In this guest blog for World Occupational Therapy Day, which falls on 27th October, OT Danny Minkow explains what it is and looks at the evidence on how it can help people after a stroke.
Imagine for a moment you are in the recovery room in a hospital. You have survived a stroke. A therapist knocks and enters your room. He says, “Good morning, my name is Danny, and I’m here for your occupational therapy. Do you know what occupational therapy is?” Unfortunately, many people say, “No, I don’t know what occupational therapy is” or, even more commonly, “Are you here to help me find work?”
So what is occupational therapy?
Occupational therapists (OTs) help people maximize their independence with an emphasis on useful or functional activities. Increasing range of motion and building muscle are important, but OTs try to find what the patient finds meaningful and what activities they need to perform. OTs also view the person within the context of their living and working environment. In general, OTs help people across their lifespan, from premature babies to the elderly, in a variety of settings and conditions.
For now, let’s stick with stroke since it’s one of the leading causes of adult disability, has been well researched, and many stroke survivors receive therapy from an occupational therapist.
One way that an OT could help someone recover from a stroke is by improving their ability to do day-to-day tasks. OTs call these tasks Activities of Daily Living. This could include things like bathing, toileting, dressing, eating, cooking, grooming, dressing, and even driving. Of course, these activities are typically important parts of a patient’s larger life roles, such as being a parent, home owner, a student, or being employed.
Since each person is different, the nature of the therapy would also depend on how the stroke has affected their life, what the person finds meaningful in their life role and what they would like to improve. So in reality, while the occupational therapist doesn’t help anyone find a job, they could help someone regain the ability to work after a trauma or in this case a stroke.
What is the evidence that occupational therapy helps?
All of this sounds lovely, but does it really work? Well, here’s some good news for all of us – teams at The Cochrane Collaboration have done some high quality research on occupational therapy for stroke. Cochrane teams look for the best available evidence on a topic and put it together in systematic reviews to establish what is known about a therapy or other health intervention.
This first Cochrane review* included 9 studies with 1258 participants and looked at occupational therapy for patients with problems in activities of daily living after stroke. They found that patients who receive occupational therapy are less likely to decline and are more likely to be independent in their ability to perform personal activities of daily living. However, it wasn’t clear what the exact nature, duration, type, and intensity of the occupational therapy was needed in order to achieve the maximum benefit, so there is room for further research there.
As you can imagine, having a stroke could affect your ability to move your hands and arms. A fascinating systematic review of reviews by Langhorne, Coupar, and Pollock investigated which therapies worked best to promote motor recovery after stroke. Their results came mainly from 10 different Cochrane reviews for recovering movement and function for the arm and hand. The most promising intervention that improved the patient’s ability to manage activities of daily living for arm function is constraint-induced movement therapy. constraint-induced movement therapy is when the therapist would constrain or limit the movement of the non-affected arm and have the patient use the affected arm to do repetitive or functional tasks.
They also found:
- Limited evidence for mental practice therapy. This is basically mentally rehearsing the activity
- Small amount of evidence for biofeedback for stroke. This allows a person to see or hear how their body is responding
- Some evidence that robotic-assisted arm training can help to regain function, but not strength
- Very limited evidence for interventions to improve hand function
This suggests that overall therapy to regain arm movement and function after a stroke will involve some form of intensive, repetitive task-specific practice.
Helping you at home
Community-dwelling stroke survivors might receive their therapy in their home. These home visits may be conducted by a multidisciplinary team that could include an occupational therapist and/or a physiotherapist (physical therapist). This review of therapy-based rehabilitation services for patients living at home more than one year after stroke looked at 14 studies, involving 1617 participants and they found that people who had a recent stroke were more independent in activities of daily living and more likely to maintain these abilities if they received therapy services at home. I can imagine that the therapist is more likely to notice day-to-day activities of the patient when they observe them living their lives as usual. They could also find household hazards when they visit someone living in their actual home for therapy.
Many stroke survivors live at a care home (such as a nursing home). This population differs from the community-dwelling population who remain in their own homes. For example, they are more likely to have high levels of immobility, incontinence, and confusion, along with other health conditions. This review of occupational therapy for care home residents with stroke was able to include only one study involving 118 participants, comparing occupational therapy and standard care. The authors concluded that since it only included one study, the effectiveness of occupational therapy for the population of stroke survivors residing in care homes is not clear. This is another area where more research is clearly needed.
Can OT improve your thinking ability?
Finally, having a stroke can also affect how a person ‘thinks’. This means a stroke can impact how someone learns new things, concentrates, or even makes decisions. This impairment can affect a person’s ability to perform everyday activities. Occupational therapists might use strategies to help someone relearn a task (remediation), or compensate by using devices to help people remember to do something. This could include using an alarm clock or medicine container. A review of occupational therapy for cognitive impairment in stroke patients included one trial with 33 participants. The authors concluded there isn’t evidence yet to establish the effectiveness of occupational therapy for cognitive impairment in people who have had a stroke. One more area for future research for OTs!
Occupational therapy is different for each person
So overall, Occupational therapists are uniquely positioned to help people recover from a stroke. The challenge with researching occupational therapy is that by its nature, occupational therapy as an intervention is client-centered. So it’s going to be different for each person, based on the challenges they face as an individual as well as what roles and activities they find meaningful. It’s a strength for the field, being so patient-centric and tailored to their needs, but it makes it really difficult to research, isolate, measure, and quantify occupational therapy as an ‘intervention’ for real life application. Also, part of the challenge is to prescribe accurately exact protocols for other therapists to implement. This may also be part of the reason why so many people don’t seem to know what occupational therapists actually do.
So where does this leave us? Well, I gave you the long answer on what occupational therapy is and how it can help people with stroke. Even though more research is needed, the good news is that there is promising evidence that working with an occupational therapist will help in recovering from a stroke. If you do end up receiving occupational therapy for any reason, at least now you will know a bit more about it and feel comforted knowing that you are in good hands.
What do you think? Tell us how an occupational therapist has helped you or someone you know!
Read more blogs about stroke here
You can find out more about World Occupational Therapy Day from the World Federation of Occupational Therapists website. In the UK, the British Association of Occupational Therapists and College of Occupational Therapists (@BAOTCOT) is leading Occupational Therapy Week from 3 – 9 November 2014 and you can find out more here.
*Editor’s note: an updated version of the review was published in July 2017, with the addition of risk of bias assessment and conclusions changed: “Occupational therapy increases independence in activities of daily living and reduces the odds of a poor outcome (deterioration or dependency). However, the evidence was rated low-quality.”
Page last updated 31 July 2017.
Occupational therapy for adults with problems in activities of daily living after stroke. Cochrane Database of In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. More 2017, Issue 7. Art. No.: CD003585. DOI: 10.1002/14651858.CD003585.pub3., , , , .
American Occupational Therapy Association. Occupational therapy practice framework: domain and process. (3rd ed.). American Journal of Occupational Therapy 2014; 68(Suppl 1): S1-S48. http://dx.dor.org/10.5014/ajot.2014.682006
Langhorne P, Coupar F, Pollock A. Motor Recovery after Stroke: A Systematic Review. Lancet Neurology 2009; 8(8): 741–54. doi:10.1016/S1474-4422(09)70150-4.
Aziz NA, Leonardi-Bee J, Phillips MF, Gladman J, Legg LA, Walker M. Therapy-based rehabilitation services for patients living at home more than one year after stroke. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD005952. DOI: 10.1002/14651858.CD005952.pub2.
Fletcher-Smith JC, Walker MF, Cobley CS, Steultjens EMJ, Sackley CM. Occupational therapy for care home residents with stroke. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010116. DOI: 10.1002/14651858.CD010116.pub2.
Hoffmann T, Bennett S, Koh CL, McKenna KT. Occupational therapy for cognitive impairment in stroke patients. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD006430. DOI: 10.1002/14651858.CD006430.pub2.
Langhorne P, Bernhardt J, Kwakkel G. Stroke Rehabilitation. Lancet 2011; 377(9778): 1693–1702. doi:10.1016/S0140-6736(11)60325-5.
British Association of Occupational Therapists and College of Occupational Therapists. Live Life Your Way. Web. http://www.cot.co.uk/. Accessed 2 September 2014.