Background: Cognitive impairment is a common and debilitating consequence of stroke. In the multidisciplinary rehabilitation team, occupational therapists play an important role in improving the daily functioning of people who have had a stroke. However, the effectiveness of interventions used by occupational therapists for cognitive impairment post-stroke has not been systematically reviewed. The current practice patterns, including the theoretical approaches, assessments, and interventions used, of Australian occupational therapists who work in this area are not known and the congruence between clinical practice and research evidence has not been studied.
Objectives: This study aimed to (1) identify the best available research evidence for the effectiveness of interventions used by occupational therapists for cognitive impairment post-stroke;
(2) survey current Australian occupational therapy practice with clients who have cognitive impairment after stroke; and (3) examine the congruence between research evidence and clinical practice in this area.
Method: The study conducted a systematic review following the Cochrane Collaboration Methodology to identify research evidence and a survey to investigate current practice. To locate articles that met the inclusion criteria of the systematic review, electronic databases were searched, 11 of the major occupational therapy journals were hand-searched and reference lists of related articles were examined. Two independent reviewers separately evaluated the methodological quality of included trials. The primary outcome of interest in this review was basic activities of daily living functioning. The secondary outcomes were instrumental activities of daily living functioning, community integration, and specific cognitive functions.
A self-administered, purpose-designed online survey was used to investigate current Australian occupational therapists’ practice with people who have cognitive impairment after stroke. The survey covered five subsections: participants’ demographic characteristics; theoretical approaches used; assessments used; interventions used; and research utilisation.
Results: Six randomised controlled trials met the inclusion criteria of the systematic review. Two of the four studies which assessed functional outcomes after intervention for cognitive impairment found a treatment effect in favour of the intervention group. The intensive combination of remedial and compensatory interventions used in one study and a predominantly compensatory intervention used in the other produced a significant improvement in participants’ general cognitive function and basic activities of daily living. The results of the other two studies which assessed functional outcomes but contained fewer intervention sessions and used remedial interventions only showed no difference between experimental and control groups. Three studies examined the effect of remedial interventions on specific domains of cognitive function, including attention and memory. Each study used several outcome measures to evaluate participants’ cognitive function and the results were varied in each study; some outcome measures showed treatment effects in favour of the experimental group, while the others showed no significant results. Due to the diverse study characteristics and results, the effectiveness of interventions used by occupational therapists for cognitive impairment remains inconclusive.
A total of 102 responses were obtained for the survey. A client-centred approach was used by participants more often than other theoretical approaches when treating people with cognitive impairment post-stroke. The Mini-Mental State Examination and the Lowenstein Occupational Therapy Cognitive Assessment were the most frequently used cognitive screening test and cognitive assessment battery, respectively. Interventions involving functional activities were used more frequently than compensatory techniques or remedial exercises. Participants relied more on colleagues’ opinions and past experience than on research literature when making intervention decisions.
The congruency between the results of the systematic review and the survey were discussed in terms of theoretical approaches, assessments, and interventions used. While a large proportion of
survey participants frequently used a client-centred approach, no research evidence was found to support the effectiveness of this approach. Some assessments were consistently used in both research and clinical settings, for example, the Mini-Mental State Examination and Barthel Index. This consistency facilitates the transferability of research results to the clinical setting and enables comparisons to be made between research studies which use the same outcome measures. For the interventions that were found to be effective, some survey participants reported using similar interventions in their practice, such as paper and pencil exercises or functional tasks. However, the interventions used by survey participants were not identical to those used in research, differing in terms of both content and dose.
Overall conclusions: In this thesis, gaps were found in the available research evidence, as well as between the available evidence and clinical practice. Suggestions for overcoming these gaps were discussed.