Method for the Evidence-Based Reviews on

Occupational Therapy and Stroke

Marian Arbesman, Deborah Lieberman, Debra R. Berlanstein

MeSH TERMS
 evidence-based practice
 occupational therapy
 research design
 stroke
 treatment outcome

Evidence-based reviews of the literature relevant to adults with stroke are important to the practice of occupational therapy. We describe the four questions that served as the focus for the evidence-based reviews of
the effectiveness of occupational therapy interventions for adults with stroke. The questions include occupation- and activity-based interventions to improve occupational performance and social participation after
stroke, as well as interventions for motor, cognitive, and psychological and emotional impairments after
stroke. We include the background for the reviews; the process followed for addressing each question, including search terms and search strategy; the databases searched; and the methods used to summarize and
critically appraise the literature. The final number of articles included in each evidence-based review; a summary of the themes of the results; the strengths and limitations of the findings; and implications for practice,
education, and research are presented.
Arbesman, M., Lieberman, D., & Berlanstein, D. R. (2015). Method for the evidence-based reviews on occupational therapy
and stroke. American Journal of Occupational Therapy, 69, 6901180020. http://dx.doi.org/10.5014/ajot.2015.013524

Marian Arbesman, PhD, OTR/L, is Consultant,

Evidence-Based Practice Project, American Occupational
Therapy Association, Bethesda, MD; President,
ArbesIdeas, Inc., Williamsville, NY; and Adjunct Assistant
Professor, Department of Rehabilitation Science,
University at Buffalo, Buffalo, NY; ma@ArbesIdeas.com
Deborah Lieberman, MSHA, OTR/L, FAOTA, is
Program Director, Evidence-Based Practice Project, and
Staff Liaison to the Commission on Practice, American
Occupational Therapy Association, Bethesda, MD.
Debra R. Berlanstein, MLS, AHIP, is Associate
Director, Hirsh Health Sciences Library, Tufts University,
Medford, MA.

ccupational therapists and occupational therapy assistants, like many other

health care professionals facing the demands of payers, regulators, and
consumers, increasingly have to demonstrate clinical effectiveness. In addition,
they are eager to provide services that are client centered, supported by evidence,
and delivered in an efficient and cost-effective manner. Over the past 25 yr,
evidence-based practice (EBP) has been widely advocated as one approach to
effective health care delivery.
Since 1998, the American Occupational Therapy Association (AOTA) has
instituted a series of EBP projects to assist members with meeting the challenge of
finding and reviewing the literature to identify evidence and, in turn, use this
evidence to inform practice (Lieberman & Scheer, 2002). Following the evidencebased philosophy of Sackett, Rosenberg, Muir Gray, Haynes, and Richardson
(1996), AOTAs projects are based on the principle that the EBP of occupational
therapy relies on the integration of information from three sources: (1) clinical
experience and reasoning, (2) preferences of clients and their families, and (3)
findings from the best available research.
A major focus of AOTAs EBP projects is an ongoing program of evidencebased review of multidisciplinary scientific literature, using focused questions
and standardized procedures to identify practice-relevant evidence and discuss its
implications for practice, education, and research. The evidence-based reviews in
this issue strengthen the knowledge of current interventions used by occupational
therapy practitioners in the delivery of services for adults with stroke.

Background
According to data from the National Health and Nutrition Examination Survey
(NHANES) for 2009, 7.2% of the U.S. population self-reported having some
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form of cardiovascular disease, with 2.7% of the overall

population reporting that they had had a stroke at some
point in time. Data from NHANES for 20092010 indicate
that 6.8 million adults in the United States age 20 yr and
older have had a stroke (Go et al., 2013). Approximately
795,000 individuals experience a new or recurrent stroke
yearly. Of those strokes, 77% are reported to be the first
occurrence of stroke, and 13% are recurrent. The estimated yearly direct medical cost for stroke is reported to
be $22.8 billion (Go et al., 2013).
According to the Centers for Disease Control and
Prevention (CDC; 2014) and the American Heart Association (Roger et al., 2012), stroke is a leading cause of
serious long-term disability. Impairments after stroke can
include but are not limited to hemiparesis, balance deficits, visual changes, cognitive deficits, fatigue, and psychological and emotional impairments (Go et al., 2013;
Jrgensen et al., 1995). These motor, cognitive, and
psychological and emotional impairments after stroke
may vary depending on the extent of neurological damage
and potential recovery and may result in decreased participation in occupations, such as activities of daily living
(ADLs) and instrumental activities of daily living (IADLs).
Because of the complex nature of impairments after stroke
and the diverse needs of the stroke population, occupational therapy practitioners must have the necessary information to provide evidence-based, client-centered, and
occupation-based interventions.
An evidence-based perspective is founded on the assumption that scientific evidence of the effectiveness of
occupational therapy intervention can be judged to be
more or less strong and valid according to a hierarchy of
research designs, an assessment of the quality of the research, or both. AOTA uses standards of evidence modeled on those developed in evidence-based medicine. This
model standardizes and ranks the value of scientific evidence for biomedical practice and is based on the grading
system of Sackett et al. (1996). In this system, the highest
level of evidence, Level I, includes systematic reviews
of the literature, meta-analyses, and randomized controlled trials (RCTs). In RCTs, participants are randomly allocated to either an intervention or a control
group, and the outcomes of both groups are compared.
Other levels of evidence include Level II studies, in
which assignment to a treatment or a control group is
not randomized (cohort or case-control study); Level III
studies, which do not have a control group (pretest
posttest, beforeafter, or cross-sectional studies); Level
IV studies, which use a single-case experimental design,
sometimes reported over several participants; and Level
V studies, which are case reports and expert opinion

that include narrative literature reviews and consensus

statements.
The evidence-based reviews on adults with stroke were
supported by AOTA as part of the Evidence-Based
Practice Project. AOTA is committed to supporting the
role of occupational therapy in this important area of practice.
Previous evidence-based reviews were completed covering
the time frame of 19802002. The current evidence-based
reviews were updated for the period 2003March 2012,
based on the need for occupational therapy practitioners to
have access to the results of the latest and best available
literature to support intervention within the scope of occupational therapy practice.
The four focused questions developed for the updated
review were based on the search strategy of the earlier
review. These questions were reviewed by review authors,
an advisory group of experts in the field, AOTA staff, and
the methodology consultant to the AOTA Evidence-Based
Practice Project.
The following four focused questions from the review
of occupational therapy interventions for people with
stroke were included in reviews:
1. What is the evidence for the effectiveness of interventions to improve occupational performance for those
with motor impairments after stroke?
2. What is the evidence for the effectiveness of interventions to improve occupational performance for those
with cognitive impairments after stroke?
3. What is the evidence for the effectiveness of activityand occupation-based interventions to improve areas
of occupation and social participation after stroke?
4. What is the evidence for the effectiveness of interventions
to improve occupational performance for those with psychological and/or emotional impairment after stroke?

Method
Search terms for the reviews were developed by the
methodology consultant to the AOTA Evidence-Based
Practice Project and AOTA staff in consultation with the
authors of each question and reviewed by the advisory
group. The search terms were developed not only to
capture pertinent articles but also to make sure that the
terms relevant to the specific thesaurus of each database were
included. Table 1 lists the search terms related to population
and intervention included in each evidence-based review. A
medical research librarian with experience in completing
evidence-based review searches conducted all searches and
confirmed and improved the search strategies.
Databases and sites searched included Medline,
PsycINFO, CINAHL, AgeLine, and OTseeker. In addition,

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Table 1. Search Terms Used for the Evidence-Based Reviews for Stroke
Categories
Search terms for stroke

Search Terms
Cerebrovascular accident, cerebrovascular disorders, hemiparesis, hemiplegia, stroke
Motor Question

Motor component

Ambulation, arm, balance, contracture, edema, hand, gait, kinematics, lower extremity, lower limb, mobility, motor
recovery, pain, postural control, recovery, spasticity, subluxation, transfers, trunk, trunk control, upper extremity,
upper limb, upper limb activity, upper limb function, weakness

Motor intervention

Activities of daily living, bilateral training, biofeedback, Bobath, Brunstroms movement therapy, constraint-induced
movement therapy, EMG, exercise, forced use, functional electrical stimulation, gravity loading, instrumental activities of
daily living, intensity, learning, massed practice, mental practice, mirror therapy, motor behavior, motor control, motor
learning, NDT, neurodevelopmental treatment, occupational therapy, orthotics, physical therapy, positioning, practice,
progressive resistive exercise, proprioceptive neuromuscular facilitation, repetitive task practice, robot assisted,
robotics, Roods approach, sling, splinting, strapping, strengthening, taping, task oriented, task-related practice,
task-specific practice, treadmill training, upper limb training, user computer interface, video games, virtual reality
Cognitive Question

Cognitive component

Adaptation, agnosia, anosognosia, aphasia, apraxia, attention, awareness, body neglect, communication, compensatory,
dual tasking, dysexecutive function, executive function, field cut, hemianopsia, inattention, insight, intellectual function,
judgment, memory, motor planning, multitasking, organization, orientation, perception, personal neglect, problem
solving, reasoning, sequencing, spatial neglect, spatial relations, vision, visual motor, visual processing, visuospatial

Cognitive intervention

Activities of daily living, adaptation, cognitive rehabilitation, cognitive reorganization, cognitive retraining, cognitive
retraining model, comprehensive rehabilitation, employment, errorless learning, goal management, instrumental
activities of daily living, multicontext approach, neurofunctional approach, occupational therapy, quadraphonic
approach, rehabilitation, remediation, strategy training, time pressure management, training, transfer of training, work
Psychological/Emotional Impairment Question

Psychological component

Affective disorders, anxiety disorders or anxiety, apathy, attention deficit hyperactivity disorder, behavior disorders,
catastrophic reaction, chronic pain, delusions, depression, emotional disorders, emotional lability, generalized anxiety
disorders, hallucinations, major depression, mania, mood disorders, motivation, neuropsychiatric disorders or
syndromes, pain, paranoia, personality change, poststroke dementia, poststroke mania, posttraumatic stress disorder,
psychosis, suicidal ideation

Psychological intervention

Activities of daily living, cognitive behavior therapy, exercise, instrumental activities of daily living, motivational
interviewing, neuropsychiatry, neuropsychology, occupational therapy, physical therapy, problem solving, rehabilitation
Occupation-Based Question

Occupation-based intervention

Activities of daily living, activity, adaptation, adaptive equipment, assistive devices, automobile driving, bathing, bicycling,
bonding humanpet, bowel and bladder management, caregiving, child rearing, community mobility, cooking,
cultural activity, daily living, dressing, driving, eating, emergency medical service communication services, employment,
feeding, financial management, functional mobility, gardening, health maintenance, health management, home
maintenance, instrumental activities of daily living, leisure (includes specific leisure such as watching television,
reading, travel), leisure activities, leisure time physical activity, mobility, occupational therapy, participation, passive
leisure time, personal hygiene, pet care, physical activity, recreation, recreational activity, religion, rest, retirement,
safety, sexual activity, shopping, showering, sleep, socialization, social participation, social pursuits, spirituality,
sports, toileting, travel, volunteer, work

Note. EMG = electromyography; NDT 5 neurodevelopmental treatment.

consolidated information sources, such as the Cochrane

Database of Systematic Reviews and the Campbell Collaboration, were included in the search. These databases are
peer-reviewed summaries of journal articles and provide
a system for clinicians and scientists to conduct evidencebased reviews of selected clinical questions and topics. Moreover, reference lists from articles included in the evidence-based
reviews were examined for potential articles, and selected
journals were hand searched to ensure that all appropriate
articles were included.
Inclusion and exclusion criteria are critical to the
evidence-based review process because they provide the
structure for the quality, type, and years of publication of
the literature incorporated into a review. The reviews for

all four questions were limited to peer-reviewed scientific

literature published in English. The intervention approaches
examined were within the scope of practice of occupational
therapy and included a performance-based outcome measure.
The literature included in the review was published between
2003 and March 2012 and included study participants with
stroke. The earlier reviews included studies published between 1980 and 2002 and more recent studies recommended
by experts in the field. These reviews excluded data from
presentations, conference proceedings, nonpeer-reviewed
research literature, dissertations, and theses. Studies from
published systematic reviews included in these evidencebased reviews were excluded from individual analysis. Studies
included in the reviews are Level I, II, and III evidence. Level

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IV and V evidence was included only when higher level

evidence on a given topic was not found.
The reviews included a total of 12,674 citations and
abstracts. The question on motor impairment had 4,930
references, the cognitive and perceptual impairments
question had 1,382, the occupation- and activity-based
question had 4,101, and the psychological and emotional
impairment question had 2,261. The AOTA EvidenceBased Practice Project methodology consultant completed
the first step of eliminating references on the basis of citation
and abstract. The four evidence-based reviews were carried
out as academic partnerships in which academic faculty
worked with graduate students to carry out the reviews.
Review teams completed the next step of eliminating references on the basis of citations and abstracts. The full-text
versions of potential articles were retrieved, and the review
teams determined final inclusion in the review on the basis of
predetermined inclusion and exclusion criteria.
A total of 273 articles were included in the final review. Table 2 presents the number and levels of evidence
of articles included for each review question. The teams
working on each focused question reviewed the articles
according to their scientific rigor and lack of bias and
level of evidence. Each article included in the review was
then abstracted using an evidence table that provides
a summary of the methods and findings of the article and
an appraisal of the strengths and weaknesses of the study
on the basis of design and methodology. AOTA staff and
the Evidence-Based Practice Project consultant reviewed
the evidence tables to ensure quality control.

the following areas: (1) task-oriented training (TOT)

using objects in natural environments, (2) TOT combined with cognitive strategies, and (3) strengthening.
The themes for the evidence for interventions for cognitive
impairments after stroke are organized by areas of impairment that limit occupational performance. These impairments and themes of the evidence include general
cognition, executive dysfunction, apraxia, memory loss, attention deficits, visual dysfunction, and unilateral neglect.
The evidence for occupation- and activity-based interventions was categorized by area of occupation, with
subthemes based on the context of service delivery. The
areas of occupation included ADLs, IADLs, leisure, social
participation, and rest and sleep. Depending on the area of
occupation, studies were subcategorized into interventions
in inpatient, outpatient, home health, and community
settings. The evidence for interventions for psychological
and emotional impairment after stroke was divided into
six themes according to the type of intervention: exercise,
behavioral therapy and stroke education, behavioral therapy
only, stroke education only, care support and coordination,
and community-based rehabilitation interventions that
include occupational therapy. The exercise theme was
further subdivided into types of exercise that were represented in the articles. Readers should refer to the individual articles for a summary of the findings of the
evidence-based reviews (Gillen et al., 2015; Hildebrand,
2015; Nilsen et al., 2015; Wolf, Chuh, Floyd, McInnis,
& Williams, 2015).

Summary of the Themes in the

Evidence-Based Reviews

Strengths and Limitations of the Reviews

and Implications for Practice, Research,
and Education

The results of the evidence-based reviews published in this

issue of the American Journal of Occupational Therapy
provide guidance for occupational therapy practitioners
working with people with stroke. By reviewing the scientific literature and appraising and synthesizing specific
studies, the authors provide guidance on critical practice questions. The evidence for interventions for motor impairments for people with stroke has themes in

The evidence-based reviews on stroke presented in this

issue have several strengths and include many aspects of
occupational therapy practice with this population. The
reviews included 273 articles, and 92% of the articles
provided Level I and II evidence, indicating that the evidence was at the highest level of evidence. The reviews also
involved evidence-based methodologies and incorporated
quality control measures.

Table 2. Articles in Each Review at Each Level of Evidence

Evidence Level
Review

II

III

IV

Total in Each Review

Motor

129

18

149

Cognitive

27

10

46

Occupation and activity based

26

39

Psychological and emotional impairment

Total

37

39

219

32

22

273

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The limitations of the evidence-based reviews are the

result of the design and methods of the individual studies,
which may include small sample sizes, lack of reporting of
treatment fidelity, and heterogeneity in terms of participant characteristics, intervention protocols, and outcome
measures. In addition, many of the studies in the review
included concurrent interventions, and separating out the
effects of a single intervention may be difficult. Please refer
to the individual evidence-based reviews for more complete information on results, interpretation of findings,
limitations, and implications for practice.
The evidence-based reviews presented in this issue
provide summaries of the best scientific literature to answer
the focused questions. The results described in these articles
can be directly integrated into clinical practice by combining
the scientific evidence with clinical expertise and client
preferences. In addition, this information may be used when
advocating for occupational therapy services to a payer or
regulator or providing information and support to a client
and caregiver at any point during the intervention process.
In the future, researchers should build on the existing
studies discussed in the evidence-based reviews included in
this issue. Clearly, more work is needed to definitively
answer the four questions that served as the basis of these
evidence-based reviews. Although some future research
can be conducted in isolation, research questions in the area
of stroke are often complex and may best be answered
through collaborative research with other disciplines involved
with the provision of services to people with stroke, such as
rehabilitation medicine, physical therapy, speechlanguage
pathology, psychology, nursing, neurology, and social work.
The future of occupational therapy depends on all
occupational therapy practitioners developing a firm grasp
of the best available evidence. This agenda is also clear for
academic programs training the next generation of occupational therapy practitioners. Educators need to be
aware of the results of the evidence-based reviews and
present this multifaceted information to students rather
than focus on a favored type of intervention. In addition,
the evidence should not be presented in a one-size-fits-all
framework but should be discussed from a client-centered
and occupation-based perspective as described in the
Occupational Therapy Practice Framework: Domain and
Process (3rd ed.; AOTA, 2014). s

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