The Core Values of Occupational Therapy: Supported by Evidence-Based Task-Oriented Training for Clients with Stroke
By: Sara E. Benham, OTD, OTR/L, ATP
Upper extremity impairment is a strong focus of occupational therapy treatment for clients who have experienced stroke. It is estimated that there are over 700,000 incidents of stroke in the United States each year with 4.8 million stroke survivors alive today (AHA, 2003). Approximately 70-80% of the survivors experience upper extremity impairment (Parker, Wade, & Hewer, 1986) which impacts occupational participation. Driven by AOTA’s Centennial Vision (AOTA, 2007) members are motivated to meet the occupational needs of clients with science-driven and evidence-based interventions. Occupational therapists have multiple treatment options from which to choose regarding upper extremity impairment mitigation. Recent high-level evidence from randomized control trials (RCTs) has supported novel approaches, such as robot-assisted therapy (Wu, Yang, Chuang, Lin, Chen, Chen, & Huang, 2012) and constraint-induced movement therapy (CIMT) (Wolf, Thompson, Winstein, Miller, Blanton, Nichols-Larsen, Morris, Uswatte, Taub, Light, & Sawaki, 2010). Emerging neuroplasticity-based exercise treatments may address and improve impairment; however occupational therapy long-term goals are usually related to the client’s participation in occupation. Task-oriented training is an intervention that focuses directly on client-centered participation in functional activities.
While task-oriented training may be more aligned with the values of occupational therapy (AOTA, 2008), clients may expect to participate in traditional and potentially beneficial exercise and strength training. Motivated by the profession’s core values to integrate task-oriented occupation, this author completed a Critically Appraised Topic (CAT) focusing on how task-oriented training compares with traditional strength training to improve upper extremity function for persons with stroke. It is important to note the limitation of this CAT: It has been individually prepared and not peer-reviewed.
A focused clinical question guided the CAT: Among people with unilateral upper extremity hemiparesis, how does task-oriented upper extremity treatment compare with upper extremity strength training on improving functional upper extremity motor return as measured on the Wolf Motor Function Test (WMFT), the Fugl-Meyer (FM), and/or the Functional Test of the Hemiparetic Upper Extremity (FTHUE)? The question was summarized from a PICO question (Patient, Intervention, Comparison, and Outcome) (Lou & Durando, 2008) to intentionally guide a client-centered search for the accurate, relevant, and high-quality evidence. Clinicians should seek the highest-quality evidence from a systematic review rather than a primary RCT, if it is available.
The CAT summarized a total of five relevant, Level I studies that included two systematic reviews. A study that investigated task-oriented training as compared to strength training was identified as ‘best evidence’ because it directly related to the PICO question (Winstein, Rose, Tan, Lewthwaite, Chui, & Azen, 2004). Both functional task practice and strength training (in addition to standard occupational therapy sessions) are superior to standard occupational therapy alone with regard to improvements in functional impairment and strength. Subjects with less stroke severity demonstrated greater improvements in both functional task practice and strength training groups. Subjects who participated in functional task training continued to improve strength at follow-up.
Two publications included in the CAT concluded that task-oriented training is an effective intervention to improve functional upper extremity performance for individuals with stroke (Timmermans, Spooren, Kingma, & Seelen, 2010) at post-intervention and follow-up (Arya, Verma, Garg, Sharma, Monia, & Aggarwal, 2012). With regard to strength training, one publication concluded that it is an effective intervention to improve grip strength and upper extremity function for individuals with stroke, however does not improve ADL performance. (Harris & Eng, 2010). Another randomized control trial concluded that self-directed exercise was effective with statistical significance to improve functional use of the upper extremity at post-intervention for subjects with chronic stroke. The amount of improvement was comparable to other novel treatment approaches previously mentioned such as CIMT and robot-aided exercise training (Pang, Harris, & Eng, 2006).
The clinical bottom line is that both task-oriented training and strength training are effective treatment interventions to improve upper extremity function after stroke. The evidence suggests that task-oriented training contributes to greater functional long-term results. Emerging evidence supports task-oriented training that includes clear functional goals and random practice components to improve functional performance at follow-up (Timmermans, Spooren, Kingma, & Seelen, 2010). These findings are most significant for clients who demonstrate mild to moderate upper extremity functional impairments.
These findings support that client-directed occupational therapy treatment with a functional task focus is an effective intervention for clients with stroke. The profession of occupational therapy is built on solid principles that support goal-directed functional participation. Therefore, it seems intuitive for occupational therapists to integrate functional, task-oriented practice in neurological treatment interventions. The advantages are easy to see: The intervention is cost-effective, statistically significant, and can be applied in any treatment setting. However, the potential disadvantages of occupational therapists overlooking the consistent utilization of task-oriented treatment may be detrimental in the near future. In an editorial of the Journal of American Physical Therapy Association, Jette and Latham (2011) reported that “task-oriented training is significantly more effective at improving function than standard impairment-focused training” (p. 1709). Now, the American Physical Therapy Association’s guidelines for practice include the alleviation of impairment and functional limitation, including “functional training in self-care and home management” (APTA, 2011, p. 57). As we progress toward the Centennial Vision of 2017, it is imperative for occupational therapists to meet society’s occupational needs. It is the responsibility of every occupational therapist to protect our unique contribution of integrating occupational, task-oriented treatment in upper extremity impairment mitigation.
About the Author
Sara Benham, OTD, OTR/L, ATP is presently assistant professor at the University of the Sciences in Philadelphia. She graduated with her master’s degree in occupational therapy from the University of Indianapolis in 2006, and in 2014, obtained her doctorate degree in occupational therapy from Thomas Jefferson University. She has 8 years experience in rehabilitation; in addition, her specialization is in assistive technology and stroke rehabilitation. She obtained an advanced certification in assistive technology from the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA). She has instructed an OT neuro-rehabilitation course for a rehab technician program in Haiti in the recent past. She presented at the Annual AOTA Conference in Baltimore on wellness apps appropriate for clients in an inpatient rehabilitation program.
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