Occupational Therapy Activities and Intervention Techniques

for Clients With Stroke in Six Rehabilitation Hospitals

Nancy K. Latham,
Diane U. Jette,
Wendy Coster,
Lorie Richards,
Randall J. Smout,
Roberta A. James,
Julie Gassaway,
Susan D. Horn

OBJECTIVE. To prospectively monitor occupational therapy activities and intervention techniques used during inpatient stroke rehabilitation in order to provide a description of current clinical practice.
METHODS. Data were collected prospectively from 954 clients with stroke receiving occupational therapy
from six U.S. rehabilitation hospitals. Descriptive statistics summarized frequency, intensity, and duration of
occupational therapy sessions; proportion of time spent in 16 therapeutic activities; and proportion of those
activities that included any of 31 interventions.

RESULTS. Clients received on average 11.8 days (SD = 7.2) of occupational therapy, with each session lasting on average 39.4 min (SD = 16.9). Upper-extremity control (22.9% of treatment time) and dressing (14.2%
of treatment time) were the most frequently provided activities. Interventions provided most frequently during
upper-extremity control activities were strengthening, motor learning, and postural awareness.

CONCLUSION. Occupational therapy provided reflected an integration of treatment approaches. Upperextremity control and basic activities of daily living were the most frequent activities. A small proportion of sessions addressed community integration.
Latham, N. K., Jette, D. U., Coster, W., Richards, L., Smout, R. J., James, R. A., Gassaway, J., & Horn, S. D. (2006).
Occupational therapy activities and intervention techniques for clients with stroke in six rehabilitation hospitals.
American Journal of Occupational Therapy, 60, 369378.

Nancy K. Latham, PhD, is Research Assistant Professor,

Health and Disability Research Institute, Boston University,
53 Bay State Road, Boston, Massachusetts 02215;
nlatham@bu.edu

Susan D. Horn, PhD, is Vice President for Research,

International Severity Information Systems, Inc., Salt Lake
City, Utah.

troke is the third largest cause of death and one of the leading causes of longterm disability in the United States (Centers for Disease Control and
Prevention, 2000). Significant progress has been made in stroke care over the past
30 years and as a result the proportion of people who survive a stroke has increased
(Centers for Disease Control and Prevention, 2000). It is now well established that
differences in post-stroke care and rehabilitation have a significant effect on outcome, with one systematic review finding that clients who received organized inpatient care in a stroke unit were more likely to be alive, independent, and living at
home 1 year after the stroke (Stroke Unit Trialists Collaboration, 2003). However,
despite evidence that post-stroke care influences outcomes, the ideal activities or
approaches to treatment that should be included in stroke rehabilitation are still
not well established (Wade & de Jong, 2000).
Occupational therapists play an important role in post-stroke rehabilitation.
The National Board for Certification in Occupational Therapy (NBCOT) Practice
Analysis reported that cerebrovascular accident was the most frequent diagnosis
seen by their survey respondents (NBCOT, 2004). Several recent systematic
reviews suggest that occupational therapy after a stroke improves the performance
of some functional tasks and reduces some impairments (Ma & Trombly, 2002;
Steultjens et al., 2003; Trombly & Ma, 2002). However, most trials provide few
details about the range of occupational therapy interventions and activities that
were used across the rehabilitation episode.
Few observational studies exist that describe the nature of occupational therapy interventions currently being used for stroke rehabilitation in the United States.
Most studies to date have been conducted in countries outside the United States
(Alexander, Bugge, & Hagen, 2001; Ballinger, Ashburn, Low, & Roderick, 1999;

The American Journal of Occupational Therapy

369

Diane U. Jette, DSc, PT, is Professor and Program Director,

Physical Therapy Program, Simmons College, Boston,
Massachusetts.
Wendy Coster, PhD, OTR, is Associate Professor and
Program Director, Therapeutic Studies and Occupational
Therapy, Boston University, Boston, Massachusetts.
Lorie Richards, PhD, OTR, is Research Health Scientist,
Veterans Affairs Research Service at the Brain
Rehabilitation Research Center, North Florida/South
Georgia Department of Veterans Affairs Medical Center,
Gainesville, Florida; and Associate Professor, Occupational
Therapy Department, University of Florida, Gainesville,
Florida.
Randall J. Smout, MS, is Senior Analyst, International
Severity Information Systems, Inc., Salt Lake City, Utah.
Roberta A. James is Data Systems Specialist, International
Severity Information Systems, Inc., Salt Lake City, Utah.
Julie Gassaway, MS, RN, is Director of Project/Product
Development, International Severity Information Systems,
Inc., Salt Lake City, Utah.

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deWeerdt et al., 2000); have described treatment activities

only in terms of duration or frequency (Alexander et al.,
2001; Bernhardt, Dewey, Thrift, & Donnan, 2004; Sulch,
Perez, Melbourn, & Karla, 2000); or have involved a limited number of clients (Ballinger et al., 1999; deWeerdt et al.,
2000). The Practice Analysis (NBCOT, 2004) reports the
frequency with which entry-level practitioners use specific
interventions, but does not break these down by client condition and surveyed therapists only within the first 3 years
of their practice.
Given the limitations of reported studies and a lack of
information about how clients with stroke are treated by
occupational therapists in the United States, we undertook
a study to describe the care provided by occupational therapists for clients with stroke in six hospital-based rehabilitation settings within the United States. Our aim was to
describe the occupational therapy plan of care by describing
the types of therapeutic activities that therapists used with
each client. We defined therapeutic activities as whole tasks
that were the focus of a therapy session. In addition, we
wished to capture the intervention techniques that the
occupational therapists used during each of these activities.
We defined intervention techniques as specific treatment
approaches used by occupational therapy practitioners to
facilitate activities. Finally, we collected data about the
duration, frequency, and intensity of occupational therapy
sessions, and the personnel who provided them. This information complements and expands information in the
NBCOT Practice Analysis (2004), by providing more
detailed information about current practice with a specific
clinical population by practitioners with a broader range of
experience. In addition, it may provide guidance to clinical
researchers about important elements of occupational therapy that need to be documented in future studies of rehabilitation outcomes.

al cohort study, a Clinical Practice Improvement approach

was used in which detailed client, process, and outcome
variables were obtained (Horn, 1997). This study was
approved by the institutional review boards at Boston
University and at each of the participating hospitals and was
classified as exempt because of its observational nature.
Nine hundred and fifty-four clients met the inclusion
criteria, which were a diagnosis code indicating that the
person had experienced a stroke (ICD-9-CM of
430438.99), was older than 18 years of age, had a recent
stroke (within 1 year of admission) as the reason for admission, and had no interruption in rehabilitation services of
greater than 30 days (see Table 1 for client characteristics).
The mean age of clients was 66.2 years (SD = 14.2). Men
composed 51% of the sample and women 49%. Fiftyseven percent of clients were White, 24% were African
American, 4.9% were Asian, and the remaining were of
other backgrounds or unknown race. Forty-three percent
of clients had left-sided hemiplegia, 43% had right-sided
hemiplegia, 10% had bilateral involvement, and the
remainder had other types of involvement.
A total of 180 occupational therapy staff participated in
this study, and of these, 61% were occupational therapists,
38% were occupational therapy assistants, and 1% were
students. In the subset of therapists who provided detailed
information about their work experience (i.e., 27%), the
occupational therapists had an average of 10.3 years of
experience (SD = 8.2, range = 132) and the occupational
therapy assistants had 8.3 years (SD = 5.6, range = 223).
Most occupational therapists or occupational therapy assistants (69%) worked full time (i.e., 40 hr per week). The
majority of therapists and assistants had obtained some
advanced training in neurology-related or geriatric-related
courses in the past 2 years. The most frequently reported

Methods

Table 1. Client Characteristics

Subjects

Age (years)
Mean
SD
Range
Gender % (n)
Male
Female
Race % (n)
White
African American
Asian
Other or unknown
Impairment % (n)
Left hemiplegia
Right hemiplegia
Bilateral involvement
Other

As part of the Post-Stroke Rehabilitation Outcomes Project

(PSROP), data were collected between March 2001 to
August 2003 from consecutive clients with stroke seen at six
rehabilitation hospitals in the United States (DeJong et al.,
2005). The sites were geographically dispersed (3 in the
West, 1 in the Central Mountain region, 1 in the South,
and 1 in the East). The facilities were a mixture of freestanding rehabilitation hospitals and rehabilitation units
that were linked to acute care hospitals. Physical Medicine
and Rehabilitation residents were involved in stroke management in 2 out of 6 of the facilities. For this observation-

Characteristic

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N = 954
66
14
1895
51
49

(487)
(467)

57.2 (546)
24.0 (229)
4.9 (47)
13.9 (132)
43.6 (416)
43.6 (416)
10.1 (96)
2.7 (26)

July/August 2006, Volume 60, Number 4

type of training was in neuromuscular interventions (i.e.,

NDT or neurodevelopmental treatment), in which 59% of
respondents said that they had participated during the past
2 years.
Instrumentation
Forms to record activity and intervention data from each
occupational therapy session and definitions for each of
these terms were developed with input from occupational
therapists involved in care of clients with stroke at each
facility participating in the PSROP (DeJong et al., 2004).
The data collection forms allowed occupational therapy
providers to describe sessions using 16 possible categories of
activities. These included Examination/Evaluation and
activities to remediate performance skill deficits or body
structure or function impairments (i.e., Pre-functional,
Upper Extremity Control, Sitting Balance/Trunk Control,
Transfers, Functional Mobility, Bed Mobility); Activities of
Daily Living (ADL: Bathing, Dressing, Grooming,
Toileting, Feeding/Eating), and Instrumental Activities of
Daily Living (IADL: Home Management, Community
Integration, Leisure Performance, Wheelchair Management). Therapists recorded the amount of time spent on
each activity with the client in 5-min increments and up to
5 specific intervention techniques (from a list of 31) that
they used to facilitate performance of that activity. Options
included neuromuscular interventions (7), musculoskeletal
interventions (4), cardiopulmonary interventions (2),
modality interventions (3), cognitive/perceptual/sensory
interventions (4), adaptive and compensatory interventions
(4), equipment interventions (i.e., prescription, application,
fabrication, and ordering), and education and training
interventions (3). Training in the use of assistive devices or
equipment during therapy could be recorded under each
treatment activity, with a list of 20 devices provided. One
category was provided for writing in interventions or equipment not provided on the form. Additional information
recorded on each session included: the amount of time
spent in evaluation, in cotreatment with other disciplines,
and in therapy sessions that included more than one client,
as well as which providers gave care during the session,
including occupational therapists, occupational therapy
assistants, and students (see Figure 1).
Procedure
One occupational therapist at each site was selected as the
lead occupational therapist for this project, and participated in a 90-min train-the-trainer session, which was conducted by project staff. Before this session, each lead occupational therapist received a training manual that contained
the occupational therapy intervention documentation

form, written instructions for completion of the form, and

definitions of all terms used on the form. The training manual also contained case studies that provided scenarios of
three occupational therapy sessions. A trainers and a
trainees copy of each case study were provided. The trainers copy provided instructions and descriptive notes about
each case study session, followed by the actual case studies
that described an occupational therapy session, including
amount of time spent on specific activities and assessments
and a completed intervention documentation form. During
the train-the-trainer session conducted by project staff with
the lead occupational therapists, the project team reviewed
the form, instructions, definitions, and care studies in
detail. Participants were encouraged to ask questions and
discuss possible scenarios that might be raised during their
upcoming training sessions with their colleagues at their
respective facilities.
During each sites internal training sessions (lasting
about 60 min), the lead occupational therapy trainer
reviewed the intervention documentation form (of which
most occupational therapists were familiar because of participation in development efforts), instructions for completing the form, and the definitions of each term used on
the form. The trainer then reviewed the first case scenario
with the trainees and described how the intervention documentation form was completed. Individually, trainees then
read the second case study and completed the form. The
trainer reviewed the second case study with the group and
discussed form completion. Trainees then completed the
third case scenario and discussed completion of the form.
After this training, during the first month of occupational therapy intervention documentation form use, each
sites lead occupational therapist conducted random co-sessions with other therapists. During this time, the lead
occupational therapist would observe an occupational therapy session and record it on an intervention documentation
form. The therapist providing the treatment session would
also complete a form and the two were compared and discussed. The lead occupational therapist continued to serve
as a resource person to the other occupational therapists
throughout the entire form use period.
A member of each sites project team (admitting nurse,
medical director, project manager) identified clients to
enroll into the study on admission and flagged the client
chart as being a study patient. Other rehabilitation
providers (physicians, therapists [physical, speech, recreational], nurses, social workers) completed their respective
project documentation form for each encounter with each
enrolled client. Data regarding other client characteristics
(e.g., demographics, severity of illness, medications) were
collected from clients medical records after their discharge.

The American Journal of Occupational Therapy

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371

Oc c u p a t i on a l T h e r a p y R e h a b i l i t a t i o n A ct i vi t i e s

Duration of Activity

Interventions

Enter in 5 minute increments.

Enter one intervention code per group of boxes.

ISIS [International Severity Information Systems], Inc., 2003. Reprinted with permission.

Figure 1. Occupational therapy data collection form

Data Analysis
Descriptive statistics were used to examine characteristics of
clients and characteristics of their episodes of care including
length of stay, number of days occupational therapy was
provided, number of occupational therapy sessions per day,
and intensity of occupational therapy (defined as the number of days occupational therapy was provided divided by
the total length of stay). The content of treatment sessions

was described by determining duration of each session, the

proportion of all occupational therapy time spent directed
to the activities listed above, and the proportion of those
activities that included specific interventions. We examined
the proportion of all occupational therapy sessions in which
more than one client was treated by a single provider and
the proportion of sessions for which occupational therapists, occupational therapy assistants, or students were
involved in the care. We also determined combinations of

372
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July/August 2006, Volume 60, Number 4

activities provided to clients during sessions, the proportion

of sessions that included examination or evaluation, and the
proportion of clients and families who received an educational intervention.

Results
The mean length of stay for the episode of care was 18.8
days (SD = 10.3, range = 175; see Table 2). Clients
received occupational therapy, on average, 11.8 days (SD =
7.2, range = 153) during an episode of care. On days that
the clients received occupational therapy, the average number of occupational therapy sessions per day was 1.6 (SD =
0.4, range = 13), and the average time for each session was
39.4 min (SD = 16.9, range = 5240).
Seventy percent of the sessions were provided by occupational therapists, 33% by occupational therapy assistants
or aides, and 7% by students. The vast majority of the sessions (91%) were provided one-on-one by an occupational
therapy provider. Only 5% of sessions consisted of cotreatment with another discipline, and in only 11% of sessions

Table 2. Episode Characteristics

Characteristic
Length of rehabilitation hospital stay (days)
Mean
SD
Range
Number of days occupational therapy provided
Mean
SD
Range
Number of occupational therapy sessions per day
Mean
SD
Range
Occupational therapy intensity*
Mean
SD
Range
Percentage of total intervention time spent in activity (%)
Upper-extremity control
Dressing
Examination/evaluation
Pre-functional
Functional mobility
Home management
Transfer
Bathing
Grooming
Community integration
Toileting
Sitting balance/trunk control
Eating
Leisure performance
Bed mobility
Wheelchair

Episodes
N = 954
18.8
10.3
175
11.8
7.2
153
1.6
0.4
13
0.64
0.19
0.021.0
22.9
14.2
10.8
9.0
7.1
6.2
6.1
4.6
4.5
3.2
2.8
2.6
2.0
1.9
0.8
0.8

*Total number of days occupational therapy provided divided by the length of

stay in days.

did a group session occur (i.e., more than one client was
treated by a single provider). See Table 3.
More than 94% of clients had some form of examination or evaluation time recorded, and approximately 7% of
sessions included only examination or evaluation. Table 2
gives the percentage time clients spent in each occupational therapy activity. Upper-extremity control (22.9% of total
treatment time) and dressing activities (14.2% of total treatment time) were the most frequently used activities, with
examination or evaluation (10.8%) and pre-functional
activities (9%), the third and fourth most common activities (see Table 3). Upper-extremity control activities were
defined as the training or facilitation of normal movement,
strength, range of movement, or alignment in the upper
extremity. Dressing activities were defined as selecting
appropriate clothing and accessories, obtaining clothing
from storage area, dressing and undressing in a sequential
fashion, and fastening and adjusting clothing, shoes, or personal devices. Pre-functional activities were described as
activities that were related to or provided preparation for
functional activities.
Table 4 provides data on the types of interventions that
occupational therapy providers used in each therapeutic
activity with their patients. Of a total of 24 types of direct
interventions from which providers could choose, 19 interventions were used during at least 5% of the sessions for one
or more of the therapeutic activities. All seven educational
or equipment provision interventions were used during 5%
of sessions for any activity. A wheelchair was the only device
used during at least 5% of sessions for any activity. Only
6.5% of patients used a wheelchair during at least one session and it was used primarily in transfer and wheelchair
management activities.

Table 3. Session Characteristics

Characteristic
Duration of Sessions (min)
Mean
SD
Range
Sessions with >1 client % (n)
Cotreatment sessions with other healthcare
disciplines % (n)
Sessions with occupational therapist % (n)
Sessions with OTA or aide % (n)
Sessions with student % (n)
Sessions with >1 occupational therapy provider % (n)
Activity combinations during sessions
(based on N =18,364) %
Evaluation only
One activity only
Upper-extremity control
Dressing
Functional mobility

The American Journal of Occupational Therapy

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Sessions
N = 18,359
39.4
16.9
5240
10.8 (1,992)
5
70
32
7
9

(1,006)
(12,943)
(5,838)
(1,234)
(1,629)

5.6
33.3
16.1
5.5
2.3

373

Bathing

Dressing

Grooming

Toileting

Eating

Transfers

Bed Mobility

Functional Mobility

Home Management

Community Integration

Leisure Performance

Upper-Extremity
Control

Wheelchair
Management

Sitting Balance

% of all sessions that

contain intervention

Neuromuscular
Balance training
Postural awareness
Motor learning
PNF
NDT
Constraint induced therapy

37.6
41.0
42.0
2.6
16.1
1.8

60.5
64.0
43.7
5.7
19.3
3.6

66.1
64.5
54.3
5.4
18.5
3.2

62.0
67.9
56.8
7.4
24.6
3.3

66.6
64.7
49.6
4.4
22.7
3.8

27.5
48.3
45.5
5.9
14.3
1.6

76.7
71.2
51.4
1.6
26.5
2.5

73.5
73.9
57.1
1.6
28.6
2.2

74.8
61.4
45.3
2.3
19.2
3.1

49.0
43.4
37.5
1.9
15.0
2.7

27.8
27.2
24.1
0.8
9.8
1.8

52.4
43.9
39.8
0.3
27.5
1.7

38.7
42.3
51.4
5.4
31.7
4.1

49.7
52.6
55.0
3.3
43.6
2.9

68.9
87.0
46.8
11.8
47.3
2.9

44.5
44.7
42.6
3.6
19.1
2.7

Adaptive/Compensatory
One-handed skills
Energy conservation
Environmental adaptation
Adaptive equipment

17.1
4.7
5.7
6.9

37.2
16.3
28.1
28.2

48.8
11.2
14.5
16.7

47.4
12.7
11.3
11.7

28.9
12.8
28.6
27.2

40.8
10.0
12.7
12.5

29.7
5.5
15.8
18.7

40.7
7.1
16.1
16.8

16.2
8.5
13.7
12.3

13.6
17.7
18.2
13.0

7.5
9.3
13.1
6.1

14.6
4.7
10.3
10.0

17.8
4.4
7.1
8.3

30.7
6.7
20.5
29.2

30.0
5.6
4.8
6.0

23.6
7.0
10.5
10.6

Musculoskeletal
Strengthening
Mobilization/Manual therapy
Passive Range of Motion (ROM)
Edema control
Aerobic exercise

30.5
9.4
23.8
3.1
3.9

17.3
3.2
6.4
1.1
2.7

22.9
4.6
9.4
1.1
2.5

18.8
4.9
9.6
1.4
3.0

22.2
9.7
12.5
3.5
2.6

14.3
3.8
7.4
1.0
1.8

36.6
12.4
22.9
5.5
3.0

37.9
9.4
24.2
4.2
3.4

45.6
9.3
18.6
2.4
5.1

28.0
4.5
8.2
1.5
3.5

12.1
2.3
5.0
0.4
2.4

47.9
5.3
29.8
1.2
3.2

53.7
16.5
42.5
7.5
3.7

35.7
20.1
27.0
8.7
7.4

47.2
12.6
32.7
3.5
3.4

31.5
7.7
19.4
3.3
2.8

Cognitive/Perceptual/Sensory
Cognitive therapy
Perceptual training
Visual training
Sensory training

47.7
34.8
24.7
8.0

44.6
23.4
8.4
3.1

44.5
29.1
11.3
5.1

49.3
34.2
14.9
5.5

43.1
27.0
11.6
4.4

63.0
40.6
19.6
7.2

30.8
23.7
9.6
5.4

35.7
22.7
13.0
4.6

34.3
21.8
11.4
4.8

43.6
21.7
12.0
3.8

38.8
24.0
14.3
3.4

45.6
25.6
14.6
2.9

27.5
18.8
10.2
8.0

42.1
34.5
15.1
8.7

37.4
24.1
10.6
5.0

34.9
22.5
11.1
5.6

4.0
2.3
2.4
1.3

3.3
1.1
1.6
0.7

0.7
1.2
0.8
0.3

0.6
1.2
1.2
0.3

2.8
1.5
2.5
1.0

0.6
2.8
1.6
0

2.5
1.3
2.5
0.3

1.4
0.8
2.4
0

1.6
0.8
1.5
0.6

1.0
0.7
1.5
0.4

1.0
0.9
2.0
0.4

0
0
2.0
0

1.5
1.7
2.1
0.5

2.4
2.4
4.9
1.3

0.8
1.0
1.3
0.1

1.6
1.2
1.5
0.4

34.0
10.6
0.9

30.7
12.7
0.4

27.3 27.7
4.9
4.5
0.26 0.3

34.0
14.0
0.6

25.8
8.0
2.1

44.2
12.8
0.5

42.6
9.5
0.8

40.6
8.3
0.3

43.7
10.8
0.4

60.4
19.2
0.5

43.1
4.7
0.2

34.9
7.6
0.2

60.4
11.1
1.6

36.1
4.1
0.1

30.8
7.9
0.4

3.2

7.0

9.1

1.6

16.5

16.1

6.4

2.1

2.9

2.7

4.5

26.7

2.4

4.6

Activity

Pre-Functional

Table 4. Interventions Used To Facilitate Activities

Interventions

Equipment
Prescription
Application
Fabrication
Ordering
Educational
Client education
Caregiver education
Staff education
Devices Used
Wheelchair

6.6

5.8

Sessions include more than one activity. bPercentages <5% not reported. Note. PNF = proprioceptive neuromuscular facilitation; NDT = neurodevelopmental treatment.

Overall, 97% of patients or their families received some

educational intervention and 22.8% of all sessions for all
patients included some form of education. Of all the sessions with some form of patient and caregiver education,
28.2% included education related to community integration, 24.2% included education related to home management, and 20.8% included education related to upperextremity control activities.
We looked particularly at the interventions used in the
most frequent activities cited: upper-extremity control and
dressing. Interventions provided most frequently to address
upper-extremity control were strengthening (included in
53.7% of sessions for upper-extremity control), motor
learning (51.4% of sessions), passive range of motion

(42.5% of sessions), and postural awareness (42.3% of sessions). In all the sessions that addressed dressing activities,
the interventions most frequently provided were balance
(included in 66.1% of sessions for dressing activities), postural awareness (64.5% of sessions), motor learning (54.3%
of sessions), one-handed skills (48.8% of sessions), and cognitive therapy (44.5% of sessions). These data probably
reflect the large emphasis placed on regaining sensorimotor
skills in this population.
A total of 40.2% of therapy time was spent on direct
practice of daily life activities, the majority of this time
(28.1%) in basic ADL. Clients engaged in the more complex activities of leisure performance, home management,
or community integration 12.1% of the time. During

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almost half their time in occupational therapy, clients were

engaged in activities that directly targeted remediating performance skill deficits or body structure and function
impairments (i.e., upper-extremity control, sitting balance,
bed mobility, wheelchair, pre-functional, transfers).

Discussion
In this descriptive study of occupational therapy provided
to clients during stroke rehabilitation, about 40% of the
occupational therapy provided directly targeted life activities (i.e., ADL and IADL), whereas half of the therapy time
targeted body function and structure or motor skills that are
presumed to underlie functional limitations post-stroke.
Upper-extremity tasks and dressing were the most frequently provided activities, and accounted for almost half of
the treatment that clients received. Evaluation or examination activities also composed a significant proportion (10%)
of occupational therapy time. In 6% of patients, no evaluation or examination session was documented. It is probable
that in many of these cases the therapist did do an evaluation, but the time devoted to this was included under each
activity (i.e., a dressing evaluation was recorded under dressing instead of examination or evaluation).
When types of activities were compared, there was
clearly a greater emphasis on basic ADL, such as dressing,
grooming, eating, and toileting than on IADL, such as
home maintenance, or on community integration and
leisure performance. This focus on more basic activities
probably reflects the fact that therapy was taking place in a
hospital setting with clients who were still in the early rehabilitation phase. In addition, the average length of stay was
less than 3 weeks, which could limit the time that is available for more advanced activities. It is interesting to note
that, in the Practice Analysis, 65% of therapists reported
that dressing was the focus of intervention for more than
25% of their clients (NBCOT, 2004). This percentage was
among the five most frequent interventions listed in that
analysis, which covered all practice areas.
Occupational therapists reported using a variety of
interventions to enable each activity. The most commonly
used interventions were neuromuscular interventions, especially balance training, postural awareness, and motor learning; however, adaptive approaches, such as teaching onehanded skills for ADL tasks, were also reported frequently.
The therapists were clearly selective in the interventions
that they chose to use with each activity, because there was
variation in the interventions that were used in each activity. For example, whereas strengthening was used overall in
31.5% of sessions, it was used in more than half (53.7%) of
upper-extremity activity sessions but in less than 1/5 (17%)

of bathing activities. The frequencies for environmental

adaptations and use of adaptive equipment also varied by
activity, with certain activities (e.g., bathing and toileting)
having much higher frequencies than others. These differences likely reflect differences in the movement demands of
these important hygiene activities, and the extent to which
commonly available adaptive equipment such as shower
stools may be needed to enable early, safe participation in
the activities.
There are few current evidence-based guidelines for the
provision of intervention to persons with stroke. The
Agency for Health Care Policy and Research Guidelines for
Post-Stroke Rehabilitation (Gresham et al., 1995) are now
outdated and the agency cautions that they should no
longer be viewed as guidance for current practice. The most
recent update of the National Clinical Guidelines for Stroke
published in the United Kingdom (Royal College of
Physicians, 2004) includes the general guideline that
Emerging evidence is showing advantages of a task-specific training or practice approach over impairment focused
approaches. Giving clients the opportunity to practice tasks
is a major element in improved outcomes (p. 9). Evidence
that supports this general guideline has been presented in
two syntheses by Trombly and Ma (Ma & Trombly, 2002;
Trombly & Ma, 2002). These authors also present more
specific guidelines regarding the conditions under which
particular approaches appear to improve outcomes (e.g.,
that practicing movements with specific goals appears to
result in more normalized movement trajectories).
However, there is also evidence that some interventions that
target body structure and function impairments also contribute to improved rehabilitation outcomes post-stroke.
For example, the Royal College of Physicians (2002) guidelines suggest that emerging evidence supports the use of
resisted exercise to improve motor function, which suggests
that a combination of approaches may lead to successful
outcomes.
Given these recommendations, it is perhaps noteworthy
that a large proportion of occupational therapy time was
spent at the body structure and function impairment or performance skill level, and 16% of sessions involved only
upper-extremity-control activities. These activities target
remediation of performance skill deficits and client factors
(American Occupational Therapy Association, 2002). A
variety of interventions appear to be used in these activities,
including balance training (44.5%), motor learning
(42.6%), and strengthening (31.5%). Overall, the findings
suggest a shift away from neurofacilitation techniques advocated in the 1960s toward more application of motor control and motor learning approaches. Therapists reported
using Brunnstrom techniques (Brunnstrom, 1970) in fewer

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375

than 2% of sessions, and the percent of sessions in which

proprioceptive neuromuscular facilitation (PNF) techniques
were used was also low. However, NDT was reported more
frequently, with a maximum of 28.6% in bed mobility sessions. A recent analysis of physical therapy intervention with
this same sample noted a similar shift in intervention patterns away from facilitation techniques toward application
of motor control and motor learning approaches in the context of functional activities (Jette et al., in press).
Both cognitive therapy and perceptual training were
reported as being used with high frequency during many of
the ADL. In the data collection protocol, cognitive therapy
is defined as including impulse control, attention, orientation, memory, problem solving, sequencing, social skills,
safety, insight, and goal setting, whereas perceptual training includes interventions to address apraxia, neglect,
awareness in space, figure ground, and care of sensory
impaired body parts (full definitions are available from the
first author of this study). Both of these categories contain
a diverse range of approaches, some of which have more
supportive evidence than others. Trombly and Ma recommend cognitive approaches such as structured instruction
and feedback to improve activity performance (Ma &
Trombly, 2002; Trombly & Ma, 2002). Some evidence also
supports interventions that involve forced awareness of
neglected space (in persons with unilateral neglect), which
may be included in the perceptual training category. One
limitation of the present study is that we cannot determine
more precisely how the reported interventions were applied
and the extent to which the applications were consistent
with emerging evidence in this area. This applications
research would be a valuable area for further investigation.
As recommended by current occupational therapy
practice guidelines, client education was a significant intervention component for all activities. As might be expected,
this category was the most frequent intervention for sessions that were addressing community integration.
Caregiver education was a less frequent intervention for
most activities, which is likely explained by the fact that
families were not present during the majority of sessions.
Nonetheless, caregiver education was a feature of almost
20% of sessions that addressed community integration.
Thus, it appears that practitioners are actively engaging
both the client and family when discharge with return to
community is the focus of treatment. On the downside,
only 5% of sessions addressed either community integration or leisure performance. The paucity of time spent in
community integration or leisure performance is unfortunate because many persons with stroke have significant
restriction in activities after discharge (Corr & Bayer, 1992)
and activity restriction has been shown to be highly related

to depression (Nieboer et al., 1998; Williamson, 2000;

Williamson & Schulz, 1992). Button (2000) found that
patients considered that the real rehabilitation was the
translation of learning from the rehabilitation context to the
home and community context.
Although this study provides an initial description of
actual occupational therapy practice for persons with
stroke, it is important to note several limitations. Most
important, we did not have specific information about each
clients pattern of impairments, and thus were unable to
link the choice of specific interventions to the clients
unique profile of difficulties. Thus, we were not able to
examine variations in practice for persons with similar
impairment profiles. This study also summarized the activities for all clients across their entire therapy episode. Future
analyses might explore whether clients with greater functional abilities or clients who were preparing for discharge
participated in more advanced activities.
Although the therapists who provided data for this
study were trained in the use of data collection forms, and
written definitions were provided in the training manual,
no specific test of reporting reliability was conducted. Thus,
there may have been some degree of misclassification of
interventions and activities. However, given the large number of participants and sessions, we do not expect these random errors to have had a large effect on the results.
This study provided a broad sketch of current occupational therapy practice for persons with stroke. It suggests
an initial framework to describe intervention techniques
and activities, from which more refined descriptions may be
developed. Without such work to characterize the actual
processes of occupational therapy, it will be difficult to conduct more precise examinations of the effectiveness of our
services. Such studies are needed in order to identify the
specific elements or approaches that lead to better outcomes
for persons with stroke.

Conclusion
Occupational therapy provided to clients with stroke at inpatient rehabilitation facilities reflected an integration of
multiple treatment approaches to facilitate performance of
daily activities. The greatest emphasis was on increasing
upper-extremity control and improving performance of
basic ADL. Most occupational therapy was provided on an
individual basis, for an average duration of about 40 min
per session, across an average hospital stay of less than 3
weeks. A small proportion of therapy time was spent on
leisure and community integration, suggesting the need for
occupational therapy services after discharge that address
these activities.

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July/August 2006, Volume 60, Number 4

Acknowledgments
Funding for this project was provided by: The National
Institute on Disability & Rehabilitation Research (NIDRR)
Grant # H133B990005 establishing the Rehabilitation
Research and Training Center on Medical Rehabilitation
Outcomes at Sargent College in Boston, Massachusetts,
with subcontracts to the Institute for Clinical Outcome
Studies in Salt Lake City, Utah; and the NRH Center for
Health & Disability Research at the National Rehabilitation Hospital and the MedStar Research Institute in
Washington, DC; the U.S. Army & Materiel Command
(Cooperative Agreement Award # DAMD17-02-2-0032)
establishing the NRH Neuroscience Research Center at the
National Rehabilitation Hospital in Washington, DC; the
Boston University Aging Research Center; and resources at
the North Florida/South Georgia VA Medical Center,
Gainesville, Florida.
The authors wish to acknowledge the role and contributions of the occupational therapists, occupational therapy
assistants, patients, and staff at each of the participating sites
in the Post Stroke Rehabilitation Outcomes Project. In particular, the authors wish to acknowledge the contributions
of: Alan Jette (Director, Health and Disability Research
Institute, Boston University); Brendan Conroy, MD (Stroke
Recovery Program, National Rehabilitation Hospital,
Washington, DC); Richard Zorowitz, MD (Department of
Rehabilitation Medicine, University of Pennsylvania
Medical Center, Philadelphia, Pennsylvania); David Ryser,
MD (Rehabilitation Department, LDS Hospital, Salt Lake
City, Utah); Jeffrey Teraoka, MD (Division of Physical
Medicine & Rehabilitation, Stanford University, Palo Alto,
California); Frank Wong, MD, and LeeAnn Sims, RN
(Rehabilitation Institute of Oregon, Legacy Health Systems,
Portland, Oregon); and Murray Brandstater, MD (Loma
Linda University Medical Center, Loma Linda, California).

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