http://informahealthcare.com/bij ISSN: 0269-9052 (print), 1362-301X (electronic) Brain Inj, 2014; 28(11): 1365–1373 ! 2014 Informa UK Ltd. DOI: 10.3109/02699052.2014.919529
ORIGINAL ARTICLE
Occupational therapist practice patterns in relation to clients with cognitive impairment following acquired brain injury Kajsa Holmqvist, Ann-Britt Ivarsson, & Marie Holmefur ¨ rebro University, O ¨ rebro, Sweden School of Health and Medical Sciences, O
Abstract
Keywords
Primary objective: To describe Swedish occupational therapist practice patterns for clients with cognitive impairment following acquired brain injury. Research design: A cross-sectional stratified random sample of 462 occupational therapists. Methods: An online questionnaire was used to collect data. Main results: The predominant practice pattern was the use of ADL-activities for assessment and therapy regardless of whether limitations in occupational performance or cognitive function were assessed or whether the approach was remedial or compensatory. For assessment, general ADL-instruments were used more often than instruments that assessed cognitive function. Instruments were used less often within municipal rehabilitation facilities compared to regional, county and primary care facilities. The most common focus of the therapies was in regard to abilities related to executive functioning. Another prominent practice pattern was a collaborative approach involving clients, relatives and other staff. The theories used in practice were, to a large extent, general in nature and did not focus specifically on cognitive functioning. Conclusions: Swedish occupational therapy practice for clients with cognitive impairments following acquired brain injury focuses highly on occupational performance. Therapies targeting executive functioning seem particularly important in practice and a collaborative approach involving clients, relatives and other staff is a prominent feature in practice.
Assessment, intervention, occupational therapy cognition
Introduction Cognitive impairments following acquired brain injury (CIABI) affect to what extent a person can manage daily activities independently, participate in social life and return to work [1–4]. Studies have shown that cognitive impairments influence the ability to perform activities of daily living (ADL) independently to a higher extent than do sensorimotor impairments only [2, 3]. Interventions targeting clients’ cognitive impairment are, therefore, important in brain injury rehabilitation. Occupational therapists (OTs) play a key role in the rehabilitation of clients with CIABI as their interventions primarily address the consequences of cognitive impairments in performance of ADL-activities [5]. Accordingly, occupational therapy interventions have also been shown to have a positive effect on the performance of ADL [6]. However, there is a scarcity of research into the content of the practice that forms these successful occupational therapy interventions and the need for studying practice patterns in order to make it possible to identify the successful components has been emphasized [6–8]. The term practice patterns’ has been widely used to describe clinical practice. Within occupational therapy
Correspondence: Kajsa Holmqvist, School of Health and Medical ¨ rebro University, SE-701 82 O ¨ rebro, Sweden. Tel: +46 19 Sciences, O 1301406. Fax: +46 10 303601. E-mail: [email protected]
History Received 1 November 2013 Revised 7 March 2014 Accepted 26 April 2014 Published online 5 June 2014
research, the term has generally included the content and forms of intervention as well as the environment in which the intervention is provided [7, 9, 10], the theoretical foundations used [9–11], the professional development and further education of the OT [9, 12] and collaboration with team members [10, 12]. An earlier interview study investigating practice patterns for clients with CIABI [13] revealed a complex OT practice due to the hidden nature of the impairments, the relation between clients’ self-awareness and motivation and the need for extensive collaboration with others besides the client. This interview study identified some additional practice areas compared to earlier research. These areas were the deliberate use of oneself therapeutically and collaboration not only with the team but also with the client, relatives and staff outside the rehabilitation team. Practice patterns in the current study include the areas of content of intervention, environment of intervention, collaboration with clients, relatives, team members and other staff, professional knowledge and further education and theoretical foundation. The use of oneself therapeutically is included as an aspect of collaboration with the client, meaning the OTs intentional use of personal traits and attitude as means in intervention [14]. Therapeutic use of self has been emphasized as an important factor for successful intervention when targeting clients with CIABI [13, 15], especially in relation to enhancing clients’ self-awareness and realistic goal-setting [13, 16].
1366
K. Holmqvist et al.
The practice patterns of occupational therapists in relation to clients with CIABI have been described in three earlier surveys, one from Australia [11] and two from Canada [17, 18]. The studies were different in their design and the practice areas that they included, but common results were the extensive use of basic and instrumental ADL training as the content of therapy. Korner-Bitensky et al. [18] found that the ADL training was general rather than directly targeting clients’ limitations due to cognitive impairment and did not use specific cognitive approaches. Blundon and Smits [17] found that the ADL training primarily took a remedial approach and used graded activities. Compensatory techniques such as memory aids were used by a majority of the OTs in both the Koh et al. [11] and Blundon and Smits [17] studies. None of these surveys addressed practice areas related to interventions directed to clients’ awareness of their disability, the evaluation of therapy outcome or collaborative practice and many aspects of OTs’ practice patterns with clients with CIABI remain to be explored further. The scarcity of research into OT practice patterns has resulted in a lack of knowledge of the exact nature in terms of specific content of the interventions used with clients with CIABI [6]. Legg et al. [6] concluded that the content of intervention needs to be clearly described to be able to explain the outcomes of occupational therapy. Stringer [7] stated that further research on practice patterns for clients with CIABI is necessary to identify to what extent current practice is in line with the best evidence. Further, it is only when the practice patterns of occupational therapy for clients with CIABI are made clear that successful occupational therapy can be developed toward evidence based practice [7, 8]. The aim of this study was to describe Swedish Occupational Therapists’ practice patterns for clients having cognitive impairment following acquired brain injury.
Brain Inj, 2014; 28(11): 1365–1373
based on response rates in other surveys [22] and the proportion of OTs estimated to work with clients with CIABI within the working areas [23]. Considering these assumptions 250 OTs from each working area (n ¼ 1000) were asked to participate. Four-hundred and five answered the whole questionnaire. Ethical principles based on the Declaration of Helsinki [24] and the Swedish Rules and Guidelines for research (CODEX) [25] were followed. Questionnaire A questionnaire that was based on a former qualitative study [13] was used. The questionnaire had been evaluated for content validity using content validity index (CVI) [26]. Test–re-test reliability had been evaluated using Svensson’s statistical method for ordinal categorical data [27]. The development process was described previously [28]. The questionnaire consisted of 44 OT practice items and nine demographic items that were formulated as statements with closed response alternatives. The practice items covered the following areas: (1) Content of intervention including assessment, therapy and evaluation of therapy outcome; (2) Environment of intervention; (3) Collaboration with client, relatives, team and other professionals; and (4) Professional knowledge and theoretical foundation. To guide the participants in completing the survey, the following terms were defined in the questionnaire: acquired brain injury, cognitive impairment, instrument for assessment, structured test and compensatory respective remedial intervention. At the end of the questionnaire, the participants had the opportunity to write comments. The questionnaire took 15 minutes to complete and all participants were asked to answer the demographic items irrespective of whether they worked with the intended client group or not. Data collection
Method A web-based questionnaire was used to collect data. As rehabilitation for clients with CIABI in Sweden takes place at different levels of care, OTs from four working areas representing different levels in the rehabilitation chain were recruited. These working areas included regional care (e.g. university hospitals), county care (e.g. rural hospitals), primary care (e.g. local medical care centre) and municipality care (e.g. care home and care at home). Sample selection A stratified random sample of 250 OTs from each of the four working areas was selected (n ¼ 1000). The participants were identified through the member register of the Swedish Association of Occupational Therapists (FSA), which includes over 90% of Sweden’s occupational therapists [19]. In the autumn of 2011, the register consisted of 2897 members within the four working areas. To allow accurate estimates for the sample as a whole with a confidence level of 95% and a 5% margin of error of the estimates, a sample size of 340 participants was needed [20]. This sample size was also considered enough to compare the working areas, provided that the participants were evenly distributed between the areas [21]. A response rate of 40–50% was estimated
The data collection was conducted during 4 weeks in August and September 2011. Texttalk websurvey software [29] was used and an e-mail with information about the study and a personal link to the questionnaire, locked to others, was sent out to the participants. Two reminders, one after 1 week and another after 2 weeks, were sent out to participants that had not responded. Data analysis Descriptive statistical analysis was used and frequency distribution was the primary analytical tool used to interpret the findings. Cross-tabulations were made on items regarding client assessment, approach to therapy, evaluation of therapy outcome and the theoretical foundations used. As nominal and ordinal data were cross-tabulated chi-squared tests were used for pair-wise comparisons between the working areas [21] and a p-value of 0.05 was considered significant. Data was analysed using Statistical Package for Social Sciences (SPSS), version 18.
Results Respondents Four hundred and five OTs responded to the whole questionnaire (response rate 41%). Fifty-seven participants responded
Occupational therapist practice patterns
DOI: 10.3109/02699052.2014.919529
1367
Table I. Demographics according to working areas (n ¼ 405).
Municipality care Primary care County care Regional care
Year of graduation as an OT (Md)
Years of experience working with the client group (Md)
Days of further education (Md)
Intensity in work with client group (Md)
2000 1992 1995 1998
1–4 1–4 5–10 1–4
1–4 1–4 6–10 6–10
1–2 days/week Few times/month 3–5 days/week 3–5 days/week
to the demographic items only. Eleven e-mails were returned due to an unknown recipient, sick leave or other absence reason. The participants were evenly distributed between the working areas. In addition, another 43 OTs contacted the researchers to decline participation. The most predominant reason for declining to participate was that the OT did not work with the intended client group. This was also the case with the 57 respondents that concluded their participation after answering the demographic items on the questionnaire. Participants’ characteristics are shown in Table I. Among the participants’ clients, the two most common diagnoses were stroke (75%) and traumatic brain injury (TBI) (20%). Ninety-two per cent of the participants worked as part of a team (in a range of 86–95% among the four working areas). A wide range of team members were mentioned, but the most frequent were physiotherapist (88%), registered nurse (74%) and physician (60%). Within the regional care and county care working areas most OTs worked in inpatient wards or in day care facilities. About half of the OTs in the county care working area also worked with clients in outpatient clinics. The majority of the OTs in primary care working area worked with clients in outpatient clinics and in the clients’ homes and the majority of the OTs in the municipality care working area worked with clients in sheltered housing environments as well as in the clients’ homes. Content of intervention Assessment The vast majority of the OTs used observations of daily activities most of the time or sometimes to assess both activity limitations (94%) and cognitive impairment (94%). Almost all participants also used interviews and 62% used tests to determine cognitive impairment (Table II). Assessment instruments were used by 88% of the participants. The ADL-taxonomy [30, 31], a general ADL instrument, was the most frequently used instrument (62%) and the Mini Mental State Examination (MMSE) [32] was the most frequently used test (40%) that focused on cognitive function. Instruments focusing on specific cognitive functions were used to a lesser extent than screening tools (Table III). There were statistically significant differences between the working areas regarding the use of assessment instruments. OTs working within county care (p ¼ 0.016) and regional care (p ¼ 0.001) reported the use of observational instruments most of the time to a higher degree than OTs within municipality care. OTs within primary care reported use of interview instruments most of the time or sometimes to a higher degree than county healthcare (p50.001), regional care (p ¼ 0.026) and municipality care (p50.001). In addition, OTs within regional care reported higher use of
interview instruments than OTs within municipality care (p ¼ 0.038). OTs within municipality care reported using tests to assess cognitive function most of the time or sometimes to a lower degree than OTs within the other working areas (county care, p50.001; regional care, p50.001; and primary care, p ¼ 0.006). In turn, OTs in primary care used such tests to a lower degree than OTs within county healthcare (p50.001) and regional care (p ¼ 0.023). Therapy The therapies used by the OTs targeted a wide range of cognitive impairments and their consequences. Impairments related to structuring/organization (91%), planning (89%) and attention (88%) occurred at the highest frequencies. Initiation (85%), short-term memory (83%) and orientation (83%) also occurred with high frequencies. Problem-solving/abstraction (72%) and long-term memory (59%) were targeted to a lesser extent followed by impulse control (52%) and behavioural changes (52%). Twenty-nine per cent of the participants reported that they also targeted control of basic instincts in their therapies. A few participants also added perceptual impairments, i.e. unilateral neglect and body image. Almost all participants preferred to perform their therapy in different activities of daily living (Table II). Ninety-six per cent prioritized their therapies according to their clients’ activity limitations before attempting to remediate the impairment. The participants used both remedial (81%) and compensatory (90%) therapies, as described specifically in Table II. There were no statistically significant differences between the working fields regarding remediation as a purpose for the therapy. OTs within municipal care reported using compensation as a purpose most of the time to a higher degree than OTs within county care (p ¼ 0.041). There were no statistically significant differences between the working fields regarding the prioritization of clients’ activity limitations. Eighty-two per cent of the participants recommended or prescribed assistive devices (AD). The most frequently used ADs are presented in Table IV. In addition to the ADs presented in Table IV, the participants also used other ADs primarily to help their clients to handle time, structure the day and to remember appointments and other events. Most examples were different types of electronic aids such as memory aids with reminders, communication devices and GPS devices. Participants also reported use of adaptations of the environment, including sensor alerting systems and structured support from another person. Therapies with the purpose of facilitating clients’ awareness of their disability were used by 82% of the participants.
1368
K. Holmqvist et al.
Brain Inj, 2014; 28(11): 1365–1373
Table II. Content of intervention and environment of intervention. Frequencies in percentages (n ¼ 405). Items (each item is abbreviated)
Yes, most of the time
Yes, sometimes
No, seldom
No, never
78 69 29 30 66 73 41 30 13
19 28 54 29 28 23 36 31 74
3 2 13 25 4 2 18 22 12
0 1 4 16 2 2 5 17 1
74 40 47 38 24 2
22 50 41 43 44 18
2 8 9 15 23 24
2 2 3 4 9 56
56 53 15
33 40 64
8 5 19
3 2 2
55 33
16 27
13 24
16 16
Assessment I assess cognitive impairment through interview with client I assess activity limitations through interview with client I assess activity limitations through interview with relatives/staff My interviews are structured I assess cognitive impairment by observing daily activities I assess activity limitations by observing daily activities My observations are structured I assess cognitive impairment with structured tests I find it difficult to separate causes of activity limitation Therapy I prefer daily activities as therapy My therapies are compensatory directed I assist clients in acquiring mental strategies My intention is to remediate clients’ cognitive functions I use graded activities to remediate cognitive functions I use computer programs for remedial therapy Evaluation of therapy outcome I evaluate the result of my therapy I use the same methods for assessment and evaluation* I find it difficult to evaluate the result of my therapy* Environment for intervention I implement my interventions in an institutional environment I implement interventions in the clients’ ordinary housing *only answered by those evaluating their therapies (n ¼ 392).
Table III. Percentage use of assessment instruments, in total and within each working field (n ¼ 354).
ADL-taxonomy Mini Mental State Examination (MMSE) Canadian Occupational Performance Measure (COPM) Assessment of Motor and Process Skills (AMPS) Neuro Cognitive Status Examination (Cognistat) Rivermead Behavioural Memory Test (RBMT) Sunnaas ADL-index Arbetsterapeutisk bedo¨mning av djupa, bakre och fra¨mre kognitiva funktioner [Swedish] (DBF) Baking Tray Task (BTT) Functional Independent Measure (FIM) Montreal Cognitive Assessment (MoCA)* Occupational Self-Assessment (OSA)* Intellektuell funktionspro¨vning (IFP) [Swedish]* Behavioural Inattention Test (BIT)* The Cognitive Assessment Battery (CAB)* Perceive, Recall, Plan, Perform (PRPP)* Nordic Stroke Driver Screening Assessment (NorSDSA)* Assessment of Awareness of Disability (AAD/A3)* A Quick test of Cognitive Speed (AQT)* The Clock Drawing Test*
Municipal Care
Primary Care
County Care
Regional Care
In total/all fields
62 37 8 5 5 0 26 5
69 48 50 27 19 21 12 14
60 41 23 31 38 35 26 40
49 33 44 37 33 37 16 20
62 40 31 25 24 23 20 19
0 5 – – – – – – – – – –
6 5 – – – – – – – – – –
26 15 – – – – – – – – – –
19 22 – – – – – – – – – –
13 12 9 7 3 3 2 2 1 1 1 1
*Instruments used by less than 10% by all participants are specified only in total.
The most commonly used therapies were structured feedback directly after a session (75%) and support for the client discovering his or her limitations using well known daily activities (68%). Less frequently used therapies were to use self-prediction before and after a session or activity (22%) and the use of video feedback (7%). Evaluation of therapy outcome Eighty-nine per cent of the participants evaluated the outcome of their therapies most of the time or sometimes. Just over
half of the participants responded that they used the same methods to evaluate outcome as for initial assessment most of the time. There were no statistically significant differences between the working areas regarding evaluation of therapies. Environment of intervention Fifty-five per cent of the participants performed their intervention in an institutional setting most of the time, while 29% did so seldom or never. Thirty-three per cent performed interventions most of the time in the clients’ home
Occupational therapist practice patterns
DOI: 10.3109/02699052.2014.919529
1369
Table IV. Percentage prescription or recommendation of assistive devices (AD) within working area (n ¼ 405).
Municipal care Primary care County care Regional care
Wall chart
Pocket chart
Day planner
Diary
Check-list
Personal Digital Assistant (PDA)
Computer/computer software
Cell phone
Wristwatch with alarm function
Do not use AD
48 59 39 43
12 25 25 31
61 86 62 62
33 63 59 57
23 49 35 45
13 8 47 30
6 18 5 26
18 50 33 56
23 38 9 17
23 3 26 19
Table V. Collaboration with client and relatives. Frequencies in percentages (n ¼ 405). Items (each item is abbreviated) Therapeutic approach/use of self/collaboration with client I set goals in collaboration with client I give client feedback after each session I use my personal traits when interacting during a session I have a purpose with my attitude toward the client Client’s motivation is crucial for a successful outcome I deliberately work to increase the clients’ motivation Collaboration, relatives I give information to relatives I discuss with relatives how to best support the client I depend on relatives for a successful outcome It is hard to know how much I can demand from relatives I work deliberately to engage relatives in the client’s rehabilitation
environment to the extent they believed the client needed it. There were no statistically significant differences between municipality and primary care or between regional and county care. Compared to regional (p50.001) and county care (p50.001), participants within municipality care reported this most of the time to a statistically significant higher degree. The same relationship was found between primary care and regional (p50.001) and county care (p50.001). Collaboration with client, relatives, team and other professionals The participants reported a high use of collaborative goalsetting and feedback discussions after each session with their clients. Their choice of attitude in their interaction with the client had a therapeutic purpose and included the use of their own personal traits during the intervention. Eighty-four per cent of the participants felt to some degree dependent on relatives to reach a successful outcome and most of them worked deliberately to involve relatives in the rehabilitation of their clients (Table V). There was a statistically significant difference between municipality care and primary care (p ¼ 0.001) regarding working deliberately to involve relatives. Participants within primary care reported this most of the time or sometimes to a higher degree than participants within municipality care. As to the rest there were no significant differences regarding collaboration with relatives. Seventy per cent of the participants stated that their team was supportive most of the time in their work with the client group and 9% seldom or never felt any support from their team. Eighty per cent asked other staff for assistance with regular therapies sometimes or most of the time, with 39% responding that they did this most of the time. OTs within municipality care did this to a statistically significant higher degree compared to regional (p ¼ 0.007) and primary care
Yes, most of the time
Yes, sometimes
No, seldom
No, never
60 62 71 78 89 76
32 32 26 19 10 21
6 5 2 2 0 2
2 1 1 1 1 1
49 42 39 9 30
45 45 45 65 50
5 10 12 22 16
1 3 4 4 4
(p50.001). About half of the OTs within municipality care asked other staff to assist with regular therapies most of the time. Professional knowledge and theoretical foundations Sixty-five per cent of the participants found theoretical foundations important in their practice most of the time. However, 36% judged their theoretical knowledge as insufficient compared to 13% that found it predominantly sufficient. A vast majority of the participants felt a need for further education within the field of occupational therapy and cognitive rehabilitation (95%). Eighty per cent of the participants used one or more theories to support their assessment of their clients’ strengths and weaknesses. The Model of Human Occupation (MoHO) [33] was used by 61% of the participants and the Canadian Model of Occupational Performance (CMOP) [34] was used by 33%. Luria’s [35] theory of brain functioning was used by 33% of the participants, but the Toglias Dynamic Interactional Approach [36] was used by only 4%. There were statistically significant differences regarding whether theory was used to support practice or not. OTs within county care (p ¼ 0.028) and regional care (p ¼ 0.005) used theory to a higher extent than OTs within municipality care. Seventy-five per cent of the participants also used theories to support communication with relatives and other professionals. The percentage use of different models used to support information to others about the client’s cognitive impairments was almost the same as the ones described for assessing clients. Seven per cent of the participants added other theories and models regarding the identification of their clients’ strengths and weaknesses and 6% added theories and models that were used to support communications with others. The additional
1370
K. Holmqvist et al.
theories and models were the same, regardless of the purpose for their use. The most commonly named were Occupational Therapy Intervention Process Model (OTIPM) [37], Sensory Integration [38] and the salutogenic model [39]. In summary, the predominant practice pattern was the use of ADL-activities for both assessment and therapy, regardless of whether the approach was remedial or compensatory or whether limitations in occupational performance or cognitive function were assessed. General ADL-instruments were used more than instruments focusing on the clients’ cognitive impairment. There were statistically significant differences between the working areas regarding instrument use. The OTs’ therapies covered a wide range of cognitive impairments, where abilities important to organize and execute occupational performance represented high percentages. Therapies focusing on activity limitations had higher priority than therapies focusing on the restoration of function. Another prominent practice pattern was a collaborative approach toward clients, relatives and other staff. Theories used to support practice were, to a large extent, general occupational therapy theories that did not focus specifically on cognitive functioning.
Discussion The aim of this study was to describe Swedish Occupational Therapists’ practice patterns for clients having CIABI. The results showed that the patterns of practice were characterized by a focus on occupational performance and the extensive use of ADL-activities for both assessment and therapy. The OTs used a combined approach to assessment [40]. The vast majority preferred to assess both activity limitations and cognitive function through the use of daily activities and tests of cognitive function were used to a lower extent. The most frequently used assessment was the ADL-taxonomy, a general instrument covering primarily personal, but to some extent instrumental, ADL [30]. A similar result was found in a Canadian study of the cognitive assessments used by OTs to assess older adults [41]. Douglas et al. [41] also found that assessments based on interviews and observations of daily activities were perceived as more useful and served a greater range of purposes than tests of cognitive function. A limitation with general ADL instruments is that their focus is not on cognition and this requires that the OT must rely on clinical reasoning skills to interpret how the cognitive impairment affects occupational performance. These skills have been shown to vary significantly depending on the OTs’ experience [42, 43] and this can influence results of the assessment. Another practice pattern identified in this study is the use of primarily general occupational therapy models to support practice, a pattern similar to that found by Koh et al. [11]. Furthermore, most OTs in this study reported insufficient theoretical knowledge in relation to the client group, along with a need for further education, and this might be connected to their choices of theoretical foundations and assessments. The use of models and assessments that do not focus on cognitive functioning demands much more from the OTs to detect cognitive impairments that affect occupational performance and to plan and perform effective interventions.
Brain Inj, 2014; 28(11): 1365–1373
A higher rate of use of cognition-specific models and assessments might raise the OTs’ feeling of competence and lead to even more effective therapies. In this study, the MMSE was found to be the most frequently used (40%) standardized test to screen cognitive function and the Montreal Cognitive Assessment (MoCa) was used by only 9% of the participants. This pattern is in line with other studies from Australia [11] and Canada [18, 41]. Douglas et al. [41] found that the MMSE was a test that was easy to access and administer and was often required by others such as physicians and was, therefore, a commonly used test. Similar reasons might explain the prevalence of the use of the test in Sweden, especially as the MMSE is regularly required in referrals for occupational therapy. However, the MMSE has been shown to have a ceiling effect in relation to the stroke population [44, 45] and the MoCA has been suggested as a better choice [44, 45]. There are reports of the use of the MoCA for clients with TBI [46, 47], but, to the authors’ knowledge, no comparative studies between the MMSE and MoCa have been performed in regards to the TBI population. Besides having better psychometric properties, the MoCA can also detect more cognitive impairments such as executive functioning and attention deficits [45] that are cognitive functions important to occupational performance. In this study, the therapies addressed executive functioning in occupational performance to a large extent, thus it is important to use assessments that correlate with these types of therapies. Like the MMSE, the MoCa is easy to get access to and to administer and, thus, the MoCa should be the primary choice in clinical practice and research. Approximately three-quarters of the OTs in this study preferred to use daily activities for therapies most of the time and these results are similar to previous survey studies [11, 18]. Performance of meaningful daily activities is important in the client’s adaptation to a new life with acquired brain injury and to gain experiences and feedback is important in their rehabilitation [48, 49]. Through occupational performance, the client can discover their own limitations and changes and find strategies to deal with them. The OT’s role is to enhance this process by giving feedback and information and to suggest strategies to manage different activities [48]. Feedback and providing the opportunity for ‘doing’ has been shown to be a key pro-active factor for client rehabilitation [49]. In this study both internal and external strategies were found to be used to a large extent in therapy as well as in feedback after each session. In relation to enhancing clients’ awareness of their disability, the uses of familiar daily activities to discover their limitations on their own were used by a majority of the OTs. According to Gustafsson et al. [50], OTs working with hospital-based stroke rehabilitation in Australia tend to try to remediate all of their clients’ limitations within each session, but the time allocated to each limitation is too short to be effective. The time allocated to cognitive impairments varied between 1–6 minutes per session depending on limitation addressed. In this study the OTs’ therapies covered a wide range of cognitive impairments and this may indicate a similar pattern in Sweden. To design therapies targeting specific cognitive impairments using ADL-activities is challenging and demands careful activity analysis and
Occupational therapist practice patterns
DOI: 10.3109/02699052.2014.919529
requires graded activities. An earlier study of OT therapies regarding attention, memory and orientation showed that there are differences in the use of graded activities, varying between 58–84%, due to cognitive impairment [17], and this variation might be explained by some cognitive functions being better suited for grading than others. In this study graded activities were used regularly by 69% of the participants, but the study provided no information about how the grading of activities might depend on differences in cognitive impairments. The complexity of using graded activities as means to remediate cognitive function is a challenge and requires deep understanding of how cognitive impairments affect occupational performance. More research in this area is needed to support effective occupational therapy practice. In this study almost all of the OTs provided information and support to the relatives of their clients. To the authors’ knowledge, collaboration with relatives has not been described in earlier surveys regarding OTs practice patterns for clients with CIABI. However, the involvement of relatives in rehabilitation is supported by findings in studies from relatives’ perspective. These studies have shown that there is strong evidence that the support of, and involvement of, relatives contribute to a feeling of competence, security and quality-of-life among both relatives and clients [51–54]. Methodological considerations A representative sample is important for the validity of a study and in this study a stratified random sample was selected to enhance representativeness [21]. To use the FSA member register as the source of participants in this study had both advantages and limitations. The advantage was the easy access to the majority of OTs working in Sweden, but the inability to specify the client group that each OT worked with was a limitation. A relatively large number of OTs that were asked to participate probably did not work with clients with CIABI. The invitation letter informed potential participants about these requirements and if the OTs did not work with the client group they were asked to answer the demographic items only. Fifty-seven OTs responded to these items only. Only one OT questioned the selection process in the comments field. The lack of control over drop-outs is a limitation of this study, but the response rate of 41% is 7% higher that the mean response rate for web surveys in general [22]. The questionnaire was used for the first time after significant effort in development and psychometric testing and appears to have worked well for the intended purpose. A few suggestions for changes were given in the comments field in the questionnaire, such as adding response alternatives on one demographic item and adding a ‘don’t know’ or ‘not applicable’ response alternative on another item. This study provides a Swedish perspective to the practice patterns of OTs working with clients with CIABI. The findings of this study were similar to those of earlier surveys of OTs in Australia [11] and Canada [17, 18] in terms of the extensive use of ADL-activities and internal and external strategies of therapy. Both of these strategies are in line with current best evidence [6, 55]. Similar patterns with earlier studies were also found regarding the use of general occupational therapy models and the use of the MMSE for
1371
client assessment. From an evidence-based perspective, the use of the MMSE is questionable and the MoCa is suggested as a better alternative [44, 45]. This study also added some further knowledge specific to the practice patterns of Swedish OTs. The high level of use of a general ADL-instrument can be seen as a weakness and highlights the need for easily accessible, easily administered and time-effective [41] observational instruments for clients with CIABI. Therapies addressed executive functioning to a high extent, which makes development of and use of assessments addressing this area crucial. The practice of involving relatives is in line with best evidence [53, 54]. The use of occupational performance in combination with feedback to enhance clients’ awareness of their disability contributes to the knowledge base of the OTs’ practice patterns for clients with CIABI. This study has contributed knowledge on what components are included in occupational therapy for clients with CIABI and to what extent they are used. However, much is still to be investigated. The components directly addressing performance of ADL activities need further investigation as they hide explanations for positive outcome of occupational therapy. In that respect studies of optimal ways of grading activities as well as the effects of strategies used in ADL are important. Another area for further research is how remedial and compensatory directed therapies should be integrated effectively.
Acknowledgement The authors thank the participating OTs who made this study possible.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. This ¨ rebro University and the Swedish study was supported by O Association of Occupational Therapists.
References 1. Fish J, Manly T, Emslie H, Evans J, Wilson BA. Compensatory strategies for acquired disorders of memory and planning: Differential effect of a paging system for patients with brain injury of traumatic versus cerebrovascular aetiology. Journal of Neurology, Neurosurgery and Psychiatry 2008;79:930–935. 2. Claesson L, Linden T, Skoog I, Blomstrand C. Cognitive impairment after stroke - impact on activities of daily living and costs of care for elderly people. The Goteborg 70+ Stroke Study. Cerebrovascular Diseases 2005;19:102–109. 3. Eriksson G, Tham K, Borg J. Occupational gaps in every day life 1-4 years after acquired brain injury. Journal of Rehabilitation Medicine 2006;38:159–165. 4. Johansson U, Bernspa˚ng B. Predicting return to work after brain injury using occupational therapy assessments. Disability and Rehabilitation 2001;23:474–480. 5. Wolf T. Rehabilitation, disability, and participation research: Are occupational therapy researchers adressing cognitive rehabilitation after stroke? American Journal of Occupational Therapy 2011;65: e46–e59. 6. Legg L, Drummond A, Langhorne P. Occupational therapy for patients with problems in activities of daily living after stroke (Review). Cochrane Database Systematic Review 2006;18:1–46. 7. Stringer A. Cognitive rehabilitation practice patterns: A survey of american hospital association rehabilitation programs. Clinical Neuropsychologist 2003;17:34–44.
1372
K. Holmqvist et al.
8. DeJong G, Horn S, Conroy B, Nichols D, Healton E. Opening the Black Box of poststroke rehabilitation: Stroke rehabilitation, patients, processes and outcomes. Archives of Physical Medicin and Rehabilitation 2005;86:S1–7. 9. Spencer K, Turkett A, Vaughan R, Koening S. School-based practice patterns: A survey of Occupational Therapists in Colorado. American Journal of Occupational Therapy 2006;60:81–91. 10. Weintraub N, Kovshi M. Changing practice patterns of schoolbased occupational therapists in Israel. Occupational Therapy International 2004;11:40–51. 11. Koh C-H, Hoffmann T, Bennett S, McKenna K. Management of patients with cognitive impairments after stroke: A survey of Australian occupational therapists. Australian Occupational Therapy Journal 2009;56:324–331. 12. Watling R, Deitz J, Kanny E, McLaughlin J. Current practice of occupational therapy for children with autism. American Journal of Occupational Therapy 1999;53:498–505. 13. Holmqvist K, Kamwendo K, Ivarsson A. Occupational therapists’ descriptions of their work with persons suffering from cognitive impairment following aqcuired brain injury. Scandinavian Journal of Occupational Therapy 2009;16:13–24. 14. Punwar A, Peloquin S. Occupational therapy principles and practice. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2000. 15. Abreu B, Peloquin S. The Quadraphonic Approach: A holistic rehabilitation model for brain injury. In: Katz N, editor. Cognition and occupation across the Life Span, models for interventions in occupational therapy. 2nd ed. Bethesda, MD: The American Occupational Therapy Association, Inc.; 2005. p 73–112. 16. Holmqvist K, Holmefur M, Ivarsson A. Therapeutic use of self as defined by Swedish occupational therapists working with clients with cognitive impairments following acquired brain injury: A Delphi study. Australian Occupational Therapy Journal 2013;60: 48–55. 17. Blundon G, Smits E. Cognitive rehabilitation: A pilot survey of therapeutic modalities used by Canadian occupational therapists with survivors of traumatic brain injury. Canadian Journal of Occupational therapy 2000;67:184–196. 18. Korner-Bitensky N, Barrett-Bernstein S, Bibas G, Poulin V. National survey of Canadian occupational therapists’ assessment and treatment of cognitive impairment post-stroke. Australian Occupational Therapy Journal 2011;58:241–250. 19. Swedish Association of Occupational therapists. Occupational therapy in Sweden and our member association. In; 2011. p 8. 20. National Statistical Service. Sample Size Caculator. Belconnen: Australian Bureau of Statistics; Swedish Association of Occupational Therapists. Stockholm; 2012. Available online at: http://www.nss.gov.au/nss/home.nsf/NSS/0A4A642C712719DCCA 2571AB00243DC6?opendocument, accessed 15 August 2011. 21. Altman D. Practical statistics for medical research. London: Chapman and Hall; 1991. 22. Shih T-H, Fan X. Comparing response rates from web and mail surveys: A meta-analysis. Field Methods 2008;20:249–271. 23. Hanson C, Shectman O, Jackson Foss J, Krauss-Hooker A. Occupational therapy: Current practice and training issues in treatment of cognitve function. NeuroRehabilitation 1997;8:31–41. 24. Word Medical Association. WMA Declaration of Helsinki - Ethical principles for medical research involving human subjects. FerneyVoltaire (France); 2008. Available online at: http://www.wma.net/ en/30publications/10policies/b3/index.html, accessed 18 february 2011. 25. Swedish Research Council. CODEX regler och riktlinjer fo¨r forskning. Uppsala: Centre for Research and Bioethics (CBR) Uppsala University; 2000. Available online at: http://www. codex.vr.se/index.shtml, accessed 18 May 2011. 26. Polit D, Beck C, Owen S. Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Research in Nursing and Health 2007;30:459–467. 27. Svensson E. Analysis of systematic and random differences between paired ordinal categorical data. Stockholm: Almquist & Wiksell; 1993. 28. Holmqvist K, Kamwendo K, Ivarsson A. Occupational therapists’ practice patterns for clients with cognitive impairment following acquired brain injury. Development of a Questionnaire. Scandinavian Journal of Occupational Therapy 2012;19:150–163.
Brain Inj, 2014; 28(11): 1365–1373
29. Texttalk. Websurvey by Texttalk: Websurveys, questionnaires, data collection and follow-ups. Gothenburg: Texttalk; 2014. Available online at: http://websurvey.texttalk.se/en/index.php, accessed 7 March 2014. 30. To¨rnquist K. Att faststa¨lla och ma¨ta fo¨rma˚ga till dagliga livets aktiviteter (ADL): En kritisk granskning av ADL-instrument och arbetsterapipraxis [Veryfying and measuring the ability to perform activities of daily living (ADL): A critical examination of ADLinstruments and the practice of occupational therapy]. Go¨teborg: Go¨teborgs universitet; 1995. 31. Sonn U, To¨rnquist K, Svensson E. The ADL-taxonomy - from idividual categorical data to ordinal categorical data. Scandinavian Journal of Occupational Therapy 1999;6:11–20. 32. Folstein M, Folstein S, McHugh P. ‘Mini-Mental-State’: A practical method for grading cognitive state of patients for the clinicians. Journal of Psychiatric Research 1975;12:189–198. 33. Kielhofner G. A model of human occupation: Theory and application. 3rd ed. Baltimore, MD: Lippincott, Williams & Wilkins; 2002. 34. Townsend E. Enabling occupation: An occupational therapy perspective. Ottawa: Canadian Association of Occupational Therapists; 1997. 35. Luria A. The working Brain. An introduction to neuropsychology. New York: Basic Books; 1973. 36. Toglia J. A dynamic interactional approach to cognitive rehabilitation. In: Katz N, editor. Cognition and occupation across the Life Span, models for intervention in occupational therapy. 2nd ed. Bethesda, MD: The American Occupational Therapy Association, Inc.; 2005. p 29–72. 37. Fisher AG. Occupational Therapy Intervention Process Model: A model for planning and implementing top-down, client-centered, and occupation-based interventions. Fort Collins, CO: Three Star Press; 2009. 38. Bundy A, Lane S, Murray E. Sensory integration: Theory and practice. 2nd ed. Philadelphia, PA: F.A. Davis; 2002. 39. Antonovsky A. The salutogenic model as a theory to guide health promotion. Health Promotion International 1996;11:11–17. 40. Vining Radomski M, Trombly Latham C. Occupational therapy for physical dysfunction. 6th ed. Philadelphi, PA: Wolters Kluwer Lippincott Williams & Wilkins; 2008. 41. Douglas A, Liu L, Warren S, Hopper T. Cognitive assessments for older adults: Which ones are used by Canadian therapists and why. Canadian Journal of Occupational therapy 2007;74: 370–381. 42. Paterson M, Higgs J, Wilcox S. Developing expertise in judgement artistry in occupational therapy practice. British Journal of Occupational Therapy 2006;69:115–123. 43. Reich S, Eastwood C, Tilling K, Hopper A. Clinical decision making, risk and occupational therapy. Health & Social Care in the Community 1998;6:47–54. 44. Toglia J, Fitzgerald KA, O’Dell M, Mastrogiovanni A, Lin D. The Mini-Mental State Examination and Montreal Cognitive Assessment in persons with mild subacute Stroke: Relationship to functional outcome. Archives of Physical Medicin and Rehabilitation 2011;92:792–798. 45. Pendlebury S, Cuthbertson F, Welch S, Metha Z, Rothwell P. Underestimation of cognitive impairment by Mini-Mental State examination versus the Montreal Cognitive Assessemnt in patients with Transient Ischemic Attack and Stroke: A population-based study. Stroke 2010;41:1290–1239. 46. Ruff R, Ruff S, Wang X-F. Headaches among operation Iraqi Freedom/Operation Enduring Freedom veterans with mild traumatic brain injury associated with exposures to explosions. Journal of Rehabilitation Research and Development 2008;45:941–952. 47. Ruff R, Ruff S, Wang X-F. Improving sleep: Initial headache treatment in OIF/OEF veterans with blast-induced mild traumatic brain injury. Journal of Rehabilitation Research and Development 2009;46:1071–1084. 48. Hoogerdijk B, Runge U, Haugboelle J. The adaptation process after traumatic brain injury. An individual and ongoing occupational struggle to gain a new identity. Scandinavian Journal of Occupational Therapy 2011;18:122–132. 49. Ekstam L, Tham K, Borell L. Couples’ approaches to change in everyday life during the first year after stroke. Scandinavian Journal of Occupational Therapy 2011;18:49–58.
DOI: 10.3109/02699052.2014.919529
50. Gustafsson L, Nugent N, Biros L. Occupational therapy practice in hospital-based stroke rehabilitation? Scandinavian Journal of Occupational Therapy 2012;19:132–139. 51. Socialstyrelsen. Nationella riktlinjer fo¨r Strokesjukva˚rd 2009 - sto¨d fo¨r styrning och ledning. Stockholm: Socialstyrelsen; 2009. 52. Lefebvre H, Pelchat D, Swaine B, Ge´linas I, Levert M. The experiences of individuals with traumatic brain injury, families, physicians and health professionals regarding care provided throughout the continuum. Brain Injury 2005;19:585–597. 53. Kalra L, Evans A, Perez I, Melbourn A, Patel A, Knapp M, Donaldson N. Training carers of stroke patients: A randomised controlled trail. British Medical Journal 2004;328:1099.
Occupational therapist practice patterns
1373
54. Bakas T, Austin J, Okonkwo K, Lewis R, Chadwick L. Needs, concerns, strategies, and advice of stroke caregivers the first six months after discharge. The Journal of Neuroscience Nursing 2002; 34:242–251. 55. Cicerone K, Dahlberg C, Malec J, Langenbahn D, Felicetti T, Kneipp S, Ellmo W, Kalmar K, Giacino J, Harley P, et al. Evidencebased cognitive rehabilitation: Updated review of the literature from 1998 through 2002. Archives of Physical Medicine and Rehabilitation 2005;86:1681–1692.
Copyright of Brain Injury is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
ORIGINAL ARTICLE
Occupational therapist practice patterns in relation to clients with cognitive impairment following acquired brain injury Kajsa Holmqvist, Ann-Britt Ivarsson, & Marie Holmefur ¨ rebro University, O ¨ rebro, Sweden School of Health and Medical Sciences, O
Abstract
Keywords
Primary objective: To describe Swedish occupational therapist practice patterns for clients with cognitive impairment following acquired brain injury. Research design: A cross-sectional stratified random sample of 462 occupational therapists. Methods: An online questionnaire was used to collect data. Main results: The predominant practice pattern was the use of ADL-activities for assessment and therapy regardless of whether limitations in occupational performance or cognitive function were assessed or whether the approach was remedial or compensatory. For assessment, general ADL-instruments were used more often than instruments that assessed cognitive function. Instruments were used less often within municipal rehabilitation facilities compared to regional, county and primary care facilities. The most common focus of the therapies was in regard to abilities related to executive functioning. Another prominent practice pattern was a collaborative approach involving clients, relatives and other staff. The theories used in practice were, to a large extent, general in nature and did not focus specifically on cognitive functioning. Conclusions: Swedish occupational therapy practice for clients with cognitive impairments following acquired brain injury focuses highly on occupational performance. Therapies targeting executive functioning seem particularly important in practice and a collaborative approach involving clients, relatives and other staff is a prominent feature in practice.
Assessment, intervention, occupational therapy cognition
Introduction Cognitive impairments following acquired brain injury (CIABI) affect to what extent a person can manage daily activities independently, participate in social life and return to work [1–4]. Studies have shown that cognitive impairments influence the ability to perform activities of daily living (ADL) independently to a higher extent than do sensorimotor impairments only [2, 3]. Interventions targeting clients’ cognitive impairment are, therefore, important in brain injury rehabilitation. Occupational therapists (OTs) play a key role in the rehabilitation of clients with CIABI as their interventions primarily address the consequences of cognitive impairments in performance of ADL-activities [5]. Accordingly, occupational therapy interventions have also been shown to have a positive effect on the performance of ADL [6]. However, there is a scarcity of research into the content of the practice that forms these successful occupational therapy interventions and the need for studying practice patterns in order to make it possible to identify the successful components has been emphasized [6–8]. The term practice patterns’ has been widely used to describe clinical practice. Within occupational therapy
Correspondence: Kajsa Holmqvist, School of Health and Medical ¨ rebro University, SE-701 82 O ¨ rebro, Sweden. Tel: +46 19 Sciences, O 1301406. Fax: +46 10 303601. E-mail: [email protected]
History Received 1 November 2013 Revised 7 March 2014 Accepted 26 April 2014 Published online 5 June 2014
research, the term has generally included the content and forms of intervention as well as the environment in which the intervention is provided [7, 9, 10], the theoretical foundations used [9–11], the professional development and further education of the OT [9, 12] and collaboration with team members [10, 12]. An earlier interview study investigating practice patterns for clients with CIABI [13] revealed a complex OT practice due to the hidden nature of the impairments, the relation between clients’ self-awareness and motivation and the need for extensive collaboration with others besides the client. This interview study identified some additional practice areas compared to earlier research. These areas were the deliberate use of oneself therapeutically and collaboration not only with the team but also with the client, relatives and staff outside the rehabilitation team. Practice patterns in the current study include the areas of content of intervention, environment of intervention, collaboration with clients, relatives, team members and other staff, professional knowledge and further education and theoretical foundation. The use of oneself therapeutically is included as an aspect of collaboration with the client, meaning the OTs intentional use of personal traits and attitude as means in intervention [14]. Therapeutic use of self has been emphasized as an important factor for successful intervention when targeting clients with CIABI [13, 15], especially in relation to enhancing clients’ self-awareness and realistic goal-setting [13, 16].
1366
K. Holmqvist et al.
The practice patterns of occupational therapists in relation to clients with CIABI have been described in three earlier surveys, one from Australia [11] and two from Canada [17, 18]. The studies were different in their design and the practice areas that they included, but common results were the extensive use of basic and instrumental ADL training as the content of therapy. Korner-Bitensky et al. [18] found that the ADL training was general rather than directly targeting clients’ limitations due to cognitive impairment and did not use specific cognitive approaches. Blundon and Smits [17] found that the ADL training primarily took a remedial approach and used graded activities. Compensatory techniques such as memory aids were used by a majority of the OTs in both the Koh et al. [11] and Blundon and Smits [17] studies. None of these surveys addressed practice areas related to interventions directed to clients’ awareness of their disability, the evaluation of therapy outcome or collaborative practice and many aspects of OTs’ practice patterns with clients with CIABI remain to be explored further. The scarcity of research into OT practice patterns has resulted in a lack of knowledge of the exact nature in terms of specific content of the interventions used with clients with CIABI [6]. Legg et al. [6] concluded that the content of intervention needs to be clearly described to be able to explain the outcomes of occupational therapy. Stringer [7] stated that further research on practice patterns for clients with CIABI is necessary to identify to what extent current practice is in line with the best evidence. Further, it is only when the practice patterns of occupational therapy for clients with CIABI are made clear that successful occupational therapy can be developed toward evidence based practice [7, 8]. The aim of this study was to describe Swedish Occupational Therapists’ practice patterns for clients having cognitive impairment following acquired brain injury.
Brain Inj, 2014; 28(11): 1365–1373
based on response rates in other surveys [22] and the proportion of OTs estimated to work with clients with CIABI within the working areas [23]. Considering these assumptions 250 OTs from each working area (n ¼ 1000) were asked to participate. Four-hundred and five answered the whole questionnaire. Ethical principles based on the Declaration of Helsinki [24] and the Swedish Rules and Guidelines for research (CODEX) [25] were followed. Questionnaire A questionnaire that was based on a former qualitative study [13] was used. The questionnaire had been evaluated for content validity using content validity index (CVI) [26]. Test–re-test reliability had been evaluated using Svensson’s statistical method for ordinal categorical data [27]. The development process was described previously [28]. The questionnaire consisted of 44 OT practice items and nine demographic items that were formulated as statements with closed response alternatives. The practice items covered the following areas: (1) Content of intervention including assessment, therapy and evaluation of therapy outcome; (2) Environment of intervention; (3) Collaboration with client, relatives, team and other professionals; and (4) Professional knowledge and theoretical foundation. To guide the participants in completing the survey, the following terms were defined in the questionnaire: acquired brain injury, cognitive impairment, instrument for assessment, structured test and compensatory respective remedial intervention. At the end of the questionnaire, the participants had the opportunity to write comments. The questionnaire took 15 minutes to complete and all participants were asked to answer the demographic items irrespective of whether they worked with the intended client group or not. Data collection
Method A web-based questionnaire was used to collect data. As rehabilitation for clients with CIABI in Sweden takes place at different levels of care, OTs from four working areas representing different levels in the rehabilitation chain were recruited. These working areas included regional care (e.g. university hospitals), county care (e.g. rural hospitals), primary care (e.g. local medical care centre) and municipality care (e.g. care home and care at home). Sample selection A stratified random sample of 250 OTs from each of the four working areas was selected (n ¼ 1000). The participants were identified through the member register of the Swedish Association of Occupational Therapists (FSA), which includes over 90% of Sweden’s occupational therapists [19]. In the autumn of 2011, the register consisted of 2897 members within the four working areas. To allow accurate estimates for the sample as a whole with a confidence level of 95% and a 5% margin of error of the estimates, a sample size of 340 participants was needed [20]. This sample size was also considered enough to compare the working areas, provided that the participants were evenly distributed between the areas [21]. A response rate of 40–50% was estimated
The data collection was conducted during 4 weeks in August and September 2011. Texttalk websurvey software [29] was used and an e-mail with information about the study and a personal link to the questionnaire, locked to others, was sent out to the participants. Two reminders, one after 1 week and another after 2 weeks, were sent out to participants that had not responded. Data analysis Descriptive statistical analysis was used and frequency distribution was the primary analytical tool used to interpret the findings. Cross-tabulations were made on items regarding client assessment, approach to therapy, evaluation of therapy outcome and the theoretical foundations used. As nominal and ordinal data were cross-tabulated chi-squared tests were used for pair-wise comparisons between the working areas [21] and a p-value of 0.05 was considered significant. Data was analysed using Statistical Package for Social Sciences (SPSS), version 18.
Results Respondents Four hundred and five OTs responded to the whole questionnaire (response rate 41%). Fifty-seven participants responded
Occupational therapist practice patterns
DOI: 10.3109/02699052.2014.919529
1367
Table I. Demographics according to working areas (n ¼ 405).
Municipality care Primary care County care Regional care
Year of graduation as an OT (Md)
Years of experience working with the client group (Md)
Days of further education (Md)
Intensity in work with client group (Md)
2000 1992 1995 1998
1–4 1–4 5–10 1–4
1–4 1–4 6–10 6–10
1–2 days/week Few times/month 3–5 days/week 3–5 days/week
to the demographic items only. Eleven e-mails were returned due to an unknown recipient, sick leave or other absence reason. The participants were evenly distributed between the working areas. In addition, another 43 OTs contacted the researchers to decline participation. The most predominant reason for declining to participate was that the OT did not work with the intended client group. This was also the case with the 57 respondents that concluded their participation after answering the demographic items on the questionnaire. Participants’ characteristics are shown in Table I. Among the participants’ clients, the two most common diagnoses were stroke (75%) and traumatic brain injury (TBI) (20%). Ninety-two per cent of the participants worked as part of a team (in a range of 86–95% among the four working areas). A wide range of team members were mentioned, but the most frequent were physiotherapist (88%), registered nurse (74%) and physician (60%). Within the regional care and county care working areas most OTs worked in inpatient wards or in day care facilities. About half of the OTs in the county care working area also worked with clients in outpatient clinics. The majority of the OTs in primary care working area worked with clients in outpatient clinics and in the clients’ homes and the majority of the OTs in the municipality care working area worked with clients in sheltered housing environments as well as in the clients’ homes. Content of intervention Assessment The vast majority of the OTs used observations of daily activities most of the time or sometimes to assess both activity limitations (94%) and cognitive impairment (94%). Almost all participants also used interviews and 62% used tests to determine cognitive impairment (Table II). Assessment instruments were used by 88% of the participants. The ADL-taxonomy [30, 31], a general ADL instrument, was the most frequently used instrument (62%) and the Mini Mental State Examination (MMSE) [32] was the most frequently used test (40%) that focused on cognitive function. Instruments focusing on specific cognitive functions were used to a lesser extent than screening tools (Table III). There were statistically significant differences between the working areas regarding the use of assessment instruments. OTs working within county care (p ¼ 0.016) and regional care (p ¼ 0.001) reported the use of observational instruments most of the time to a higher degree than OTs within municipality care. OTs within primary care reported use of interview instruments most of the time or sometimes to a higher degree than county healthcare (p50.001), regional care (p ¼ 0.026) and municipality care (p50.001). In addition, OTs within regional care reported higher use of
interview instruments than OTs within municipality care (p ¼ 0.038). OTs within municipality care reported using tests to assess cognitive function most of the time or sometimes to a lower degree than OTs within the other working areas (county care, p50.001; regional care, p50.001; and primary care, p ¼ 0.006). In turn, OTs in primary care used such tests to a lower degree than OTs within county healthcare (p50.001) and regional care (p ¼ 0.023). Therapy The therapies used by the OTs targeted a wide range of cognitive impairments and their consequences. Impairments related to structuring/organization (91%), planning (89%) and attention (88%) occurred at the highest frequencies. Initiation (85%), short-term memory (83%) and orientation (83%) also occurred with high frequencies. Problem-solving/abstraction (72%) and long-term memory (59%) were targeted to a lesser extent followed by impulse control (52%) and behavioural changes (52%). Twenty-nine per cent of the participants reported that they also targeted control of basic instincts in their therapies. A few participants also added perceptual impairments, i.e. unilateral neglect and body image. Almost all participants preferred to perform their therapy in different activities of daily living (Table II). Ninety-six per cent prioritized their therapies according to their clients’ activity limitations before attempting to remediate the impairment. The participants used both remedial (81%) and compensatory (90%) therapies, as described specifically in Table II. There were no statistically significant differences between the working fields regarding remediation as a purpose for the therapy. OTs within municipal care reported using compensation as a purpose most of the time to a higher degree than OTs within county care (p ¼ 0.041). There were no statistically significant differences between the working fields regarding the prioritization of clients’ activity limitations. Eighty-two per cent of the participants recommended or prescribed assistive devices (AD). The most frequently used ADs are presented in Table IV. In addition to the ADs presented in Table IV, the participants also used other ADs primarily to help their clients to handle time, structure the day and to remember appointments and other events. Most examples were different types of electronic aids such as memory aids with reminders, communication devices and GPS devices. Participants also reported use of adaptations of the environment, including sensor alerting systems and structured support from another person. Therapies with the purpose of facilitating clients’ awareness of their disability were used by 82% of the participants.
1368
K. Holmqvist et al.
Brain Inj, 2014; 28(11): 1365–1373
Table II. Content of intervention and environment of intervention. Frequencies in percentages (n ¼ 405). Items (each item is abbreviated)
Yes, most of the time
Yes, sometimes
No, seldom
No, never
78 69 29 30 66 73 41 30 13
19 28 54 29 28 23 36 31 74
3 2 13 25 4 2 18 22 12
0 1 4 16 2 2 5 17 1
74 40 47 38 24 2
22 50 41 43 44 18
2 8 9 15 23 24
2 2 3 4 9 56
56 53 15
33 40 64
8 5 19
3 2 2
55 33
16 27
13 24
16 16
Assessment I assess cognitive impairment through interview with client I assess activity limitations through interview with client I assess activity limitations through interview with relatives/staff My interviews are structured I assess cognitive impairment by observing daily activities I assess activity limitations by observing daily activities My observations are structured I assess cognitive impairment with structured tests I find it difficult to separate causes of activity limitation Therapy I prefer daily activities as therapy My therapies are compensatory directed I assist clients in acquiring mental strategies My intention is to remediate clients’ cognitive functions I use graded activities to remediate cognitive functions I use computer programs for remedial therapy Evaluation of therapy outcome I evaluate the result of my therapy I use the same methods for assessment and evaluation* I find it difficult to evaluate the result of my therapy* Environment for intervention I implement my interventions in an institutional environment I implement interventions in the clients’ ordinary housing *only answered by those evaluating their therapies (n ¼ 392).
Table III. Percentage use of assessment instruments, in total and within each working field (n ¼ 354).
ADL-taxonomy Mini Mental State Examination (MMSE) Canadian Occupational Performance Measure (COPM) Assessment of Motor and Process Skills (AMPS) Neuro Cognitive Status Examination (Cognistat) Rivermead Behavioural Memory Test (RBMT) Sunnaas ADL-index Arbetsterapeutisk bedo¨mning av djupa, bakre och fra¨mre kognitiva funktioner [Swedish] (DBF) Baking Tray Task (BTT) Functional Independent Measure (FIM) Montreal Cognitive Assessment (MoCA)* Occupational Self-Assessment (OSA)* Intellektuell funktionspro¨vning (IFP) [Swedish]* Behavioural Inattention Test (BIT)* The Cognitive Assessment Battery (CAB)* Perceive, Recall, Plan, Perform (PRPP)* Nordic Stroke Driver Screening Assessment (NorSDSA)* Assessment of Awareness of Disability (AAD/A3)* A Quick test of Cognitive Speed (AQT)* The Clock Drawing Test*
Municipal Care
Primary Care
County Care
Regional Care
In total/all fields
62 37 8 5 5 0 26 5
69 48 50 27 19 21 12 14
60 41 23 31 38 35 26 40
49 33 44 37 33 37 16 20
62 40 31 25 24 23 20 19
0 5 – – – – – – – – – –
6 5 – – – – – – – – – –
26 15 – – – – – – – – – –
19 22 – – – – – – – – – –
13 12 9 7 3 3 2 2 1 1 1 1
*Instruments used by less than 10% by all participants are specified only in total.
The most commonly used therapies were structured feedback directly after a session (75%) and support for the client discovering his or her limitations using well known daily activities (68%). Less frequently used therapies were to use self-prediction before and after a session or activity (22%) and the use of video feedback (7%). Evaluation of therapy outcome Eighty-nine per cent of the participants evaluated the outcome of their therapies most of the time or sometimes. Just over
half of the participants responded that they used the same methods to evaluate outcome as for initial assessment most of the time. There were no statistically significant differences between the working areas regarding evaluation of therapies. Environment of intervention Fifty-five per cent of the participants performed their intervention in an institutional setting most of the time, while 29% did so seldom or never. Thirty-three per cent performed interventions most of the time in the clients’ home
Occupational therapist practice patterns
DOI: 10.3109/02699052.2014.919529
1369
Table IV. Percentage prescription or recommendation of assistive devices (AD) within working area (n ¼ 405).
Municipal care Primary care County care Regional care
Wall chart
Pocket chart
Day planner
Diary
Check-list
Personal Digital Assistant (PDA)
Computer/computer software
Cell phone
Wristwatch with alarm function
Do not use AD
48 59 39 43
12 25 25 31
61 86 62 62
33 63 59 57
23 49 35 45
13 8 47 30
6 18 5 26
18 50 33 56
23 38 9 17
23 3 26 19
Table V. Collaboration with client and relatives. Frequencies in percentages (n ¼ 405). Items (each item is abbreviated) Therapeutic approach/use of self/collaboration with client I set goals in collaboration with client I give client feedback after each session I use my personal traits when interacting during a session I have a purpose with my attitude toward the client Client’s motivation is crucial for a successful outcome I deliberately work to increase the clients’ motivation Collaboration, relatives I give information to relatives I discuss with relatives how to best support the client I depend on relatives for a successful outcome It is hard to know how much I can demand from relatives I work deliberately to engage relatives in the client’s rehabilitation
environment to the extent they believed the client needed it. There were no statistically significant differences between municipality and primary care or between regional and county care. Compared to regional (p50.001) and county care (p50.001), participants within municipality care reported this most of the time to a statistically significant higher degree. The same relationship was found between primary care and regional (p50.001) and county care (p50.001). Collaboration with client, relatives, team and other professionals The participants reported a high use of collaborative goalsetting and feedback discussions after each session with their clients. Their choice of attitude in their interaction with the client had a therapeutic purpose and included the use of their own personal traits during the intervention. Eighty-four per cent of the participants felt to some degree dependent on relatives to reach a successful outcome and most of them worked deliberately to involve relatives in the rehabilitation of their clients (Table V). There was a statistically significant difference between municipality care and primary care (p ¼ 0.001) regarding working deliberately to involve relatives. Participants within primary care reported this most of the time or sometimes to a higher degree than participants within municipality care. As to the rest there were no significant differences regarding collaboration with relatives. Seventy per cent of the participants stated that their team was supportive most of the time in their work with the client group and 9% seldom or never felt any support from their team. Eighty per cent asked other staff for assistance with regular therapies sometimes or most of the time, with 39% responding that they did this most of the time. OTs within municipality care did this to a statistically significant higher degree compared to regional (p ¼ 0.007) and primary care
Yes, most of the time
Yes, sometimes
No, seldom
No, never
60 62 71 78 89 76
32 32 26 19 10 21
6 5 2 2 0 2
2 1 1 1 1 1
49 42 39 9 30
45 45 45 65 50
5 10 12 22 16
1 3 4 4 4
(p50.001). About half of the OTs within municipality care asked other staff to assist with regular therapies most of the time. Professional knowledge and theoretical foundations Sixty-five per cent of the participants found theoretical foundations important in their practice most of the time. However, 36% judged their theoretical knowledge as insufficient compared to 13% that found it predominantly sufficient. A vast majority of the participants felt a need for further education within the field of occupational therapy and cognitive rehabilitation (95%). Eighty per cent of the participants used one or more theories to support their assessment of their clients’ strengths and weaknesses. The Model of Human Occupation (MoHO) [33] was used by 61% of the participants and the Canadian Model of Occupational Performance (CMOP) [34] was used by 33%. Luria’s [35] theory of brain functioning was used by 33% of the participants, but the Toglias Dynamic Interactional Approach [36] was used by only 4%. There were statistically significant differences regarding whether theory was used to support practice or not. OTs within county care (p ¼ 0.028) and regional care (p ¼ 0.005) used theory to a higher extent than OTs within municipality care. Seventy-five per cent of the participants also used theories to support communication with relatives and other professionals. The percentage use of different models used to support information to others about the client’s cognitive impairments was almost the same as the ones described for assessing clients. Seven per cent of the participants added other theories and models regarding the identification of their clients’ strengths and weaknesses and 6% added theories and models that were used to support communications with others. The additional
1370
K. Holmqvist et al.
theories and models were the same, regardless of the purpose for their use. The most commonly named were Occupational Therapy Intervention Process Model (OTIPM) [37], Sensory Integration [38] and the salutogenic model [39]. In summary, the predominant practice pattern was the use of ADL-activities for both assessment and therapy, regardless of whether the approach was remedial or compensatory or whether limitations in occupational performance or cognitive function were assessed. General ADL-instruments were used more than instruments focusing on the clients’ cognitive impairment. There were statistically significant differences between the working areas regarding instrument use. The OTs’ therapies covered a wide range of cognitive impairments, where abilities important to organize and execute occupational performance represented high percentages. Therapies focusing on activity limitations had higher priority than therapies focusing on the restoration of function. Another prominent practice pattern was a collaborative approach toward clients, relatives and other staff. Theories used to support practice were, to a large extent, general occupational therapy theories that did not focus specifically on cognitive functioning.
Discussion The aim of this study was to describe Swedish Occupational Therapists’ practice patterns for clients having CIABI. The results showed that the patterns of practice were characterized by a focus on occupational performance and the extensive use of ADL-activities for both assessment and therapy. The OTs used a combined approach to assessment [40]. The vast majority preferred to assess both activity limitations and cognitive function through the use of daily activities and tests of cognitive function were used to a lower extent. The most frequently used assessment was the ADL-taxonomy, a general instrument covering primarily personal, but to some extent instrumental, ADL [30]. A similar result was found in a Canadian study of the cognitive assessments used by OTs to assess older adults [41]. Douglas et al. [41] also found that assessments based on interviews and observations of daily activities were perceived as more useful and served a greater range of purposes than tests of cognitive function. A limitation with general ADL instruments is that their focus is not on cognition and this requires that the OT must rely on clinical reasoning skills to interpret how the cognitive impairment affects occupational performance. These skills have been shown to vary significantly depending on the OTs’ experience [42, 43] and this can influence results of the assessment. Another practice pattern identified in this study is the use of primarily general occupational therapy models to support practice, a pattern similar to that found by Koh et al. [11]. Furthermore, most OTs in this study reported insufficient theoretical knowledge in relation to the client group, along with a need for further education, and this might be connected to their choices of theoretical foundations and assessments. The use of models and assessments that do not focus on cognitive functioning demands much more from the OTs to detect cognitive impairments that affect occupational performance and to plan and perform effective interventions.
Brain Inj, 2014; 28(11): 1365–1373
A higher rate of use of cognition-specific models and assessments might raise the OTs’ feeling of competence and lead to even more effective therapies. In this study, the MMSE was found to be the most frequently used (40%) standardized test to screen cognitive function and the Montreal Cognitive Assessment (MoCa) was used by only 9% of the participants. This pattern is in line with other studies from Australia [11] and Canada [18, 41]. Douglas et al. [41] found that the MMSE was a test that was easy to access and administer and was often required by others such as physicians and was, therefore, a commonly used test. Similar reasons might explain the prevalence of the use of the test in Sweden, especially as the MMSE is regularly required in referrals for occupational therapy. However, the MMSE has been shown to have a ceiling effect in relation to the stroke population [44, 45] and the MoCA has been suggested as a better choice [44, 45]. There are reports of the use of the MoCA for clients with TBI [46, 47], but, to the authors’ knowledge, no comparative studies between the MMSE and MoCa have been performed in regards to the TBI population. Besides having better psychometric properties, the MoCA can also detect more cognitive impairments such as executive functioning and attention deficits [45] that are cognitive functions important to occupational performance. In this study, the therapies addressed executive functioning in occupational performance to a large extent, thus it is important to use assessments that correlate with these types of therapies. Like the MMSE, the MoCa is easy to get access to and to administer and, thus, the MoCa should be the primary choice in clinical practice and research. Approximately three-quarters of the OTs in this study preferred to use daily activities for therapies most of the time and these results are similar to previous survey studies [11, 18]. Performance of meaningful daily activities is important in the client’s adaptation to a new life with acquired brain injury and to gain experiences and feedback is important in their rehabilitation [48, 49]. Through occupational performance, the client can discover their own limitations and changes and find strategies to deal with them. The OT’s role is to enhance this process by giving feedback and information and to suggest strategies to manage different activities [48]. Feedback and providing the opportunity for ‘doing’ has been shown to be a key pro-active factor for client rehabilitation [49]. In this study both internal and external strategies were found to be used to a large extent in therapy as well as in feedback after each session. In relation to enhancing clients’ awareness of their disability, the uses of familiar daily activities to discover their limitations on their own were used by a majority of the OTs. According to Gustafsson et al. [50], OTs working with hospital-based stroke rehabilitation in Australia tend to try to remediate all of their clients’ limitations within each session, but the time allocated to each limitation is too short to be effective. The time allocated to cognitive impairments varied between 1–6 minutes per session depending on limitation addressed. In this study the OTs’ therapies covered a wide range of cognitive impairments and this may indicate a similar pattern in Sweden. To design therapies targeting specific cognitive impairments using ADL-activities is challenging and demands careful activity analysis and
Occupational therapist practice patterns
DOI: 10.3109/02699052.2014.919529
requires graded activities. An earlier study of OT therapies regarding attention, memory and orientation showed that there are differences in the use of graded activities, varying between 58–84%, due to cognitive impairment [17], and this variation might be explained by some cognitive functions being better suited for grading than others. In this study graded activities were used regularly by 69% of the participants, but the study provided no information about how the grading of activities might depend on differences in cognitive impairments. The complexity of using graded activities as means to remediate cognitive function is a challenge and requires deep understanding of how cognitive impairments affect occupational performance. More research in this area is needed to support effective occupational therapy practice. In this study almost all of the OTs provided information and support to the relatives of their clients. To the authors’ knowledge, collaboration with relatives has not been described in earlier surveys regarding OTs practice patterns for clients with CIABI. However, the involvement of relatives in rehabilitation is supported by findings in studies from relatives’ perspective. These studies have shown that there is strong evidence that the support of, and involvement of, relatives contribute to a feeling of competence, security and quality-of-life among both relatives and clients [51–54]. Methodological considerations A representative sample is important for the validity of a study and in this study a stratified random sample was selected to enhance representativeness [21]. To use the FSA member register as the source of participants in this study had both advantages and limitations. The advantage was the easy access to the majority of OTs working in Sweden, but the inability to specify the client group that each OT worked with was a limitation. A relatively large number of OTs that were asked to participate probably did not work with clients with CIABI. The invitation letter informed potential participants about these requirements and if the OTs did not work with the client group they were asked to answer the demographic items only. Fifty-seven OTs responded to these items only. Only one OT questioned the selection process in the comments field. The lack of control over drop-outs is a limitation of this study, but the response rate of 41% is 7% higher that the mean response rate for web surveys in general [22]. The questionnaire was used for the first time after significant effort in development and psychometric testing and appears to have worked well for the intended purpose. A few suggestions for changes were given in the comments field in the questionnaire, such as adding response alternatives on one demographic item and adding a ‘don’t know’ or ‘not applicable’ response alternative on another item. This study provides a Swedish perspective to the practice patterns of OTs working with clients with CIABI. The findings of this study were similar to those of earlier surveys of OTs in Australia [11] and Canada [17, 18] in terms of the extensive use of ADL-activities and internal and external strategies of therapy. Both of these strategies are in line with current best evidence [6, 55]. Similar patterns with earlier studies were also found regarding the use of general occupational therapy models and the use of the MMSE for
1371
client assessment. From an evidence-based perspective, the use of the MMSE is questionable and the MoCa is suggested as a better alternative [44, 45]. This study also added some further knowledge specific to the practice patterns of Swedish OTs. The high level of use of a general ADL-instrument can be seen as a weakness and highlights the need for easily accessible, easily administered and time-effective [41] observational instruments for clients with CIABI. Therapies addressed executive functioning to a high extent, which makes development of and use of assessments addressing this area crucial. The practice of involving relatives is in line with best evidence [53, 54]. The use of occupational performance in combination with feedback to enhance clients’ awareness of their disability contributes to the knowledge base of the OTs’ practice patterns for clients with CIABI. This study has contributed knowledge on what components are included in occupational therapy for clients with CIABI and to what extent they are used. However, much is still to be investigated. The components directly addressing performance of ADL activities need further investigation as they hide explanations for positive outcome of occupational therapy. In that respect studies of optimal ways of grading activities as well as the effects of strategies used in ADL are important. Another area for further research is how remedial and compensatory directed therapies should be integrated effectively.
Acknowledgement The authors thank the participating OTs who made this study possible.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. This ¨ rebro University and the Swedish study was supported by O Association of Occupational Therapists.
References 1. Fish J, Manly T, Emslie H, Evans J, Wilson BA. Compensatory strategies for acquired disorders of memory and planning: Differential effect of a paging system for patients with brain injury of traumatic versus cerebrovascular aetiology. Journal of Neurology, Neurosurgery and Psychiatry 2008;79:930–935. 2. Claesson L, Linden T, Skoog I, Blomstrand C. Cognitive impairment after stroke - impact on activities of daily living and costs of care for elderly people. The Goteborg 70+ Stroke Study. Cerebrovascular Diseases 2005;19:102–109. 3. Eriksson G, Tham K, Borg J. Occupational gaps in every day life 1-4 years after acquired brain injury. Journal of Rehabilitation Medicine 2006;38:159–165. 4. Johansson U, Bernspa˚ng B. Predicting return to work after brain injury using occupational therapy assessments. Disability and Rehabilitation 2001;23:474–480. 5. Wolf T. Rehabilitation, disability, and participation research: Are occupational therapy researchers adressing cognitive rehabilitation after stroke? American Journal of Occupational Therapy 2011;65: e46–e59. 6. Legg L, Drummond A, Langhorne P. Occupational therapy for patients with problems in activities of daily living after stroke (Review). Cochrane Database Systematic Review 2006;18:1–46. 7. Stringer A. Cognitive rehabilitation practice patterns: A survey of american hospital association rehabilitation programs. Clinical Neuropsychologist 2003;17:34–44.
1372
K. Holmqvist et al.
8. DeJong G, Horn S, Conroy B, Nichols D, Healton E. Opening the Black Box of poststroke rehabilitation: Stroke rehabilitation, patients, processes and outcomes. Archives of Physical Medicin and Rehabilitation 2005;86:S1–7. 9. Spencer K, Turkett A, Vaughan R, Koening S. School-based practice patterns: A survey of Occupational Therapists in Colorado. American Journal of Occupational Therapy 2006;60:81–91. 10. Weintraub N, Kovshi M. Changing practice patterns of schoolbased occupational therapists in Israel. Occupational Therapy International 2004;11:40–51. 11. Koh C-H, Hoffmann T, Bennett S, McKenna K. Management of patients with cognitive impairments after stroke: A survey of Australian occupational therapists. Australian Occupational Therapy Journal 2009;56:324–331. 12. Watling R, Deitz J, Kanny E, McLaughlin J. Current practice of occupational therapy for children with autism. American Journal of Occupational Therapy 1999;53:498–505. 13. Holmqvist K, Kamwendo K, Ivarsson A. Occupational therapists’ descriptions of their work with persons suffering from cognitive impairment following aqcuired brain injury. Scandinavian Journal of Occupational Therapy 2009;16:13–24. 14. Punwar A, Peloquin S. Occupational therapy principles and practice. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2000. 15. Abreu B, Peloquin S. The Quadraphonic Approach: A holistic rehabilitation model for brain injury. In: Katz N, editor. Cognition and occupation across the Life Span, models for interventions in occupational therapy. 2nd ed. Bethesda, MD: The American Occupational Therapy Association, Inc.; 2005. p 73–112. 16. Holmqvist K, Holmefur M, Ivarsson A. Therapeutic use of self as defined by Swedish occupational therapists working with clients with cognitive impairments following acquired brain injury: A Delphi study. Australian Occupational Therapy Journal 2013;60: 48–55. 17. Blundon G, Smits E. Cognitive rehabilitation: A pilot survey of therapeutic modalities used by Canadian occupational therapists with survivors of traumatic brain injury. Canadian Journal of Occupational therapy 2000;67:184–196. 18. Korner-Bitensky N, Barrett-Bernstein S, Bibas G, Poulin V. National survey of Canadian occupational therapists’ assessment and treatment of cognitive impairment post-stroke. Australian Occupational Therapy Journal 2011;58:241–250. 19. Swedish Association of Occupational therapists. Occupational therapy in Sweden and our member association. In; 2011. p 8. 20. National Statistical Service. Sample Size Caculator. Belconnen: Australian Bureau of Statistics; Swedish Association of Occupational Therapists. Stockholm; 2012. Available online at: http://www.nss.gov.au/nss/home.nsf/NSS/0A4A642C712719DCCA 2571AB00243DC6?opendocument, accessed 15 August 2011. 21. Altman D. Practical statistics for medical research. London: Chapman and Hall; 1991. 22. Shih T-H, Fan X. Comparing response rates from web and mail surveys: A meta-analysis. Field Methods 2008;20:249–271. 23. Hanson C, Shectman O, Jackson Foss J, Krauss-Hooker A. Occupational therapy: Current practice and training issues in treatment of cognitve function. NeuroRehabilitation 1997;8:31–41. 24. Word Medical Association. WMA Declaration of Helsinki - Ethical principles for medical research involving human subjects. FerneyVoltaire (France); 2008. Available online at: http://www.wma.net/ en/30publications/10policies/b3/index.html, accessed 18 february 2011. 25. Swedish Research Council. CODEX regler och riktlinjer fo¨r forskning. Uppsala: Centre for Research and Bioethics (CBR) Uppsala University; 2000. Available online at: http://www. codex.vr.se/index.shtml, accessed 18 May 2011. 26. Polit D, Beck C, Owen S. Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Research in Nursing and Health 2007;30:459–467. 27. Svensson E. Analysis of systematic and random differences between paired ordinal categorical data. Stockholm: Almquist & Wiksell; 1993. 28. Holmqvist K, Kamwendo K, Ivarsson A. Occupational therapists’ practice patterns for clients with cognitive impairment following acquired brain injury. Development of a Questionnaire. Scandinavian Journal of Occupational Therapy 2012;19:150–163.
Brain Inj, 2014; 28(11): 1365–1373
29. Texttalk. Websurvey by Texttalk: Websurveys, questionnaires, data collection and follow-ups. Gothenburg: Texttalk; 2014. Available online at: http://websurvey.texttalk.se/en/index.php, accessed 7 March 2014. 30. To¨rnquist K. Att faststa¨lla och ma¨ta fo¨rma˚ga till dagliga livets aktiviteter (ADL): En kritisk granskning av ADL-instrument och arbetsterapipraxis [Veryfying and measuring the ability to perform activities of daily living (ADL): A critical examination of ADLinstruments and the practice of occupational therapy]. Go¨teborg: Go¨teborgs universitet; 1995. 31. Sonn U, To¨rnquist K, Svensson E. The ADL-taxonomy - from idividual categorical data to ordinal categorical data. Scandinavian Journal of Occupational Therapy 1999;6:11–20. 32. Folstein M, Folstein S, McHugh P. ‘Mini-Mental-State’: A practical method for grading cognitive state of patients for the clinicians. Journal of Psychiatric Research 1975;12:189–198. 33. Kielhofner G. A model of human occupation: Theory and application. 3rd ed. Baltimore, MD: Lippincott, Williams & Wilkins; 2002. 34. Townsend E. Enabling occupation: An occupational therapy perspective. Ottawa: Canadian Association of Occupational Therapists; 1997. 35. Luria A. The working Brain. An introduction to neuropsychology. New York: Basic Books; 1973. 36. Toglia J. A dynamic interactional approach to cognitive rehabilitation. In: Katz N, editor. Cognition and occupation across the Life Span, models for intervention in occupational therapy. 2nd ed. Bethesda, MD: The American Occupational Therapy Association, Inc.; 2005. p 29–72. 37. Fisher AG. Occupational Therapy Intervention Process Model: A model for planning and implementing top-down, client-centered, and occupation-based interventions. Fort Collins, CO: Three Star Press; 2009. 38. Bundy A, Lane S, Murray E. Sensory integration: Theory and practice. 2nd ed. Philadelphia, PA: F.A. Davis; 2002. 39. Antonovsky A. The salutogenic model as a theory to guide health promotion. Health Promotion International 1996;11:11–17. 40. Vining Radomski M, Trombly Latham C. Occupational therapy for physical dysfunction. 6th ed. Philadelphi, PA: Wolters Kluwer Lippincott Williams & Wilkins; 2008. 41. Douglas A, Liu L, Warren S, Hopper T. Cognitive assessments for older adults: Which ones are used by Canadian therapists and why. Canadian Journal of Occupational therapy 2007;74: 370–381. 42. Paterson M, Higgs J, Wilcox S. Developing expertise in judgement artistry in occupational therapy practice. British Journal of Occupational Therapy 2006;69:115–123. 43. Reich S, Eastwood C, Tilling K, Hopper A. Clinical decision making, risk and occupational therapy. Health & Social Care in the Community 1998;6:47–54. 44. Toglia J, Fitzgerald KA, O’Dell M, Mastrogiovanni A, Lin D. The Mini-Mental State Examination and Montreal Cognitive Assessment in persons with mild subacute Stroke: Relationship to functional outcome. Archives of Physical Medicin and Rehabilitation 2011;92:792–798. 45. Pendlebury S, Cuthbertson F, Welch S, Metha Z, Rothwell P. Underestimation of cognitive impairment by Mini-Mental State examination versus the Montreal Cognitive Assessemnt in patients with Transient Ischemic Attack and Stroke: A population-based study. Stroke 2010;41:1290–1239. 46. Ruff R, Ruff S, Wang X-F. Headaches among operation Iraqi Freedom/Operation Enduring Freedom veterans with mild traumatic brain injury associated with exposures to explosions. Journal of Rehabilitation Research and Development 2008;45:941–952. 47. Ruff R, Ruff S, Wang X-F. Improving sleep: Initial headache treatment in OIF/OEF veterans with blast-induced mild traumatic brain injury. Journal of Rehabilitation Research and Development 2009;46:1071–1084. 48. Hoogerdijk B, Runge U, Haugboelle J. The adaptation process after traumatic brain injury. An individual and ongoing occupational struggle to gain a new identity. Scandinavian Journal of Occupational Therapy 2011;18:122–132. 49. Ekstam L, Tham K, Borell L. Couples’ approaches to change in everyday life during the first year after stroke. Scandinavian Journal of Occupational Therapy 2011;18:49–58.
DOI: 10.3109/02699052.2014.919529
50. Gustafsson L, Nugent N, Biros L. Occupational therapy practice in hospital-based stroke rehabilitation? Scandinavian Journal of Occupational Therapy 2012;19:132–139. 51. Socialstyrelsen. Nationella riktlinjer fo¨r Strokesjukva˚rd 2009 - sto¨d fo¨r styrning och ledning. Stockholm: Socialstyrelsen; 2009. 52. Lefebvre H, Pelchat D, Swaine B, Ge´linas I, Levert M. The experiences of individuals with traumatic brain injury, families, physicians and health professionals regarding care provided throughout the continuum. Brain Injury 2005;19:585–597. 53. Kalra L, Evans A, Perez I, Melbourn A, Patel A, Knapp M, Donaldson N. Training carers of stroke patients: A randomised controlled trail. British Medical Journal 2004;328:1099.
Occupational therapist practice patterns
1373
54. Bakas T, Austin J, Okonkwo K, Lewis R, Chadwick L. Needs, concerns, strategies, and advice of stroke caregivers the first six months after discharge. The Journal of Neuroscience Nursing 2002; 34:242–251. 55. Cicerone K, Dahlberg C, Malec J, Langenbahn D, Felicetti T, Kneipp S, Ellmo W, Kalmar K, Giacino J, Harley P, et al. Evidencebased cognitive rehabilitation: Updated review of the literature from 1998 through 2002. Archives of Physical Medicine and Rehabilitation 2005;86:1681–1692.
Copyright of Brain Injury is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
