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The AOTA Centennial Vision outlined in 2007 challenged the occupational therapy profession to become a “powerful, widely recognized, science-driven, and evidence-based” profession that could adapt to changing societal and cultural needs and flourish well into the future. That challenge can be met by simply being effective at what we do; this will increase our value and validate our worth. Neurorehabilitation in occupational therapy can also thrive if we verify that the interventions we use and the strategies we implement are grounded in evidence. Professional effectiveness will emerge by (1) increasing the dissemination of research that supports the methods we use and informs others of the successful patient outcomes we achieve and (2) expanding development and validation of instruments that quantitatively and qualitatively measure functional outcomes. Occupational therapists can individually develop professional effectiveness by fostering greater academic–clinical alliances, objectifying evaluation and intervention methods, and preparing future practitioners appropriately for evidence-driven practice.
Five years ago, when the American Journal of Occupational Therapy (AJOT) published the American Occupational Therapy Association’s (AOTA’s) Centennial Vision and Executive Summary (AOTA, 2007), the leaders of the profession articulated a strategic plan to move the profession into the future and design a pathway to promote the importance of occupational therapy. Obtaining information from analysts at the Institute for Alternative Futures in Washington, DC, these leaders outlined how the profession would be shaped given future trends in health care, science, and technology. They gathered input from professional partners, special interest groups, practitioners, scientists, educators, and staff to determine what drivers of change would affect occupational therapy practice in the years ahead. Societal issues, such as aging and an increasingly diverse population, health care costs and reimbursement, preventive medicine, and changing lifestyle values, were at the forefront of the factors that could have a significant impact on occupational therapy and how it is defined for, and delivered to, future generations.
Building on current knowledge and assimilating the expert information and ideas put forward in 2007, a vision statement emerged that may hold even greater relevance today: “We envision that occupational therapy is a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society’s occupational needs” (AOTA, 2007, p. 613). This vision aligned with the association’s goal
to ensure that individuals, policymakers, populations, and society value and promote occupational therapy’s practice of enabling people to improve their physical and mental health, secure well-being, and enjoy higher quality of life through preventing and overcoming obstacles to participation in the activities they value. (AOTA, 2007, p. 614)
The predictions of 2007 are proving to be alarmingly accurate: The U.S. population older than age 65 will more than double in the next 45 years, and the Latino population will triple (Passel & Cohn, 2008). We are beginning to see the effects of the Patient Protection and Affordable Care Act of 2010 (ACA; Pub. L. 111–148), which will potentially provide health care to an estimated additional 32 million people and increase government regulation of health care options and reimbursement (Metzler, Tomlinson, Nanof, & Hitchon, 2012). Preventative medicine is now a major component of the ACA, which has extended coverage to include general physicals and wellness visits (Healthcare.gov, 2011). Finally, generational factions with discrete personal characteristics (e.g., Baby Boomers, Generation X, Millennials) have evolved. These factions are influencing individual lifestyle choices that will affect society as a whole (Pew Research Center, 2011).
The key to occupational therapy’s becoming that powerful, widely recognized, science-driven, and evidence-based profession appears to lie in one word: value. Only when other entities, be they payers, scientists, customers, patients, physicians, legislators, or other professionals, value what we do and understand the significant contribution we make to the health and well-being of those we serve can that vision truly be attained. Although many ideas can be generated as to how we can embark on what seems to be the insurmountable task of increasing occupational therapy’s value as a profession, the simplistic answer may surprise you. We can increase our value to others simply by being effective at what we do.
Professional effectiveness results when we can see the future and plan our present to meet the needs of patients, consumers, policymakers and, just as important, the students who will become the health care professionals of tomorrow. Effectiveness as a profession can emerge when we verify that the interventions we use, the approaches we take, and the strategies we implement are grounded in evidence and can be successful in improving patient outcomes. In 2000, Margo Holm’s Eleanor Clarke Slagle lecture focused on our responsibility to be “competent in, and make a habit of,” searching for and assessing the value of the evidence (p. 584). Doing so makes us consumers of research—one of the first steps needed for our profession to begin to evaluate existing knowledge, interconnect this knowledge with our clinical skills, and expand the base of scientific inquiry within occupational therapy (Abreu, Peloquin, & Ottenbacher, 1998). Indeed, scientific inquiry and the evidence generated will be the driver that will enable the profession to navigate through the inevitable health care challenges that lie ahead (Gutman & Mortera, 1997).
The practice area of neurorehabilitation has certainly felt the effects of the current health care challenges. For example, lengths of stay in inpatient hospitals for stroke have declined from approximately 6.8 days in 1997 to approximately 4.8 days in 2010 (Agency for Healthcare Research and Quality, 2012), leaving less time for intervention. Lengths of stay at inpatient rehabilitation facilities have also shown a reduction from 19.6 days in 2000 to 16.5 days in 2008 (Granger, Markello, Graham, Deutsch, & Ottenbacher, 2009). Payment for outpatient occupational therapy is limited to $1,880 by Medicare, and extensions are typically given only if cases are medically complex. Valid and copious justification is needed to extend treatment beyond the designated timeline. Home health providers are continually scrutinized for the few therapy visits allowed, and clinicians are inundated with documentation and regulatory requirements. Shorter lengths of stay, fewer visits, and less reimbursement of services are necessitating changes in our practice. We must become more efficient with the time we are given with our patients, and we must expand our knowledge and use those interventions that are grounded in evidence and effective for meeting our goals.
The American Journal of Occupational Therapy is committed to publishing articles that focus on the clinical and research-related priorities of the profession, and foremost in this effort are intervention effectiveness studies (Gutman, 2010). Table 1 outlines the number of neurorehabilitation-related publications identified in the previous three Centennial Vision reviews (Gillen, 2010; Rao, 2012; Wolf, 2011).
Neurorehabilitation research publications increased during 2011, yielding the largest number of publications (58); however, a special issue on head injury that year resulted in an extraordinary number of articles being submitted. Those articles not published in the special issue were distributed across subsequent issues, accounting for the large number of neurorehabilitation articles in 2011. The publication numbers for the past 2 yr have remained fairly consistent, averaging about 20/yr. This article reviews all the neurorehabilitation-related articles published in the 2012 volume of AJOT, including effectiveness studies as well as those that highlight other areas such as education, efficiency, basic research, professional issues, occupational engagement and health, and instrument development and testing (Table 2).
Twenty-three publications on the topic of neurorehabilitation were identified. Of those, 10 (43%) were classified as intervention effectiveness studies (Finlayson, Preissner, & Cho, 2012; Glasgow, Fleming, Tooth, & Peters, 2012; Hayner, 2012; Martin, Johnston, & Sadowsky, 2012; Nilsen, Gillen, DiRusso, & Gordon, 2012; Polatajko, McEwen, Ryan, & Baum, 2012; Schepens, Braun, & Murphy, 2012; Skubik-Peplaski, Carrico, Nichols, Chelette, & Sawaki, 2012; Sledziewski, Schaaf, & Mount, 2012; Yang, Lin, Chen, Wu, & Chen, 2012); 6 (26%) discussed instrument development and testing (Engstrand, Krevers, & Kvist, 2012; Flinn, Pease, & Freimer, 2012; Katz, Bar-Haim Erez, Livni, & Averbuch, 2012; Mennem, Warren, & Yuen, 2012; Stefanovich, Williams, McKee, Hagemann & Carnahan, 2012; Tucker, Edwards, Mathews, Baum & Connor, 2012); 2 (8%) were basic research studies (Baker, Aufman, & Poole, 2012; Prager & Lang, 2012), 1 (4%) concerned a specific professional issue (Yuen, Brooks, Azuero, & Burik, 2012); 1 (4%) was centered on education (Frost & Barkley, 2012); and 3 (13%) involved issues of efficiency (Cimarolli, Morse, Horowitz, & Reinhardt, 2012; Craig, 2012; O’Brien, Bynon, Morarty, & Presnell, 2012). One article used qualitative analysis (Craig, 2012) and 1 used mixed methods (Finlayson et al., 2012); all other studies used quantitative methods. As in previous years, intervention effectiveness studies and instrument development and testing represented the largest percentage of publications in neurorehabilitation research this past year.
Within the effectiveness studies were 5 randomized controlled trials (RCTs; Glasgow et al., 2012; Nilsen et al., 2012; Polatajko et al., 2012; Schepens et al., 2012; Yang et al., 2012), which marks a notable increase in RCTs over previous years (2 in 2010, none in 2009). These effectiveness studies are classified as having Level I status—systematic reviews, meta-analyses, or RCTs (see the classification system outlined in Lieberman and Scheer, 2002). Five effectiveness studies were classified as Level III, one-group, nonrandomized studies (Finlayson et al., 2012; Hayner, 2012; Martin et al., 2012) or Level V, case reports (Skubik-Peplaski et al., 2012; Sledziewski et al., 2012). The diagnoses targeted for the interventions being assessed included stroke (n = 5), spinal cord injury (n = 2), joint stiffness (n = 2), and multiple sclerosis (n = 1).
Instrument development and testing was the next most common area of publication, with 6 articles published during 2012. Three studies examined instruments used with the stroke population: Katz et al. (2012) and Mennem et al. (2012) assessed the reliability and validity of the Dynamic Lowenstein Occupational Therapy Cognitive Assessment (DLOTCA) and the Self-Report Assessment of Functional Visual Performance (Gilbert & Baker, 2011), respectively. Tucker et al. (2012) reported the consistency and reliability of methods used to modify the administration and formatting of some commonly used assessments such as the SF–36 (Ware & Sherbourne, 1992), the Stroke Impact Scale (Duncan et al., 1999), and the Activity Card Sort (Baum & Edwards, 2001) when working with people with aphasia. The other three focused on orthopedic or peripheral hand conditions, with Engstrand et al. (2012) describing standard guidelines for finger goniometry measurement in people with Dupuytren’s contracture, Flinn et al. (2012) investigating the reliability of the Flinn Performance Screening Tool for grading the severity of carpal tunnel syndrome, and Stefanovich et al. (2012) assessing the effectiveness of a global rating scale and checklist to grade orthotic fabrication skills of occupational therapy students.
This review examines 23 articles published in AJOT from January 2012 through November 2012 related to neurological rehabilitation. Of the 75 articles published in AJOT during this time period, those on this topic represented 30% of the total published studies.
Two intervention effectiveness studies over the past year focused on how specific factors interact with occupational therapy intervention and potentially affect patient outcomes. This theme was apparent in the Finlayson et al. (2012) article, which determined that age, level of impairment, and gender had a significant effect on outcomes of a fatigue management program for people with multiple sclerosis. In contrast, the Glasgow et al. (2012) article determined that the length of time a capener splint was worn (6–12 hr/day vs. 12–16 hr/day) to improve finger extension range of motion (ROM) after hand injury was not a significant factor in patient outcomes.
Three of the effectiveness studies and 1 efficiency study compared novel, specific approaches with general approaches or “standard” occupational therapy: Polatajko et al. (2012) found that people with stroke who engaged in a client-centered, cognitive-based goal achievement intervention performed better on functional tasks than those who engaged in traditional therapist-driven occupational therapy; Schepens et al. (2012) described that a “tailored” approach was better than a general occupational therapy approach when instructing people with osteoarthritis in activity pacing; the tailored approach group reported less joint stiffness over time. Likewise, Yang et al. (2012) found that two robot-assisted training regimens (unilateral and bilateral) improved upper-extremity movement in people with stroke differentially and better than standard occupational therapy intervention on selected measures. O’Brien et al. (2012) reported that a targeted occupational therapy intervention combined with a functional conditioning program reduced the length of stay for older people admitted to the hospital as a result of acute trauma when compared with length-of-stay data for people previously admitted receiving only standard occupational therapy treatment.
Another theme present in the effectiveness literature reviewed from the past year was the additive effect of specific interventions when used in conjunction with standard occupational therapy treatment: Using mental practice in addition to occupational therapy appeared to have beneficial effects in reducing impairments and improving perception of occupational performance after stroke when compared with relaxation imagery combined with occupational therapy (Nilsen et al., 2012); intense repetitive task training combined with neuromuscular electrical stimulation assisted in improving motor function of the hand and grip strength in people with tetraplegia (Martin et al., 2012). Last, occupational therapy combined with the use of the REO-Go™ (Motorika, Trussville, AL) upper-extremity robotic trainer increased active range of motion (AROM), strength, and independence during self-care tasks for people with incomplete spinal cord injury (Sledziewsi et al., 2012).
The final 2 effectiveness studies examined the effect of a novel or specific intervention that could be considered a subset of occupational therapy practice. Hayner (2012) assessed the use of a tri-pull method of taping for improving glenohumeral subluxation, ROM, and function in the upper extremities of people with chronic stroke. Skubik-Peplaski et al. (2012) examined how true occupation-based practice affected neuroplasticity and upper-extremity motor recovery after stroke.
The articles focusing on instrument development and testing were diverse, examining reliability and validity measures for new instruments such as the Flinn Performance Screening Tool for people with carpal tunnel syndrome (Flinn et al., 2012) and the Self-Report Assessment of Functional Visual Performance for people with homonymous hemianopia (Mennem et al., 2012), both of which revealed adequate score reliability. A novel global rating of change test and checklist was developed with input from several experienced occupational therapists and hand therapists to assess occupational therapy students’ skills in orthotic fabrication (Stefanovich et al., 2012). Tests more commonly seen in occupational therapy practice were also validated: The reliability of goniometry was measured in a population with Dupuytren’s disease; interrater reliability was high when standardized guidelines were followed (Engstrand et al., 2012). The Lowenstein Occupational Therapy Cognitive Assessment (LOTCA) was also found to have high correlations between raters when used with people with stroke (Katz et al., 2012).
Two studies examined the predictive value of initial occupational therapy measures of impairment: Vision impairment was found to be a strong predictor of decreased time spent in occupational therapy subacute rehabilitation sessions and a higher functional dependency level at discharge (Cimarolli et al., 2012). In contrast, Prager and Lang (2012) found that initial AROM measures at the wrist for people with acute stroke are weak predictors of upper-extremity function at 3 mo.
Two articles addressed specific occupational performance issues: Baker et al. (2012) identified computer equipment problems experienced by people with systemic sclerosis. This study determined that changing the seating, using foot and wrist rests, and adjusting computer components were the most frequent accommodation strategies used. Some of the most problematic driving scenarios were identified by certified driver rehabilitation specialists in the Yuen et al. (2012) study. Turning left into oncoming traffic, navigating four-way intersections, and reacting to unexpected events were acknowledged to be the most difficult when retraining people to drive after injury or illness.
Finally, 2 articles discussed occupational therapy practice, with the Craig (2012) review indicating that occupational therapy has a comprehensive role in home health services and that activities of daily living (ADLs), environmental modification, and caregiver training are foremost in typical home health occupational therapy interventions. Additionally, modification of standardized assessment protocols to accommodate people with aphasia was found to be effective; Tucker et al. (2012) described how these tools can be adapted to meet the needs of the patient and implemented in occupational therapy practice while still maintaining reliability.
A variety of instruments were used across the studies conducted. Common standardized assessments often seen in occupational therapy practice such as the SF–36, LOTCA, Jebsen–Taylor Test of Hand Function, Canadian Occupational Performance Measure, Box and Block Test, Fugl-Meyer Assessment, and upper-extremity motricity index were used in a majority of the articles reviewed (n = 14). Other, less commonly used instruments or tools developed for the specific research question posed were also present: the Computer Problems Survey, the Patient Transfer Curriculum Survey, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Self-Efficacy for Energy Conservation Questionnaire, and the Modified Telephone Interview for Cognitive Status. Impairment-level measures frequently used in occupational therapy practice, such as the Modified Ashworth Scale, manual muscle testing, goniometry, and ROM, were also present in the studies reviewed.
All 10 intervention effectiveness studies included impairment-level outcomes. Cimarolli et al. (2012) addressed vision impairment reduction in their efficiency study. The Prager and Lang (2012) basic research study likewise addressed whether initial upper-extremity AROM measurements would predict upper-extremity function 3 mo after stroke. As is evident in the reviewed articles, impairment-level measures that yield specific, objective data enable quantitative analysis and can be a starting point for scientific inquiry. Along with these measures, some of the studies also used instruments that yielded qualitative information such as the Self-Efficacy for Energy Conservation Questionnaire, the Self-Report Assessment of Functional Visual Performance, and a semistructured interview.
As can be seen in the previous AJOT reviews, neurorehabilitation research articles continue to be generated at a rate of approximately 20 per year, which is relatively low. On a positive note, the quality of the studies appear to be improving: Five intervention studies from the past year are ranked as Level I (systematic reviews, meta-analyses, or randomized controlled trials). A PubMed search for research articles using the keywords occupational therapy and effectiveness yielded approximately 130 articles. However, when diagnosis-specific keywords such as stroke and spinal injury were added, the numbers were still surprisingly low (ns = 11 and 4). Although occupational therapy researchers may be publishing outside of AJOT, there remains a paucity of occupational therapy intervention effectiveness research in general.
Barriers outlined in the Centennial Vision (AOTA, 2007), such as “rigid adherence to the status quo” (p. 614) and “misalignment between the current occupational therapy priorities and the external environment” (p. 614), could certainly have an impact on the amount of research being published. The number of occupational therapy clinician–researchers is few despite initiatives by the association, educational programs, and professional leaders; clinicians are required to focus on service delivery, and many do not see research as clinically relevant (Cusick, 2001). A large disconnect still appears to exist between the academic and clinical environments in philosophy and priorities (Peloquin & Abreu, 1996), and even with the strong move toward evidence-based practice, use of research evidence by clinicians is suggested to be modest at best (Dysart & Tomlin, 2002). Effectiveness studies are the means by which we increase our value as a profession and impart to others the importance of our services. As we move forward, we will need to find the means to enable clinicians and researchers to engage in this type of inquiry and provide support for publication and dissemination of findings.
Instrument development continues and will be a critical element in occupational therapy’s achieving effectiveness as a profession. The use of standardized instruments that provide objective, measurable data can increase the value of a profession by validating the need for service provision, determining the appropriate health care services needed, addressing public policy issues, and assisting in the assessment of workforce requirements (Moore & Jull, 2009). At a minimum, it informs others of our ability to meet patient outcomes and determine the benefit of our interventions. The research reviewed in the past year is a movement in that direction; we can begin by measuring impairment-level outcomes, which lend themselves to easy, efficient measurement, to provide the data and pair these with activity or participation measures that will provide information, producing comprehensive assessments of patient function.
As part of the Centennial Vision summary, eight elements were identified as being highly relevant to the vision both members and nonmembers wanted to emerge over the next 10 yr. In examining a few of these elements, we can see some of the challenges that lie ahead and the steps we will need to take to move closer toward our Centennial Vision.
Academic–clinical alliances are needed to expand our ability to perform effectiveness studies and embark on scientific inquiry that will assist in broadening the evidence base of occupational therapy. Academics skilled in research may often not have direct access to patient populations they wish to study; similarly, clinicians who would like to experiment with research activities may not have access to the academicians who could feasibly assist them in the process. These types of collaborations can potentially generate larger numbers of research participants to conduct viable effectiveness trials and yield more robust and powerful results.
In the articles reviewed, 9 of the studies with the largest participant numbers (mean N = 85.77, standard deviation = 62.43) used surveys (Baker et al., 2012; Frost & Barkley, 2012; Stefanovich et al., 2012; Yuen et al., 2012). Additionally, secondary analysis of existing data for the entire sample (Cimarolli et al., 2012; Finlayson et al., 2012; Schepens et al., 2012) or part of the sample (O’Brien et al., 2012) was used in 4 of the articles, and the final large subject study was a scoping review using current topic-specific literature (Craig, 2012). The direct patient intervention studies (Engstrand et al., 2012; Flinn et al., 2012; Glasgow et al., 2012; Hayner, 2012; Katz et al., 2012; Martin et al., 2012; Mennem et al., 2012; Nilsen et al., 2012; Polatajko et al., 2012; Prager & Lang, 2012; Sledziewski et al., 2012; Tucker et al., 2012; Yang et al., 2012) all had fewer participants than the survey studies (mean N = 23.71, standard deviation = 22.94).
Survey and secondary analysis designs can be efficient and less time consuming than investigations involving assessment of direct interventions with patient populations. However, some researchers have suggested that direct human subject investigation is a natural model for occupational therapy (Schwartzberg, 1980), and perhaps this should be our gold standard for research. Clinicians in practice can easily develop single-subject and case-series designs; some of these methods can be quite robust and implemented by clinician–researchers with little statistical expertise (Nourbakhsh & Ottenbacher, 1994). Clearly, rigorous investigations that can use any thoughtful design to examine the effectiveness of the interventions we provide to typical patient populations and do so within the clinical environment will always be prove to be informative and useful.
Academic faculty can bridge the academic–clinical gap through specific activities such as engagement in faculty clinical practice, clinical consultation, educational consultation, collaborative grant writing, and mentoring (Peloquin & Abreu, 1996). Clinical faculty can accept fieldwork students, volunteer to instruct patient-centered courses at academic institutions, and enlist the assistance of researchers to begin scholarly activities such as developing creative clinic-based case studies or case designs. Beginning that arduous step to participate in collaborative grant writing with academics will also improve occupational therapy’s effectiveness as a profession. Research that begins with questions posed by clinicians is that which will eventually be most easily translated to clinical practice (Strzelecki, 2008).
Using evidence databases and drawing on other effectiveness studies will continue to be critical in advancing the profession. These efforts should begin early with students in allied health curricula and focus on answering clinically relevant questions (Boruff & Thomas, 2011). In a recent study of occupational therapy students, knowledge of evidence-based concepts was determined to be directly related to the formal instruction received on the topic (Thomas, Saroyan, & Snider, 2012).
As mentioned previously, standardized and normed instruments can assist in documenting change in status more accurately, which can in turn improve occupational therapy’s effectiveness (Watts, Broiler, & Schmidt, 1989). In addition, the development of new, valid, and reliable tools that are efficient and have ease of administration are those that the profession will need and will adopt as we strive for professional excellence and effectiveness. The past year’s publications indicate a commitment to this initiative. Using impairment-, activity-, and participation-level assessments in combination with understanding the important person-specific factors will be most informative (Coster, 2008). When occupational therapists can provide this rich quantitative and qualitative information to families, payers, and providers, we will become more effective at what we do.
According to the 2010 AOTA Compensation and Workforce Study (AOTA, 2010), more than two-thirds of all occupational therapists surveyed (67.7%) currently practice in hospital-based settings (non–mental health), skilled nursing settings, and schools. Our effectiveness studies and research efforts should be focused toward the patient populations served and the challenges faced in these settings. In recent years, the profession has embraced community-based practice settings and nontraditional roles and worksites for occupational therapists; however, the data have indicated that occupational therapists are primarily engaged in traditional medical model and educational model practices.
Most important, occupational therapy educational programs must recognize that the majority of students they graduate will be employed in traditional hospital settings and school systems. Curricula should reflect this priority with an emphasis in these areas and appropriate time spent on the courses that prepare students not only to succeed but also to thrive in the environments in which they will build their careers. Students should have continual and ample opportunities to work with actual patient populations and experience hands-on learning that will promote exceptional practice. Educators must instill in these leaders of the future a desire for lifelong learning and continual questioning of the status quo. Model educational programs will be those that are able to modify curricular elements to reflect both the current and the future health care needs of society and give to the occupational therapy workforce skilled, competent professionals informed and prepared to meet those needs.
As occupational therapists, we can increase our value to consumers, insurers, policymakers, and society simply by being more effective at what we do: Neurorehabilitation practice will be more effective if we step outside our comfort zone and are proactive in developing the clinical–academic alliances needed to improve patient care through rigorous scientific inquiry. We will be more effective if clinicians begin to engage in simple research designs that can answer the most basic clinical questions. We are effective if practicing therapists recognize the importance of standardized instruments and implement measures and interventions grounded in evidence. And we will become extremely effective if educators prepare future occupational therapy professionals for the realistic needs of the current and future health care systems in which they will be employed. Herein lies our value, our growth, and our future.
The author gratefully acknowledges the assistance of Monica Watford in the preparation of this manuscript.
*Indicates studies that were systematically reviewed for this article.