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Canadian Occupational Therapy Foundation Outcomes That Matter
Final Report
Project title: The effectiveness of occupational therapy education and functional training
programs for older adults
Principal investigator: Seanne Wilkins
Address: School of Rehabilitation Science, McMaster University, Institute of Applied Health
Sciences, 1400 Main Street West, Hamilton, Ontario L8S 1C7
E-mail: swilkins@mcmaster.ca Phone: 905-525-9140 ext 27839 Fax: 905-524-0069
Co-investigators: Bonny Jung, Laurie Wishart, Mary Edwards, Shelley Gamble Norton
Background:
There is a diversity of ways in which aging and chronic illness have an impact on the lives of older adults. This
diversity would suggest that occupational therapists must practice in a client-centred way to ascertain what
aspects of occupation and occupational performance are important to their older clients. Occupational
performance is the result of a dynamic relationship among persons, environment and occupation across the life
course (Canadian Association of Occupational Therapists [CAOT], 1997). Once these occupational performance
issues are determined, occupational therapists in partnership with their clients must determine what interventions
would result in outcomes that would make a difference to the clients= health and occupational performance and
thus, improve the quality of their day-to-day lives. Clients expect that interventions will be effective, as do other
professionals, care providers and funders. Thus, occupational therapists must provide interventions that are based
on research evidence.
Enabling occupation with older adults often takes the form of education and functional training in occupational
performance (i.e., self-care, productivity and leisure). Programs may include education only, functional training
only or a combination of both education and functional training. The education component is usually a didactic
approach directed toward knowledge. It includes the dissemination of information through such activities as
presentations, written information, demonstrations and counselling (Hammond, 1997). The functional training
component is directed towards enabling achievement of the individuals’ goals in occupational performance.
Strategies for enabling change may involve developing, maintaining, restoring, or promoting occupational
performance or preventing occupational dysfunction and may involve skill development in activities such as
dressing, meal preparation, volunteering and hobbies (CAOT, 1997). It may include a greater use of
demonstration than the education component and also includes practice by clients with occupational therapist
supervision. The occupational therapist, in collaboration with the client, develops and monitors a home practice
program to be used between therapy sessions (Hammond, 1997).
To date there has been no critical review of the research literature in this area that determines whether these
occupational therapy intervention strategies used separately or in combination are effective in enabling
occupation and occupational performance and in enhancing the quality of life (QOL) for older adults. Thus, a
critical review of the research literature was undertaken.
1
Objectives:
A critical review was undertaken to address the following question:
What is the effectiveness of occupational therapy education and functional training programs in improving
health, occupational performance and quality of life for older adults who may or may not have chronic illnesses?
Methods:
Original criteria for considering studies for this review (criteria were ultimately revised)
Types of studies (qualitative and quantitative)
The review selected both qualitative and quantitative studies involving occupational therapy education and
functional training programs for older adults with chronic illness. The descriptive critical review (see Table 1)
includes all articles which reported a study of the effect of occupational therapy education and functional
training programs in developing, maintaining, restoring and/or promoting occupational performance and quality
of life of older adults. The quantitative study designs included randomized control trials, cohort, single case,
before-after, case control, cross-sectional and case study designs. The qualitative study designs included
ethnography, grounded theory, participatory action research, and phenomenology designs.
Types of participants
Older adults (aged 65 or older) with a diagnosis of a chronic illness (i.e., an illness lasting 6 months or more)
involved in education and training programs which may be offered in any setting (in-patient, out-patient,
community based).
Types of intervention
Studies included must be described as occupational therapy education and/or functional training programs. The
programs may be offered separately or in combination by occupational therapists.
Types of outcome measures
Outcomes must include measurement of occupational performance, such as participation in daily activities,
and/or in specific areas of self-care, productivity and/or leisure, and/or environmental contexts/conditions.
Revised inclusion criteria
The original inclusion criteria were pre-tested on a sample of 10 articles to refine and clarify the inclusion
criteria, train the research group in applying the criteria, and ensure that the criteria were applied consistently
across the research group (Mulrow & Oxman, 1997). Identification of appropriate studies required 75%
agreement of the research team. Discussion and consensus of the research group resolved discrepancies.
Inclusion criteria were modified after review of 10 articles:
• sampling included studies with participants 65 and over but not exclusively older adults due to the paucity of
studies with only adults 65 and older,
• sampling included well older adults and/or older adults with chronic illness because there have been
important studies utilizing occupational therapy education and functional training programs with well older
adults,
• study design modified to include quasi-experimental and to exclude cross-sectional and case study designs in
order to focus on the highest level of evidence, and
• setting of studies specific to out-patient and community given that there have been critical reviews done of
specialized in-patient programs including occupational therapy such as stroke units and that there is a trend
toward providing more occupational therapy in the community than in the past.
Search strategy for identification of studies
Selection of the studies for inclusion in this review was a multiple stage process and followed recommended
procedures in the Cochrane Collaboration Handbook (Mulrow & Oxman, 1997).
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Review included the medical and social sciences literature pertaining to occupational therapy and was conducted
by an occupational therapist (research associate) who works with older adults in the community.
1. Computer search – electronic data bases:
Medline, 1966-present
CINAHL, 1966-present
Health Star, 1985-present
Best Evidence,1991-present
Ageline, 1978-present
Psych Lit, Social Sciences Index , Sociological Abstracts 1980-present
Review of Cochrane library
2. Hand searching
Review of bibliographies supplied by field experts.
Abstracts, specifically Journal of Physical and Occupational Therapy in Geriatrics, The Gerontologist, OT
Practice: 1980-present.
3. Citation review
Review of all reference lists of retrieved articles.
The search involved combining keywords related to education and functional training programs for well and/or
older adults with chronic illness.
Keywords included:
patient/client education; purposeful activity; meaningful activity; occupational therapy,/evaluation;
rehabilitation,/evaluation; outcome assessment,/health care; long term care; community health services;
quality of life; health promotion; chronic illness; aged/aging; arthritis (rheumatoid & osteoarthritis),
osteoporosis, COPD, diabetes, Parkinson’s disease, hypertension, stroke, PVD, CHF; falls; driving.
Methods of review
(a) Article selection:
Lists of the articles from the search were reviewed beginning with assessment of each title and abstract by the
principal investigator and research associate to determine whether the article met the inclusion criteria. If it was
not possible to determine if a particular article met the inclusion criteria, then the full text of the article was
reviewed. Each identified article was entered into a reference system (i.e., PAPYRUS).
b) Data abstraction:
Principal investigator and research associate reviewed the articles against inclusion criteria to ensure that all
potentially relevant articles were retrieved. Articles that met the inclusion criteria were reviewed using the
Guidelines for Critical Review for quantitative and qualitative studies developed by the McMaster University
Occupational Therapy Evidence-Based Practice Research Group (Law et al., 1998a,b). Once a group of articles
was retrieved, each of the 5 members of the research group reviewed the articles using aforementioned
guidelines. Evaluations of reviews were compared to acquire an assessment of 75% of agreement of the primary
rated categories on the review forms.
c) Data analysis:
The descriptive review is outlined in table format to summarize the important methodological issues and
implications of the research findings for occupational therapists (Table 1). Note that groupings (prevention,
stroke, and rheumatoid arthritis) emerged during our analysis and articles in Table 1 are listed alphabetically in
these groups.
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Results:
1.Literature search:
The first search using electronic databases found 322 articles pertaining to the applied keywords. Following
application of inclusion criteria, a total of 105 articles were identified. Hand searching and citation review
identified 10 additional articles. Following the extensive review process, 18 articles were accepted based on the
revised criteria.
2. Data extraction and analysis:
Descriptive review: Table 1 summarizes the important components and conclusions of the accepted studies and
provides an assessment of the methodological issues and implications for occupational therapists.
Implications for practice and policy:
This critical review suggests that there is evidence to support the effectiveness of occupational therapy education
and functional training programs for older adults although there is a need for ongoing, well-controlled and
longitudinal research in this area. The evidence varies across the 18 studies described in Table 1. It may be most
beneficial to consider the studies reviewed by grouping them into programs provided for the purposes of
prevention of functional decline or programs provided to people with different chronic illnesses. Although the
search was not designed to focus on specific conditions, these groups emerged as a result of our analysis.
It is hoped that this review will be useful to occupational therapists working with older adults in different
settings or with different populations as well as influence policy related to occupational therapy practice.
Relative to influencing policy, occupational therapists may find this review useful in discussions with policy
makers as supporting evidence for programs or program changes.
There are some issues regarding the reporting of the studies that are common across most articles. There is
generally a lack of detail regarded the actual occupational therapy program that is being provided. This results in
an inability to understand the specific intervention or group of interventions and to duplicate the study.
Similarly, in studies including both occupational therapy and physiotherapy, there is a lack of clarity as to what
is being done uniquely by each professional leading to results that cannot be attributed to one or the other
profession.
There are many methodological issues across the studies (Table 1). While the ideal design of a randomized
control trial has been used in most of the studies included, there is often contamination and co-interventions that
may or may not be considered within the limitations of the study description. In many studies the analysis is
poor or not clearly described leaving the reader to try to decipher the tables of results. Most of the studies do not
include long-term follow-up to enable discussion of the effectiveness of the intervention over time, an important
factor in policy decision making. Also in some situations the type of follow-up may not be appropriate for the
type of outcomes being measured (e.g., a postal questionnaire rather than direct observation to determine the
effectiveness of a program on independence in ADL). While this may be a funding issue, it can weaken the
results of the study. Results may not be generalizable to other populations or situations. Although it is
encouraging to see studies being conducted in this area, the review emphasized the need for studies that are
methodologically more rigorous to help support policy changes related to occupational therapy.
We did not include studies of older adults with dementia, developmental delays, or mental illness. Since our
focus was on occupational performance, we did not include studies focusing only on performance components
(i.e., range, strength, pain), rote exercise, object or imagery based exercise, laboratory-based studies, or health
utilization studies (economic analysis).
We divided the studies into the following groups: prevention, stroke and rheumatoid arthritis.
NOTE that Table 1 has been organized to cluster the articles into these groupings.
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PREVENTION: There are 5 research studies in Table 1 that address this issue (Clark et al., Clemson et al.,
Close et al., Cummings et al., Liddle et al.). The strongest evidence amongst these studies is provided by the
work of Clark et al. This large scale RCT with well older adults living in the community provides statistically
significant evidence for a specific occupation based program which offers meaningful choices in an
individualized program provided by occupational therapists aware of barriers and supports in the community.
This is in contrast to two control groups: a generalized activity (social) group and a group with no intervention.
The results are specific to health function and QOL domains but cannot be generalized to people in different
living situations and with different SES (socioeconomic status) or to people with disabilities. The remaining 4
studies consider the importance of the environment of older adults relative to falls (Clemson et al., Close et al.,
Cummings et al.) and loss of independence (Liddle et al.). The qualitative study by Clemson identifies the need
for ownership of ideas and exerting control (joint decision-making and negotiation; importance of options and
choices) within the context of environment and life experiences strongly influenced acceptance and follow
through of environmental changes to reduce falls. The RCT by Close et al. provides evidence of the usefulness
of a bi-disciplinary approach (medicine & OT) to decrease the number of falls as well as the rate of recurrent
falls at 4 and 12 months. The focus of occupational therapy was on advice and education about home safety as
well as recommendations for modifications and equipment. Modifications were made and equipment supplied
for the participants. The RCT by Cummings et al. provides evidence that a home visit by an occupational
therapist can prevent falls inside and outside the home among people with a history of falls provided there is
follow-up and funding for modifications. The RCT by Liddle et al. involved older adults living in the
community with no to severe impairment on ADL. There were no statistically significant differences in 3 groups
regarding providing equipment, modifying home environments and using community resources to affect
independence and quality of life. Easily available services as well as motivation to seek help by participants may
have resulted in the lack of difference between groups.
Implications for practice:
• health and QOL can be promoted among well older adults through an occupation based intervention that
includes meaningful choices of activities, is individualized and is provided by occupational therapists
• with well older adults, being engaged through social activity groups is no more effective in promoting health
and QOL than no intervention
• with older adults requiring home modifications, acceptance and follow through of home modifications can
be enhanced through ownership of the ideas, the opportunity for exerting control through joint decision-
making and negotiation, and through options and choices for change within the actual environment
• a medical/occupational therapy prevention approach that considers both intrinsic and extrinsic fall risk
factors can play a significant role in reducing the number of falls and the rate of recurrent falls in older
adults
• home visits by occupational therapists can reduce the risk of falls both in and outside the home in older
adults with a history of falls if there is thorough follow-up as well as funding for modifications
Implications for policy:
• in programs where the goal for well older adults is promoting health and QOL, the type of intervention
group must be considered
• a structured, occupation based group provided by an occupational therapist is more effective than a social
activity group run by non-occupational therapists
• when consideration is being given to the implementation of a home modification program for older adults,
consideration must be given to factors such as active participation of the older adult in the decision-making,
options and choices for change, funding for the home modifications and thorough follow-up
• if the focus of the program is the reduction of falls, other professionals in addition to occupational therapists
may enhance the success of the program
STROKE: There are 11 research studies included in Table 1 (Corr & Bayer; Drummond & Walker; Gilbertson
et al.; Jongbloed & Morgan; Logan et al.; Parker et al.; Tangeman et al.; Walker, Drummond et al.; Walker,
Gladman et al.; Werner & Kessler; Widen Holmqvist, von Koch et al.). These studies can be further subdivided
into interventions consisting of: A. occupational therapy, B. occupational therapy focusing on specific skills (i.e.,
leisure and dressing), and C. rehabilitation (i.e., occupational therapy [OT] and physiotherapy [PT]).
A. Occupational therapy: In the RCT by Corr and Bayer, there is little evidence for the provision of ongoing
5
occupational therapy after discharge from a stroke unit due to co-interventions. While there were statistically
significant difference in the number of assisted devices used, independence in feeding, use of telephone and a
reduction in hospital readmission, the lack of control of co-interventions prevents a positive evaluation of the
occupational therapy intervention. In the RCT by Gilbertson et al., there is evidence that a brief community
based program of occupational therapy tailored to the individual needs of older adults after discharge from
hospital can improve performance in ADL and EADL in the short term (8 weeks) but not at 6 months although
the intervention group was more likely to have improved and the change in ADL scores was significantly better
than control group. The RCT by Logan et al. supports the provision of enhanced occupational therapy service
(early rehabilitation intervention, longer and more visits) compared to usual service (wait list, provision of
assisted devices) with statistically significant differences in EADL at 3 months but only on mobility section of
EADL at 6 months as well as better moods for caregivers. In the RCT by Walker, Gladman et al., there is
evidence of occupational therapy significantly reducing disability and handicap in older adults with stroke who
were not admitted to hospital. Focusing on personal care and IADL, there were significant differences in scores
in ADL, EADL, caregiver strain and handicap.
B. Specific occupational therapy intervention: 1. Leisure: There are mixed results in 3 studies focusing on
leisure programs. In a small RCT by Drummond and Walker, there is evidence that leisure rehabilitation
maintains and increases leisure participation at 3 and 6 months. In a larger, multi-centred study, Parker et al.
attempted to replicate these study results. While all estimates were in the direction of improvement at 6 months,
these were not statistically significant. At 12 months, there was no significant difference between the
intervention and control group. In a RCT by Jongbloed and Morgan, there was no statistical difference in
involvement in leisure activities or satisfaction with involvement in activities between intervention and control
groups at 5 or 18 weeks. Methodological issues in the latter 2 studies may have resulted in lack of support for
leisure rehabilitation for this population.
2. Dressing: In a randomized cross-over design, Walker, Drummond et al. evaluate an intensive occupational
therapy intervention for older adults with persistent dressing problems 6 months after discharge from hospital.
They found significant differences between groups on dressing, perceived health and ADL performance.
Dressing improvements were maintained at 3 months but did not generalize to other areas of ADL.
C. Rehabilitation: A before and after design was used by Tangeman et al. to evaluate the effect of a 1 month
intensive outpatient OT/PT rehabilitation program for people 1 year post stroke. Significant improvement was
made in weight shift, balance, and ADL with skills retained at 3 month follow-up. In a RCT by Werner and
Kessler, there is evidence that functional gains are possible with intensive OT/PT outpatient rehabilitation for
older adults who had received inpatient rehabilitation. There was significant increase in functional independence
and sickness impact at 3 months but these were not sustained at 9 months. Widen Holmqvist, von Koch et al., in
a RCT, evaluated an in-home rehabilitation program with OT, PT and consultant social worker for older adults
after early discharge from hospital as compared to rehabilitation in hospital, day care or outpatient care. No
significant differences were found at 3 months although there was a reduction of hospitalizations for intervention
group. This group was also more satisfied with care especially in their active participation in planning their
rehabilitation program. Although not sufficiently to attain statistical significance, at 6 months the difference in
outcomes favoured the home rehabilitation group in motor capacity, manual dexterity, walking, EADL, and
perceived dysfunction. Follow-up at 12 months has not yet been reported.
Implications for practice:
• there is evidence that community based occupational therapy programs tailored to the individual needs of
older adults following discharge from hospital can improve performance in some ADL and EADL in the
short-term (8 weeks) although not in the long term (6 months) and help decrease hospital readmission
• an early, more intensive and comprehensive occupational therapy program provided over a longer period of
time as opposed to the provision of assistive devices only may make a difference in EADL at 3 months but
not at 6 months
• there is evidence that, amongst people not admitted to hospital following stroke, a home-based occupational
therapy program can make a difference in ADL, EADL, caregiver strain and handicap at 6 months
• evidence for the effectiveness of occupational therapy leisure interventions provides inconclusive results;
while a small RCT provided evidence that a leisure rehabilitation program resulted in maintained and
increased leisure activities at 3 and 6 months, two other studies showed no evidence of difference; thus,
more research is needed in this area
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• specific, intensive occupational therapy intervention (dressing) programs in the home can improve dressing
skills, ADL and perceived health
• the client’s home is an optimal environment for occupational therapists to consider dressing
• in contrast to literature suggesting there is recovery only in the first 3 months following stroke, there is
evidence that intensive, short-term rehabilitation programs including both OT and PT for people 1 year post-
stroke makes a difference in weight shift, balance and ADL at 3 months but not at 9 months
• with older adults between 6 months and 5 years post stroke, an intensive OT/PT program can improve
functional independence and sickness impact at 3 months and dressing and bathing at 9 months
• early discharge home with interdisciplinary (OT, PT, social work consultation) rehabilitation intervention
could be implemented for a selected group of older adults following stroke
Implications for policy:
• in occupational therapy programs for older adults with strokes, there is an ongoing need for program
evaluation to ensure that the goals of the programs are being met over time
• brief, intensive and comprehensive occupational therapy programs that are tailored to the individual needs of
older adults as well as offered earlier may be more effective than the provision of assitive devices only
• brief community based occupational therapy intervention that focus on specific issues of relevance to older
adults may be more effective than programs covering all aspects of occupational therapy
• occupational therapy programs provided to people with strokes who are not admitted to hospital are effective
in improving ADL and EADL and in reducing dependency on the social and health care systems
• the client’s home is an optimal environment for occupational therapists to address persistent dressing
problems
• short, intensive OT/PT rehabilitation programs introduced after the time that is usually considered optimal
for recovery from stroke may be effective
• intensive OT/PT rehabilitation provided in the home following early discharge may be as effective as
rehabilitation provided in hospital, daycare or outpatient services and may lead to a reduction in
hospitalization as well as increase satisfaction of older adults with care and involvement in the planning of
their programs
RHEUMATOID ARTHRITIS: There are 2 studies included in Table 1 (Helewa et al., Gerber et al.). In the
RCT conducted by Helewa et al., a home occupational therapy program was found to be effective in improving
daily function (i.e., self-care, productivity and QOL) in people with rheumatoid arthritis even when treatment
was delayed for 6 weeks. In a randomized pilot study, Gerber et al. found no significant differences in outcomes
for people using a didactic workbook-based occupational therapy program with behavioural and health education
strategies than for people involved in a standard occupational therapy program including videotapes, written
materials, individualized teaching and review of ADL difficulties. However, the group using the didactic
workbook-based occupational therapy program did show some positive change.
Implications for practice:
• there is evidence that a comprehensive, 6 week occupational therapy home program (addressing self-care,
productivity and leisure as well as environmental contexts based on the particular needs of the individual)
for people with rheumatoid arthritis does improve their functioning in areas of self-care, household
management, mobility and QOL
• a 6 week occupational therapy home program may not be long enough for significant gains in social
function, communication, leisure and appearance
• traditional energy conservation methods used by occupational therapists may not be as effective as a
systematic workbook-based occupational therapy patient education program but more research needs to be
done in this area
Implications for policy:
• a comprehensive, 6 week home occupational therapy program geared to the needs of the individual is
effective for people with rheumatoid arthritis especially in improving function in self-care, productivity and
QOL for at least 6 additional weeks
• a longer program may be needed to have an impact on leisure and psychosocial skills
• a 6 week delay in intervention does not change the effectiveness of the program although the individual may
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encounter disability during that time
• a systematic, didactic workbook-based occupational therapy educational program for energy conservation
may be more effective than traditional occupational therapy for people with rheumatoid arthritis
Summary of key implications across categories: In summary, there were themes across studies which are
important to consider in conducting effective occupational therapy education and functional training programs
for older adults. These include:
client-centred approach individualized and focused on issues relevant to the older adult
meaningful choices or options
exerting control and taking ownership of ideas
partnership and joint decision-making between client and occupational therapist
intensive and systematic programs
follow-up
Dissemination plan:
The critical review will be made available to occupational therapists in a variety of ways: on the COTF Web site
on the Internet and on the McMaster University School of Rehabilitation Science Web site (Mobility, Aging and
Participation Research Group page). An abstract for a paper presentation has been accepted for the annual
conference of the Canadian Association of Occupational Therapists in May of 2001. An article will be submitted
to the Canadian Journal of Occupational Therapy as well as a brief description of the critical literature review
findings will be submitted in Occupational Therapy Now (the newsletter of the CAOT) with references made to
the complete review on web sites.
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Acknowledgements
We would like to thank the Canadian Occupational Therapy Foundation for providing the funding for this
project.
9
References
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Appendix
Table 1: Descriptive Review of the Literature on the Effectiveness of Occupational Therapy
Education and Functional Training Programs for Older Adults
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Table 1: DESCRIPTIVE REVIEW OF THE LITERATURE
THE EFFECTIVENESS OF OCCUPATIONAL THERAPY EDUCATION AND FUNCTIONAL TRAINING PROGRAMMES FOR OLDER ADULTS
Wilkins, S., Jung, B., Wishart, L., Edwards, M., Gamble Norton, S.
* See glossary at end of table ** Note all results are significant (p ≤.05) unless stated otherwise
PREVENTION
Author/ Purpose Design, Sample & Research Focus/ **Results Conclusions, Methodology & Implications
date Outcomes Intervention
Clark et al. • to evaluate the D: RCT (3 groups) •OT group received 2hrs/wk of • significant benefit for C: older adults benefit from OT intervention
(1997) effectiveness of S: N=361; culturally group intervention (OT OT group across health that is occupation based, highly individualized
preventative OT diverse, independent facilitated) & 9hrs of individual function & QOL and assists in overcoming barriers
services compared to living, community intervention (i.e., didactic & domains M:
social activity dwelling, older direct experience) over a 9 mth • being regularly + applicable to various ethnicities
intervention or no adults with mean age period; interventions available engaged in activity - some outcome measures may not be useful
intervention on 74 yrs; (Mandal et al., 1999; Jackson et through social control for well, older adults
QOL, health & O: measures at 0 & al., 1998) program was no more - can’t generalize to different living
functioning of 9 mths; battery of • health through occupation effective in promoting situations/SES or older adults with disabilities
independent multi- self-administered focusing on appreciation of health than no - no follow-up
ethnic older adults questionnaires: importance of meaningful intervention - lack of definitions for some inclusion &
physical & social activity and specific knowledge exclusion criteria
function; self-rated about how to select or perform I: health and well-being can be promoted
health; life activities to achieve healthy through occupation based intervention
satisfaction; & lifestyle administered by OTs
depression • social control group received
2.25 hrs/wk of group
intervention (nonprofessional
facilitated) & activities designed
to encourage social interaction
among group members
• non-treatment control group
received no intervention
13
Author/ Purpose Design, Sample & Research Focus/ **Results Conclusions, Methodology & Implications
date Outcomes Intervention
Clemson et • to explore D: qualitative • to gain an understanding of • 8 conceptual C: lack of adherence to implement
al. (1999) perspectives of ethnographic study why these older women did not categories with core modifications related to need for ownership of
older women who S: N=9; age ≥ 65 implement home safety concept of “exerting ideas & ability to control within the context of
did not follow yrs; independent, recommendations control” relevant to all environment
through with OT community dwelling categories related to M:
recommended older women; how women manage - some implications noted may go beyond data
environmental referred to OT for risk - no design limitations noted
modifications to home assessment to - did not interview women who implemented
reduce risk of falls in decrease risk of falls suggestions
the home but did not I: importance of ownership of ideas and
implement exerting control within the context of
recommendations environment and life experiences influences
O: in-depth, semi- acceptance and follow through of
structured home recommendations
interviews;
interviews coded &
themes identified
Close et al. • to determine the D: RCT (2 groups) • intervention group had 1 • at 12 mths, C: one medical and one OT visit focused on
(1999) effectiveness of a S: N=397; mean age outpatient visit for medical significantly fewer falls prevention is effective in decreasing falls
structured of 79 yrs; assessment & 1 home OT visit falls and significantly M:
medical/OT community dwelling to assess falls risk; provide falls lower rate of recurrent – co-intervention & contamination may have
assessment in older adults, who education; advise regarding falling in intervention occurred
decreasing falls of had a fall-related home modifications and referral group - design limitations not discussed
older adults visit to hospital to relevant services -follow-up completed by postal questionnaire
compared to usual emergency •control group had no I: medical/OT prevention approach that
care control group O: measures at medical/OT assessment considers both intrinsic and extrinsic fall risk
who have fallen or at baseline, 4, 8 & 12 factors can play a significant role in reducing
risk of further falls mths; # of falls, the risk of falls in older adults
ADL, use of health
services; follow-up
through mailed
questionnaires
14
Author/ Purpose Design, Sample & Research Focus/ **Results Conclusions, Methodology & Implications
date Outcomes Intervention
Cummings • to determine the D: RCT (2 groups) • intervention group received • at 1 yr statistically C: home visits prevent falls among older
et al. effectiveness of OT S: N=530; mean age OT home safety assessment, significant decrease in people who have a history of falls; this effect
(1999) home visits targeted of 77 yrs; recommendations given and falls for older adults suggests that OT intervention may change
at environmental community dwelling follow-up including supervised who had fallen in year people’s behaviour in conjunction with home
hazards to reduce the older adults; adults completion of and funding for prior modifications
risk of falls in with cognitive modifications • no benefit for people M:
community dwelling impairment were not • 2 wk telephone follow-up without history of falls + discussed co-interventions
older adults who excluded if they • control group received no •only 50% of home +specified recommendations re: home
have had a recent lived with informed direct OT intervention but 19 of modifications in place modifications
hospital visit/ caregiver control group received non- after 1 yr therefore OT - small sample size
admission compared O: follow-up study OT home visits visit has effect on falls - intention-to-treat analysis
to no intervention measures at baseline beyond modifications I: OT home visits can prevent falls in/outside
& 12 mths; the home in older adults with falls history
determining number
of falls
Liddle et al. • to determine effect D: RCT ( 2 groups) • intervention, control, non • no significant C: experimental group doing no better than
(1996) on quality of life and & 3rd non intervention group assessed in difference between control group in enhancing quality of life and
independence of intervention group home by OT groups at baseline independence
older adults S: N=105; age range • OT only informed • significant change M:
receiving OT of 69-94 yrs; intervention group of from baseline within - no control of prognosis variables for
intervention of home community dwelling recommendations on group but no statistical independence & quality of life
modifications & older adults living community services, home difference between - contamination: control group was using
community services with no to severe modifications and equipment & groups community service (e.g., MOW, homecare);
referral as compared impairment in ADL recommendations carried out or • at 6 mths more of special equipment and had home
to control group who O: organized by independent intervention than modifications
received OT • measures at 0 & 6 research nurse control group used - selection bias - “special group”- high
recommendations mths; quality of life, • control group ADL equipment and functioning & affluent
but not carried out sickness impact, recommendations not carried more had seen their - no specific details of OT intervention
and non intervention morale, life out family physician at I: consultation model can be effective with
group who did not satisfaction and • non intervention group at least once certain populations; possible to enable people
require any health baseline did not require any to follow through on recommendations
intervention • non intervention intervention
group contacted by
telephone and postal
questionnaire after 6
mths
15
STROKE
Author/ Purpose Design, Sample & Research Focus/ **Results Conclusions, Methodology & Implications
date Outcomes Intervention
Corr & • to evaluate the D:RCT (2 groups) • OT interventions included: • at 1 yr post-stroke C: OT interventions are beneficial compared
Bayer effectiveness of S: N=110; mean age learning new skills; facilitation significant number of to usual care but cannot conclude that benefits
(1995) usual services and 75 yrs of more independence in ADL assisted aids used, resulted directly from OT intervention due to
OT intervention O: follow-up mailed & return of function; enabling independence in co-interventions
compared to “usual questionnaire at 2, 8, use of equipment; information feeding, use of M:
care” (control) on 16 and 24 weeks given to patient and caregiver telephone and + limitations described
ADL & EADL in measuring and referral to other agencies reduction in hospital - lack of detail re: level of stroke impairment
adults post-stroke ADL/EADL, QOL, • control group received no readmissions in - limited statistical analysis
and discharged from depression, caregiver special intervention or follow- intervention vs control - gender imbalance between groups
a stroke unit QOL, & additional up, but could receive any group - contamination & co-interventions not
descriptive available services as required • no significant measured
information (i.e., difference in ADL, - limited amount of OT intervention
home circumstances, EADL & depression - missing data
use of health I: OT intervention improves some ADL &
services, provision EADL outcomes and plays a role in
of aids and hospital decreasing hospital readmissions 1 yr post-
readmissions) stroke
Drummond • to evaluate the D: RCT (3 groups) • OT leisure group had weekly • in OT leisure C: OT leisure rehabilitation is an effective
& Walker effectiveness of S: N=65; mean age home visits (>30min) for 3mths rehabilitation group’s way of maintaining & increasing leisure
(1995) leisure rehabilitation 64 yrs (29-84); then biweekly for 3mths leisure scores were participation in older adults post-stroke
program compared older adults admitted focusing on leisure pursuits significantly better at 3 M:
to conventional OT to stroke unit and • conventional OT group & 6 mths + accounted for age variance
and usual care discharged into received home visits for the - co-interventions may have affected outcome
(control group) in community same amount of time focusing - small sample size
older adults who O: measures at on ADL and perception - SES not adequately collected
were post-stroke and baseline on • control group no intervention - no long term follow-up
discharged from a admission to stroke other than what was received in - lack of information regarding level of
stroke unit unit, 3 & 6 mths: hospital/ social services impairments & disabilities
leisure; I: OT leisure rehabilitation increases the level
frequency/total of leisure participation of older adults post-
leisure activity, gross stroke
motor function &
functional
performance
16
Author/ Purpose Design, Sample & Research Focus/ **Results Conclusions, Methodology & Implications
date Outcomes Intervention
Gilbertson • to establish if a D: RCT into 2 • intervention was developed • significance at 8 wks C: a brief program of OT improves the ADL
et al. brief program of groups through use of focus groups after intervention but & EADL of clients with stroke in the short
(2000) domicilary OT S: N=138; mean age with clients, caregivers and not at 6mths term but may not be sustained
compared to of 71 yrs ( 28-89 OTs; 6 wk program was client- • 8 wks adjusted M:
receiving routine yrs); with clinical centred, tailored to needs of analysis (based on - cost analysis deducted but measurement not
services could diagnosis of stroke, each older adult (i.e., self-care, hemianopia, lower clear
improve the referred to OT domestic or leisure activities) Barthel, longer - method of follow-up at 6 mths with postal
recovery of persons O: measures at • approximately 10 visits of 30- hospital stay at questionnaire vs interviews
post-stroke baseline and 8 wks 45min baseline) significance - small sample size
discharged from addressing: ADL, • intervention based on goals achieved on EADL, - limited power to detect modest effect on
hospital EADL, client and liaison with other agencies ADL and global outcomes
satisfaction, resource (advice, equipment, services) outcome of I: results lend limited support to principle of
use and subjective • control group received routine deterioration in ADL extending routine stroke rehabilitation from
health services inpatient to community
Jongbloed • to determine effect D: RCT (2 groups) • intervention group received OT • overall, no statistical C: no significant differences in leisure noted
& Morgan of OT leisure skills S: N=40; mean age intervention to assist subjects in difference between between stroke survivors in the intervention and
(1991) intervention 69.6yrs (42-86 yrs); resuming former leisure activities groups pertaining to control groups; may be explained by
compared to OT post-stroke within 15 and to learn to engage in new activity (time) intervention too limited, environmental
visits with no leisure mths, community activities or both involvement and influence on activity
specific intervention dwelling adults who • control group was visited by satisfaction with M:
on activity completed a OT and asked questions about involvement + independent evaluator
involvement & rehabilitation leisure activity but no leisure + pre-stroke activity level considered prior to
satisfaction in stroke program intervention provided randomization
survivors O: measures at 0, 5 • 1hr visits x5wks for both - no pure control group
& 18 wks: groups - tests may not be sensitive enough to detect
involvement and differences in satisfaction
satisfaction with - contamination (e.g. unclear if same therapist
involvement in for both groups; control group asked
activity; depression questions about leisure)
- no group comparison or impairment,
disability, time post-stroke
I: further research must be completed to
establish the effectiveness of OT leisure
specific intervention
17
Author/ Purpose Design, Sample & Research Focus/ **Results Conclusions, Methodology & Implications
date Outcomes Intervention
Logan et al. • to determine the D: RCT (2 groups) • enhanced group were seen • enhanced group at 3 C: support for use of enhanced OT with older
(1997) effect on ADL & S: N=111; mean age more quickly after referral, mths demonstrated adults post-stroke
EADL of social 73 yrs; community longer & more visits better EADL M:
service OT dwelling and first • control group received usual • at 6 mth, only + independent assessor
compared to time post-stroke OT service (i.e., prioritized, mobility section of - OT intervention not clear
enhanced OT service O: measures at 3 & waiting list and intervention EADL was significant; - no baseline measures
in older adults post- 6 mths of functional focused on provision of caregiver lower GHQ - lack of information re interventions received
stroke and psychological assistive devices) (i.e., better moods) at 6 by control at 3, 6 mths
outcomes; EADL mths - lack of information re: amount of therapy
and ADL & health • more equipment per I:
questionnaire person but significance • benefit of early intervention
completed at 6mths for stair rail only • importance of enhanced OT service vs
equipment only service
• caregivers of enhanced service less
distressed than caregivers of usual service
Parker et al. • to evaluate the D: multi-centred • participants in both treatment • no significant C: no major short or long term beneficial
(2001) effect of OT leisure RCT (3 groups) groups received OT differences between effect of the additional leisure or conventional
therapy or S: N= 466 at 5 sites; interventions (i.e., min of 10 groups at 6 & 12 mths occupational therapy on the mood, ADL
conventional OT mean age 72 yrs; sessions ≥30 minutes in length) • at 6 mths leisure ability or leisure participation of older adults
compared to control community dwelling at home up to 6 mths after treatment group was in post-stroke living in the community
group on mood, older adults post- recruitment the direction of M:
leisure participation stroke who were • treatment goals in improvement but not + large sample size
in independence in recently discharged conventional group focused on significant - no information on interventions received in
ADL of older adults from hospital improving independence in hospital
post-stroke 6 to 12 O: measures at self-care tasks - no information on levels/types of
mths after hospital baseline, 6 & 12 • treatment goals in leisure impairments
discharge mths: mood, IADL, group focused on leisure - not enough information on standards of
leisure, handicap and activity therapy and who provided therapy
caregiver burden • control group received no - co-intervention from other community rehab
occupational therapy services
intervention - inadequate intensity of treatment
• all participants were eligible - insensitivity of outcome measures
for existing rehab services in I: further research is needed to support the
the area effectiveness of OT leisure and ADL
intervention
18
Author/ Purpose Design, Sample & Research Focus/ **Results Conclusions, Methodology & Implications
date Outcomes Intervention
Tangeman • to investigate the D: before and after • evaluation in clinic and • significant C: after 1 mth of intensive rehabilitation,
et al. effect of a 1 month design client’s home followed by improvement in wt significant improvement on all 3 outcome
(1990) intensive outpatient S: N=40 community mutual goal setting during first shift, balance, ADL measures ( wt shift, balance & ADL)
rehabilitation dwelling individuals week • new skills retained • at 3 mths functional gains retained
(OT/PT) for at least 1 year post- • intervention group for 3 mth follow-up M:
individuals who are stroke who ambulate participated in 5 wk rehab - before and after design
1 year post-stroke independently; mean program to improve functional - need for longer follow-up
age of 66 yrs (27- skills in a variety of - volunteer bias
77yrs) environments with 2hrs of - no blinding
O: measures at 0, 1 individual OT & PT/day/4 I: intensive, short-term OT/PT rehabilitation
& 3 mths: weight days/wk; group discussion on is of benefit for adults one year post-stroke
shift; balance and 5th day.
ADL
Walker, • to evaluate D: randomized • clients received regular • significant C: intensive OT dressing practice at 6 mths
Drummond intensive OT cross-over design; dressing practice regarding differences between after discharge from hospital produced a
et al. treatment for older where clients technique, energy conservation, groups on dressing, significant impact in the clients’ dressing
(1996) adults with persistent received perceptual strategies and advice perceived health and ability with a lasting effect
dressing problems at intervention for 3 regarding choice of clothing ADL performance M:
6 mths after mths followed by 3 • mean of 6 OT visits completed between the control +independent assessor at 3, 6 mths
discharge from mths of no during treatment phase and treatment phases - no baseline dressing scores given at time of
hospital intervention or the • during no treatment phase • dressing discharge
reverse clients had no contact with improvements were - no long term follow-up
S: N=30; mean age research occupational therapist; not lost over time (i.e., I:
of 68 yrs; clients all other rehab continued as maintained for 3 mths) • intensive OT intervention in the home can
who experienced a usual • dressing have a positive effect on an individual’s
stroke 6 mths prior; improvements did not independence dressing, ADL & perceived
living in community generalize into other health
following hospital areas of ADL • client’s home is an optimal environment for
discharge • dysphasia and poor OTs to consider the ADL of dressing
O: measures colour matching ability
completed at 3 & 6 were negatively
mths: dressing; associated with
ADL; and client’s improvement in the
perceived health specific dressing
difficulty
19
Author/ Purpose Design, Sample & Research Focus/ **Results Conclusions, Methodology & Implications
date Outcomes Intervention
Walker, • to assess the D: RCT (2 groups) • intervention group received •significant difference C: OT significantly reduces disability and
Gladman et efficacy of an OT S: N=185; mean age OT visits up to 5mths between groups handicap in individuals with stroke not
al. (1999) intervention of 74 yrs ; clients < • OT encouraged independence • clients with OT admitted to hospital and living in the
compared to no one mth post-stroke; in ADL & EADL intervention community
intervention for clients were not • clients were also encouraged demonstrated M:
older adults with admitted to hospital to take part in leisure pursuits significant + blind assessor
strokes who were and were living in • specific tasks were set as improvement in ADL, - no specifics on level of the clients’
not admitted to the community homework when possible EADL, caregiver strain impairment resulting from stroke
hospital O: measures • control group received no and handicap - co-intervention may have occurred in control
completed at 0 & 6 additional input from research • no significant effect group as no specifics given on types of
mths: EADL, ADL, OT but may have received input on mood of client or “other” services received
gross motor from existing services caregiver - frequency of intervention not described,
function, mood, actual specifics of intervention not described,
caregiver strain and OTs providing intervention not described
handicap I:
• need to advocate at the family physician or
homecare level for OT referrals for people
post-stroke who are not admitted to hospital
• OT intervention may result in less
dependence on social and health care systems
and decrease need for institutionalization
20
Author/ Purpose Design, Sample & Research Focus/ **Results Conclusions, Methodology & Implications
date Outcomes Intervention
Werner & • to demonstrate the D: RCT (2 groups) • intervention group received a • significant increase C: functional gains are possible in an
Kessler effectiveness of with 2:1 ratio treated 12 week intensive outpatient in functional outpatient setting for older adults post-stroke
(1996) intensive out patient S: N=49; mean age rehab program (i.e., 1hr OT and independence (i.e., who have had inpatient rehabilitation
rehabilitation (OT/ 62.5 yrs; older adults 1hr PT 4x/wk) eating, bathing, M:
PT) compared to no living in the • initial assessment by dressing, shower or tub + blind assessor (OT)
outpatient community; physiatrist, OT & PT, followed transfers & stair + accounted for all dropouts
rehabilitation to experienced stroke by a team meeting defining climbing) & motor - selection bias
increase functional between 6 mth & 5 functional interventions (e.g., recovery during 3mth - analysis poorly reported
status of older adults yrs ago transfers, walking, self-care & treatment period - lack of equal attention control group
with a stroke O: measures feeding) • largest change in - exclusion of dropouts in data analysis
completed at 0, 3 & • therapy focused on dressing and bathing I: intensive OT/PT intervention increases
9 mths: functional neuromuscular facilitation and and gains were functional independence in older adults post-
independence, motor functional tasks maintained at 9 mths stroke
recovery, mobility • control group did not receive • no significant change
tasks, hand function, any outpatient therapy in functional
motor rating, independence at 9mths
depression, self- • significant change
esteem and regarding sickness
psychological health impact (i.e., fewer
functional and
emotional complaints)
from 0-3mths but not
3-9 mths
21
Author/ Purpose Design, Sample & Research Focus/ **Results Conclusions, Methodology & Implications
date Outcomes Intervention
Widen • to evaluate D: RCT (2 groups) • intervention group received a • no significant C: no difference between 2 groups
Holmqvist rehabilitation of S: N=81; mean age 3 to 4 month rehab program differences at 3 & 6 • no worse off with early discharge and home
et al., 1998 moderately disabled 72 yrs; adults with [i.e., mean of 12 visits (range of mths rehabilitation
(3mth older adults with moderate 3-31)] at home [OT, PT, SW • home rehabilitation M:
outcomes); strokes at home after neurological (consultation)] is equally beneficial to + documented other interventions
von Koch early supported impairment, • rehab program emphasized a other rehab services + assessor blinded (PT)
et al., 2000 discharge from continent and task and context oriented • home rehabilitation + interventions described in previous article
(6 mth hospital as compared independent in approach group 52% reduction (Widen Holmqvist et al., 1995)
outcome) to older adults feeding 1 week after • control group received routine in length of stay in - frequency of visits not well documented
receiving first or recurrent rehab service which included a hospital - potential for contamination because of
rehabilitation in acute strokes and heterogeneous set of • overall intervention introduction of home based rehabilitation for
hospital, daycare or had an average of interventions (i.e., rehabilitation group was more control group
through outpatient 4wks hospitalization in hospital, day care & satisfied with care, - limited information on type of stroke, co-
care in routine care outpatient) especially with active morbidities
O: measures: participation in - reported results descriptive and difficult to
baseline, 3, 6 & 12 planning their rehab follow
mths addressing program I: early home discharge could be
social activity, • 12 month outcomes implemented for a selected group of older
dysphasia, ADL & not yet reported adults post-stroke
IADL, motor
capacity, falls,
walking ability,
coordination,
subjective
dysfunction, manual
dexterity, client
satisfaction
22
RHEUMATOID ARTHRITIS
Author/ Purpose Design, Sample & Research Focus/ **Results Conclusions, Methodology & Implications
date Outcomes Intervention
Helewa et • to assess the D: RCT (2 groups) • intervention group received • at 6 wks intervention C: OT improves function in adults with RA; a
al. (1991) effectiveness of a S: N=105; mean age intensive occupational therapy group had significantly 6 wk delay did not change efficacy of
home OT program in 54yrs (18-70yrs); treatment (i.e.: hand & foot improved in daily intervention
improving function community dwelling management; ADL education & function (i.e., dressing, M:
for adults with RA adults with RA functional intervention; eating, grooming, + improved QOL assumed with adequate
compared to control having limitations vocational assessment & hygiene, household measurement
group with physical education, leisure activities and management, light - unclear inclusion criteria regarding
functioning, no other psychosocial counselling) at housekeeping, heavy functional limitations
sources of disability, home for first 6 wks followed cleaning, & mobility) - 6 week time frame may not be long enough
stable clinically, on by less intensive follow-up but no change in social to show change in social function
stable drug therapy, • control group received no OT function, - no follow-up
no surgery in last intervention for first 6 weeks communication and - co-intervention not discussed
3mths & not followed by 6 weeks of leisure - not enough information on reliability and
pregnant intensive OT • at 12 wks no validity of primary outcome measure
O: measures at 0, 6, significant difference - lack of information on amount of
12 wks: global between groups intervention
functional capacity - not a true RCT as control group received
score (i.e., self-care, intervention during 6-12 wks
productivity and I: occupational therapy can have positive
leisure areas) short-term effects on improving the
functioning of adults with RA
23
Author/ Purpose Design, Sample & Research Focus/ **Results Conclusions, Methodology & Implications
date Outcomes Intervention
Gerber et • to compare D: randomized pilot • intervention group had • OT workbook group C: workbook-based occupational therapy
al. (1987) effectiveness of an study standardized group sessions showed positive but education intervention did not appear to be
OT workbook for S: N=25; mean age 1.5/wk hrs for 6wks and not significant more effective than standard OT techniques in
teaching energy 54 yrs (33-84); >18 provided with didactic differences in rest changing behaviours and functioning of adults
conservation yrs; adults with workbook with behaviour during physical with RA
behaviours with rheumatoid arthritis; modification and health activity, time spent M:
standard OT excluding adults education strategies being physically active + defined the 2 interventions clearly
techniques to change using w/c’s & those • goals to decrease the amount • no significant - pilot study therefore results should be
behaviours, who had surgery or intensity of pain and fatigue difference between interpreted with caution
influence level of within 30 days of and increase participation in groups at pre- - larger study needed
physical activity and entry activities intervention & 3 mths - more sensitive measures required
modify disease O: measures at 0 & • control group with two 1.5 hr post-intervention in - longer study duration
activity and function 3 mths: grip traditional OT treatment disease activity, - unequal attention between groups
of adults with strength, joint sessions (i.e., energy walking and group I: further research required to determine best
rheumatoid arthritis tenderness, joint conservation, adaptive aids and strength OT intervention method to promote
swelling, walking splints) behavioural/ functional change in adults with
time, psychosocial rheumatoid arthritis
adjustment, health
status, ADL, pain,
fatigue
24
Glossary of Short Forms
ADL Activities of Daily Living
C Conclusions
D Design
EADL Extended Activities of Daily
Living
GHQ General Health Questionnaire
hrs hours
I Implications
IADL Instrumental Activities of Daily
Living
M Methodology
MOW Meals on wheels
mth/mths month/months
O Outcomes measured
OT Occupational Therapy
PT Physical Therapy
QOL Quality of Life
RA Rheumatoid Arthritis
S Sample
SES Socioeconomic status ( occupation,
income & education)
vs versus
w/c wheelchair
wk/wks week/weeks
wt weight
yr/yrs year/years
25
