review addressed IADL
review each addressed a different occupational outcome. A
performance: 1 Level I systematic review, 4 Level I RCTs,
study completed by Song, Oh, Kim, and Seo (2011) ex-
2 Level II nonrandomized controlled studies, and 5 Level
amined the efficacy of a sexual rehabilitation intervention
III studies. The studies were further classified by the area of
program for stroke patients and spouses. The intervention
practice in which they were conducted.
was found to be effective in improving sexual knowledge,
Interventions in Inpatient Settings. Several studies
satisfaction, and frequency of activity. The experimental
evaluated the use of VR-based intervention programs to
group participated in a 40- to 50-min education session 1
improve various areas of occupation poststroke. Saposnik
day before discharge from inpatient care that addressed
et al. (2010) compared the impact on upper-extremity
common sexual problems and causes of changes post-
function of using Nintendo Wii gaming VR (VRWii) with
stroke, general instructions for a healthy sexual life, and
that of using recreational therapy in standard care. All specific strategies for sexual reactivation. This information
participants received the standard therapy after stroke was also compiled in a booklet and given to the participants
(average of 2 hr/day of physiotherapy and occupational in the experimental group. Song et al. found a significant
therapy per patient tolerance). Participants in the VRWii difference between the experimental group and wait-list
group participated in eight 60-min sessions over a 14-day controls in participation in and satisfaction with sexual ac-
period using sporting games and cooking activities. Par- tivity after a rehabilitation program targeting sexual function.
ticipants in the recreational therapy group engaged in lei- In a Level III study, Mountain et al. (2010) found
sure activities (card games, playing Bingo or Jenga) and limited evidence for the use of the Wheelchair Skills Pro-
were directed to use the affected arm as much as possible to gram (WSP) to teach powered wheelchair skills. Participants
complete the activity. The results of the study support the each completed five 30-min training sessions using the
use of VR over recreational therapy to improve upper- WSP. The authors found a significant improvement in
extremity function. powered wheelchair performance (maneuvering, assembly,
Kim et al. (2007) conducted a study examining the reaching objects from chair, transfers, etc.) after partici-
effect of the occupation-based VR activity of safely pating in the WSP, which included topics such as safety,
crossing the street on skill development of patients with variability and distribution of practice, simplification of skills,
unilateral neglect. The control groups were assigned on transfers to and from the wheelchair, and more.
the basis of level of comfort with computers (i.e., a com- Finally, in a Level I RCT, Devos et al. (2009) ex-
puter-friendly control group and a computer-unfriendly amined the carryover effect of driving skills from a com-
control group). Kim et al. found limited evidence for the prehensive training program in a driving simulator when

The American Journal of Occupational Therapy 6901180060p5

compared with a cognitive training program. Participants Both of these studies had methodological issues (e.g.,
were randomized into two groups: simulator group and lack of dosed-matched control, underpowered) and thus
cognitive group. All participants received a total of 15 did not provide sufficient evidence to support the use of
training sessions for 1 hr 3 times/wk in addition to tra- these occupation-based interventions in the outpatient
ditional rehabilitation services. Those in the simulator setting.
group who were trained in a stationary simulator with an Interventions in Community Settings. Limited to mod-
automatic transmission completed 12 modules to train erate evidence generally supports occupation-based inter-
six specific driving skills. Those in the cognitive group ventions to improve occupational performance in IADLs in
engaged in commercially available games involving cog- the community setting. One systematic review by Graven,
nitive skills identified as necessary for driving. Devos et al. Brock, Hill, and Joubert (2011) found limited evidence
found moderate evidence for the use of driving simulation for activity- and occupation-based interventions that ad-
training over commercially available cognitive training pro- dressed depressive symptoms and decreased participation
grams to improve on-the-road driving skills. The inter- and quality of life poststroke. The study found that a
vention group demonstrated significantly improved skills comprehensive rehabilitation program (frequent attendance
while on the road; however, no difference was found be- at a day hospital or outpatient clinic) or rehabilitation that
tween groups in actual driving performance (Devos et al., addressed leisure activity resulted in decreased depression
2009). and increased participation and quality of life. Conversely,
Although each of these studies found a positive effect they found no evidence for the use of self-management
of the test intervention, the studies in general were un- programs, interdisciplinary management (intermittent home
derpowered and do not provide sufficient evidence for the visits and phone calls), or information provision. The
interventions’ use at this time. evidence from this study is limited by the broad in-
Interventions in Outpatient Settings. Logan et al. (2004) clusion criteria in the review that included a wide array
evaluated the efficacy of occupational therapy intervention of interventions.
that exposed participants to mobility aids and general Hartman-Maeir et al. (2007) compared the func-
community mobility education. All participants received tional status, leisure activity, and satisfaction of stroke
one session of occupational therapy in which paper re- survivors engaged in a community rehabilitation program
sources were provided. The session also included education with those of people who were not participating in a pro-
on local mobility services as well as advice and encour- gram. The goal of the community rehabilitation program
agement. The experimental group additionally received was to increase function by providing a structure to the
an assessment of barriers and three to seven occupational participants’ day, decrease social isolation, and increase coping
therapy intervention sessions at home for as long as 3 mo. strategies to reduce caregiver burden. The study found lim-
Intervention sessions included information on returning ited evidence for the use of a rehabilitation program
to driving, alternative resources to cars and buses, use of targeting community participation compared with a non-
adaptations, and overcoming fear. Logan et al. found active control group. The authors found a significant in-
moderate evidence for this intervention over the pro- crease in activity participation and satisfaction in the
vision of leaflets of information concerning local mobility intervention group; however, the control group had
services. Additionally, they found that participants were higher functional performance at the conclusion of the
making significantly more trips outside the home after study.
the intervention. A Level III single-group study by Pettersson, Törnquist,
In a Level III study, Yip and Man (2009) showed and Ahlström (2006) provided limited evidence to support
insufficient evidence for a VR rehabilitation training (a the use of a powered wheelchair or scooter over not using
computer-based program with a joystick to control move- a device at all. They found a positive effect on community,
ment) to increase community mobility. The training showed social, and civic life participation. For example, after the use
positive changes in community mobility skills (e.g., a de- of the powered device, participants reported having either
crease in the time taken to travel to the grocery store and no or little difficulty with community mobility (i.e., going
the amount of dangerous behaviors); however, results for a walk or going to the library).
were not significant because of the small sample size (N 5 Finally, in the community setting, Söderström, Pettersson,
4). Although Yip and Man found that participants’ and Leppert (2006) found limited evidence for a driver’s
community mobility skills improved, the study was un- education program combining classroom instruction and
derpowered to determine statistical significance of the on-the-road training to improve driving performance
change. after a failed government driver’s test. In this Level III

6901180060p6 January/February 2015, Volume 69, Number 1

pretest–posttest study, 13 of 15 participants passed the the group receiving occupational therapy compared with
driving test after the intervention. A limitation of this study a control group receiving usual care (which typically ex-
is that it used no active control group for comparison. cluded occupational therapy). The treatment group re-
ported a significant increase in satisfaction with their
Leisure performance. Egan et al. explained that participants re-
Only 2 Level I RCTs examining leisure addressed the porting on performance may have continued to compare
focused question and met the inclusion and exclusion criteria their performance to prestroke levels, in spite of trends in
of this review. Corr, Phillips, and Walker (2004) found treatment notes that showed resumption of occupations
limited evidence for a day rehabilitation program that through activity modification.
included a focus on leisure activity to improve self-rated In a Level I RCT, Kendall et al. (2007) found limited
ADL and IADL performance. Participants in this random- evidence to support the use of the Chronic Disease Self-
ized crossover study were placed into two groups: Group A Management Program to improve occupational perfor-
(who received intervention immediately after discharge for mance and social and family role participation poststroke.
6 mo and then did not receive it for an additional 6 mo) Both the treatment and the control groups received
and Group B (who did not receive the intervention for 6 standard poststroke rehabilitation during the intervention
mo postdischarge but then received the service for the next period. Although the intervention was generally associ-
6 mo). The intervention, provided 1 day/wk, consisted of ated with a more stable adjustment in maintaining family
arts and crafts, social events, outings, and the opportunity roles, self-care, and work productivity at all four assess-
to learn a new skill (e.g., computer training). The study ment times over 1 yr, the final outcomes were not sig-
found improvement in self-rated performance and satis- nificantly different between groups. Moreover, Kendall
faction with performance averaged across areas of self-care, et al. found no differences in performance in social roles
leisure, and productivity. The study found no improve- between groups at any time during the study. The au-
ments in extended ADL scores after the intervention. thors reported that the intervention group had more
A Level I RCT by Desrosiers et al. (2007) found stable adjustment over the course of the study; however,
moderate evidence for a home-based leisure program in they found no statistically significant difference between
Canada to increase both self-reported participation in and groups at the conclusion of the study.
satisfaction with leisure pursuits. An occupational thera- In a Level I RCT pilot study, Polatajko, McEwen,
pist and recreational therapist facilitated leisure par- Ryan, and Baum (2012) found moderate evidence for the
ticipation through leisure awareness, self-awareness, and Cognitive Orientation to daily Occupational Performance
competency development in the treatment group. The rec- (CO–OP) strategy-based intervention in supporting client-
reational therapist also administered the control treatment, centered occupational performance goals compared with a
which was home visits consisting of discussions unrelated to remediation-based usual-care group. The CO–OP group
leisure. After the intervention, the treatment group reported reported significantly greater improvements in occupa-
significant increases in satisfaction with leisure pursuits, time tional performance. Specifically, the small sample (N 5 8)
spent in active leisure activities (vs. passive, home-based lei- showed significantly greater improvements in self-rated
sure requiring no physical activity), and total number of occupational performance in identified goal areas.
leisure activities compared with the control group. Overall, these 3 studies provide limited evidence to
Together, these studies found some evidence to support support the use of occupation-based interventions to ad-
occupation-based interventions to increase participation in dress social participation goals for people with stroke.
leisure occupations.
Rest and Sleep
Social Participation One RCT by Taylor-Piliae and Coull (2012) examined
Three Level I studies evaluated the use of occupation- the safety and appropriateness of a Tai Chi program to
based interventions to increase social participation after address sleep quality poststroke. Participants in the Tai
stroke. Egan, Kessler, Laporte, Metcalfe, and Carter (2007) Chi group participated in the class 3 times/wk for 12 wk,
found insufficient evidence for a client-centered, occupation- and the usual-care group received weekly phone calls along
based intervention to improve occupational performance with written materials for engagement in community-
poststroke compared with usual care. This small Level I based physical activities. The results of the study did not
RCT found no significant increase in reported perfor- support the use of a Tai Chi program over information
mance in areas of self-care, leisure, and productivity for about community exercise programs to improve sleep

The American Journal of Occupational Therapy 6901180060p7

quality poststroke. The results of this study do not provide use of occupation-based interventions to address these areas of
evidence to support the use of occupation-based interventions occupation; the findings can be summarized as follows:
to improve rest and sleep poststroke. • The evidence supports the use of occupation-based inter-
ventions to improve occupational performance after stroke.
Discussion and Implications for Practice, • The majority of the evidence supports interventions
targeting ADL performance.
Education, and Research
• The evidence related to IADL performance is disparate
Implications for Practice and more difficult to draw definitive conclusions from.
• Limited to no evidence supports occupation-based in-
The majority of the literature that addressed the focused
terventions to address other areas of occupation be-
question of this review supports the use of occupation-
yond ADLs and IADLs.
based interventions to improve ADLs, with the best available
• Several of the studies included were preliminary in
evidence supporting the use of occupation-based inter-
nature or had methodological issues that could limit
ventions to improve ADLs in the home (Legg & Langhorne, the generalizability of the findings.
2004; Legg et al., 2007, 2009). Overall, more evidence
supports the use of occupation-based interventions to im- Implications for Education
prove ADL performance in the inpatient, outpatient, and Educational programs preparing occupational therapy
community settings than supports impairment remediation practitioners for evidence-based practice can use the results
approaches; however, the literature in this area is limited by of this review to help students understand and support
several methodological issues, including small samples that occupational therapy’s role in using occupation-based in-
did not allow for statistical comparison, poor description of terventions. Moreover, it is also important that educational
interventions, lack of an appropriate control condition, and programs emphasize to future practitioners the importance
lack of an appropriate or sensitive outcome measure. of being able to articulate to their patients, other health
Given the broad spectrum of specific IADL activities, it care providers, and the public what occupational therapy
is not surprising that the evidence in this area was much intervention is and why they are doing it. Poor descrip-
more disparate than with ADL activities. The studies that tions of interventions limit the ability to understand and
were evaluated provided limited evidence to support the use replicate the intervention with future patients. Finally, the
of VR-based interventions to improve IADL performance results of this review can also be used by practitioners and
poststroke. Also, emerging evidence from preliminary future practitioners to understand the importance of mea-
studies has supported driver education and wheelchair skills suring outcomes of their interventions. The use of in-
training. The remaining studies reviewed were inconclusive appropriate outcome measures (e.g., a measure that does
and provided little to no evidence to support occupation- not match the intervention or a measure that lacks sensi-
based interventions to improve IADL performance. A tivity) limits the ability to evaluate interventions.
strength and limitation of this evidence-based review was
that it was focused on evaluating studies that used not only Implications for Research
an occupation-based intervention but also an occupation- or With the exception of the studies that evaluated ADL
participation-based outcome measure. This limited the performance, the studies used disparate and at times un-
breadth of the articles, specifically with regard to IADLs, that developed outcome measures to evaluate interventions. This
were included because much of the literature in this area finding speaks to the need within the occupational therapy
evaluated interventions using much more proximal outcome profession to develop well-validated, sensitive, performance-
measures, that is, impairment reduction. Practitioners should based outcome measures that can be used to evaluate clinical
look to the literature related to specific IADL occupation- and research outcomes. The development of science in
based interventions to evaluate the evidence related to their use occupational therapy will be hindered until practitioners
to improve other outcomes poststroke. have the appropriate tools to evaluate their interventions.
Very few studies evaluated the use of occupation-based Another implication of this evidence-based review is
interventions to improve leisure, social participation, and highlighted by the overemphasis on ADL performance. In
rest or sleep poststroke. The studies that were included in general, regardless of diagnosis, occupational therapy is too
this review were almost all preliminary studies evaluating focused on ADL performance, which limits practitioners’ role
the primary effect of the intervention with a pilot sample. in the other areas of occupation that are meaningful to clients.
These studies provide insufficient evidence to support the Interventions targeting IADLs, leisure, social participation,

6901180060p8 January/February 2015, Volume 69, Number 1

rest and sleep, work and productivity, and so forth need to be not necessarily represent the official views of the National
developed and evaluated. Finally, a very acute need that can Institutes of Health.
easily be addressed by the research community is that to
better develop and describe interventions. Several of the ar- References
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