Nicol Korner-Bitensky PhD; Associate Professor. Sheila Barrett-Bernstein MSc; Occupational Therapist. Gabrielle Bibas MSc; Occupational Therapist. Valérie Poulin MSc; Occupational Therapist.
National survey of Canadian occupational therapists’ assessment and treatment of cognitive impairment post-stroke
Version of Record online: 3 JUN 2011
© 2011 The Authors. Australian Occupational Therapy Journal © 2011 Occupational Therapy Australia
Australian Occupational Therapy Journal
Volume 58, Issue 4, pages 241–250, August 2011
How to Cite
Korner-Bitensky, N., Barrett-Bernstein, S., Bibas, G. and Poulin, V. (2011), National survey of Canadian occupational therapists’ assessment and treatment of cognitive impairment post-stroke. Australian Occupational Therapy Journal, 58: 241–250. doi: 10.1111/j.1440-1630.2011.00943.x
- Issue online: 20 JUL 2011
- Version of Record online: 3 JUN 2011
- Accepted for publication 29 March 2011.
- best practice;
Aim: This study examined variations in management of cognitive impairment post-stroke among occupational therapists and factors associated with variations in practice.
Methods: Canada-wide cross-sectional telephone survey. Clinicians’ practices were examined using standard patient cases (vignettes).
Setting: Acute care, inpatient rehabilitation and community-based sites providing stroke rehabilitation in all Canadian provinces.
Participants: Occupational therapists (n = 663) working in stroke rehabilitation as identified through provincial licensing bodies.
Main outcome measures: Type and frequency of cognition-related problem identification, assessment and intervention use.
Results: Respectively, 69%, 83% and 31% of occupational therapists responding to the acute care, inpatient rehabilitation and community-based vignettes recognised cognition as a potential problem. Standardised assessment use was prevalent: 70% working in acute care, 77% in inpatient rehabilitation and 58% in community-based settings indicated using standardised assessments: 81%, 83% and 50%, respectively, indicated using general cognitive interventions.
Conclusion: The Mini-Mental State Examination was often used incorrectly to monitor patient change. Executive function, a critical component of post-stroke assessment, was rarely addressed. Interventions were most often general (e.g. incorporated in activities of daily living) rather than specific (e.g. cueing, memory aids, computer-based retraining).
Fifteen million people each year experience a stroke (Mackay & Mensah, 2004) and it is estimated that of these, 3–9 million will experience post-stroke cognitive impairments (Hachinski et al., 2006; Patel, Coshall, Rudd & Wolfe, 2002; Rasquin, Verhey, van Oostenbrugge, Lousberg & Lodder, 2004; Tatemichi et al., 1994). These cognitive impairments are associated with increased hospital stay (Galski, Bruno, Zorowitz & Walker, 1993), dependence (Galski et al.; Patel et al.; Tatemichi et al.), functional impairment (Tatemichi et al.) and death (Patel et al.). It is crucial that rehabilitation professionals, especially occupational therapists who are responsible for determining readiness for community reintegration, be astute at recognising, assessing and treating post-stroke cognitive deficits.
Cognition includes acquiring, processing and using information (Duchek, 1991; Toglia, Golisz & Goverover, 2009). It consists of inter-related processes that produce thought and goal-directed behaviour (Vining Radomski, 2002). Primary cognitive capacities include orientation, attention and memory that together form the pre-requisites for executive functioning such as reasoning, concept formation and problem solving.
In the past decade, numerous practice guidelines related to cognitive impairment post-stroke have emerged (Bates et al., 2005; Cicerone et al., 2000; Duncan et al., 2005; Intercollegiate Stroke Working Party, 2004; Lindsay et al., 2010). Overall, most indicate the need for screening of the patient upon hospital admission using a standardised tool. Most also indicate that a patient with potential deficits should be examined using cognitive assessments that are re-administered periodically (Intercollegiate Stroke Working Party) and that, when necessary, cognitive rehabilitation be initiated.
Many standardised screening instruments exist (for a review see Blake, McKinney, Treece, Lee & Lincoln, 2002), including the Mini-Mental State Examination (MMSE) (Folstein, Folstein & McHugh, 1975) and Montreal Cognitive Assessment (MoCA) (Nasreddine et al., 2005). There are also comprehensive assessments such as the Cognitive Competency Test (CCT) (Tupper & Cicerone, 1990) and those that focus on executive function such as the Executive Interview (EXIT-25) by Royall, Mahurin and Gray (1992). There are also function assessments that include a cognitive subscale or a series of questions such as that found within the Functional Independence Measure (FIM) (Granger, Hamilton, Keith, Zielezny & Sherwins, 1986). Finally, assessments such as the Kitchen Task Assessment (Baum & Edwards, 1993) allow assessment through observation of function. This form of assessment is often referred to as a top-down approach (Vining Radomski, 2002) rather than a bottom-up approach where the impairment is measured.
With respect to cognitive rehabilitation, interventions can focus on improving specific cognitive constructs (Salter, Teasell, Bitensky, Foley & Bhogal, 2009) or can be functionally based to improve performance (Brain Injury Association of America, 2007). The goal is to either restore lost function or to provide the patient with strategies to compensate for deficits.
A structured literature review conducted to identify studies on how post-stroke cognitive issues are managed using CINAHL, PsychINFO and OTSeeker revealed three that touch on clinician practices (Douglas, Liu, Warren & Hopper, 2007; Edwards et al., 2006; Koh, 2008). All examined assessment use, with one also examining intervention use (Koh). Two specifically focussed on occupational therapists (Douglas et al.; Koh); two addressed stroke specifically (Edwards et al., 2006; Koh). In the study by Edwards et al., the cognitive impairments identified using standardised assessments were compared with cognitive impairments recorded in the medical chart. Fifty of 53 patients studied had a sensory or cognitive impairment identified through formal assessment that was not noted in the chart suggesting that, without standardised assessment, important impairments go unnoticed. In the published thesis by Koh, 102 Australian occupational therapists were surveyed regarding their assessment and intervention practices for clients with cognitive deficits post-stroke. The most frequently used screening tool was the MMSE, used by 68% of clinicians. The most commonly mentioned comprehensive assessment, mentioned by 45%, was the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) (Itzkovich, Elazar, Averbuch & Katz, 2000). Twenty-two per cent of respondents stated that they did not use any standardised assessments. The two most frequently used interventions were basic activities of daily living (ADL) training (88.5%) and instrumental ADL training (83.9%). Finally, in the Canadian survey (Douglas et al.), 247 occupational therapists were questioned regarding cognitive assessment use with older adults: 75 different assessment processes were mentioned.
While the three studies reveal some aspects of cognitive assessment and intervention, they also leave many unanswered questions regarding the consistency of practices for a given patient post-stroke and the management of cognitive impairment across the continuum of care. Thus, the overall purpose of this study was to explore occupational therapists’ practices and variation in practice as related to the management of cognitive impairment following stroke at various stages of rehabilitation. The specific objectives were to identify occupational therapists’ management of post-stroke cognition, including: (i) ability to detect impairments; (ii) assessment use and timing of use; (iii) intervention use; and (iv) desired use of assessments and interventions. In addition, the relationship between clinician practices related to cognition (problem detection, assessment use and intervention use) and personal and institutional variables was also examined.
Beginning in 2005, a Canada-wide cross-sectional survey was conducted to examine stroke rehabilitation practices of 1755 clinicians working with patients in acute care, inpatient rehabilitation and community-based services. Prompted by a vignette describing a typical patient that matched the clinician’s work setting (acute, inpatient rehabilitation, community-based), clinicians were asked to identify problems and indicate assessments and interventions they would use for this patient in both actual and ideal clinical practice. This article focuses on the management of cognitive impairments by 663 occupational therapists providing stroke rehabilitation services. Research ethics approval was granted by McGill University, Montreal, Canada.
Sample size considerations
Sample size was based on the calculation for a single proportion (prevalence) using an assumption that at least 20% of clinicians would use standardised cognitive assessments. With a confidence interval of 95% and a margin of error set at 5%, approximately 246 clinicians per vignette were required to allow stable estimates of prevalence.
Clinicians were identified from lists provided by the provincial licensing agencies and the Canadian Association of Occupational Therapists. In Canada, a clinician must be registered to work as an occupational therapist and as such, these are representative lists. Inclusion criteria were: working with an adult stroke clientele for at least three months; treating at least two patients with stroke per month; and being present in the work setting for six months in the past year.
Development of the case vignette
Using focus group methodology, three vignettes representing typical patients with stroke, each in a different phase of recovery – acute care, inpatient rehabilitation or community-based – were developed by three different groups of expert clinicians and researchers. The focus group members were asked to describe the impairments, activity limitations and participation restrictions of the client.
Clinical vignettes have been shown to be a valid form of treatment discernment (Jones, Gerrity & Earp, 1990). Vignettes allow for the exploration of variations in clinicians’ practices while using concrete and standardised stimulus that enables approximation of a real-life decision-making response.
Questionnaire development and content
The telephone interview questionnaire was designed in accordance with Dillman’s guidelines (Dillman, 2000). It was reviewed for face validity and pre-tested on a convenience sample of five clinicians. The first portion consisted of questions regarding the work environment as well as the socio-demographics of the clinician (see Table 1). Next, open-ended questions concerning problem identification and typical use of assessments and interventions for the patient depicted in the vignette were posed (i.e. ‘State each problem you identified based on the information in the vignette’ and ‘Indicate the assessments you would typically use for the client and when you would use each’). Clinicians were also asked to specify their desired use of assessments and interventions in an ‘ideal’ world that the clinician may have wanted to use if the resources, necessary training or time were not a constraint.
|Cognition problem identifier||Standardised specific cognitive assessment user||Cognition intervention user|
|n = 407||n = 256||n = 418||n = 245||n = 471||n = 192|
|Mean age ± SD (year) (three missing)||36.1 (8.7)*||38.1 (9.5)||36.3 (8.6)*||37.7 (9.6)||36.3 (8.7)*||38.1 (9.6)|
|Mean time spent on continuing education ± SD (hours/month) (two missing)||5.5 (6.8)||5.9 (8.2)||5.8 (7.0)||5.5 (7.9)||5.3 (5.0)||6.6 (11.1)|
|Diploma (n = 34)||4.2||6.6||3.8||7.3||3.6*||8.9|
|Bachelor’s (n = 601)||90.7||90.6||91.9||88.6||91.5||88.5|
|Master’s (n = 28)||5.2||2.7||4.3||4.1||4.9||2.6|
|Work Schedule (%)|
|Full-time (n = 479)||76.9*||64.8||73.7||69.8||74.9*||65.6|
|Experience with stroke clientele (%) (three missing)|
|< 1 year (n = 31)||3.7*||6.3||5.0*||4.1||5.1||3.7|
|1–3 years (n = 151)||25.2||19.2||23.3||22.1||24.3||19.4|
|4–10 years (n = 218)||35.3||29.4||36.1||27.9||32.2||35.1|
|> 10 years (n = 260)||35.8||45.1||35.6||45.9||38.4||41.9|
|Specialty certification (%)|
|Yes (n = 186)||31.4*||22.7||31.1*||22.9||28.7||26.6|
|Teaching institution (%) (one missing)|
|Yes (n = 424)||66.3||60.4||66.3||60.2||67.4*||55.7|
|Presence of stroke team/unit (%)|
|Yes (n = 184)||34.2||17.6||30.4*||23.3||32.9*||15.1|
|Research conducted in setting (%) (one missing)|
|Yes (n = 168)||29.0*||19.6||28.0*||20.9||27.2*||20.8|
|Student placements (%) (two missing)|
|Yes (n = 612)||94.8*||89.0||94.7*||88.9||94.0*||89.1|
Trained interviewers traced potential participants and conducted the telephone interviews. The vignette corresponding to the clinician’s working environment was faxed 24–48 hours before the 25-minute telephone interview. Participants were asked to avoid discussing the vignette with colleagues. Throughout the interview, the interviewer used a standard script when asking questions and responding to queries.
Two research assistants coded clinicians’ open-ended responses. Three authors reviewed the codes for accuracy and consistency. Next, clinicians’ responses were grouped to classify practice behaviours. To elucidate, a clinician was considered a ‘cognition problem identifier’ if s/he used one or more terms indicated in Table 2, according to descriptors found in the International Classification of Functioning, Disability and Health (ICF) sections on attention, memory and higher level cognitive functions (World Health Organization, 2001).
|Problem||Acute care||Inpatient rehabilitation||Community-based|
|n = 183||n = 253||n = 227|
|Cognitive problem identifier||68.9||83.0||31.3|
A clinician was considered a ‘cognitive assessment user’ if s/he reported the use, at any point in time (admission, interim, discharge or follow-up) of a cognition-related assessment either of a standardised or non-standardised nature and was dedicated in its entirety or partially to the measurement of cognition. A series of classifications were subsequently created to categorise assessment use in a more detailed manner. Specifically, a clinician was considered a ‘standardized assessment user’ when using assessments that are known to be scored and administered under uniform conditions and have known reliability and validity. Under this classification, further delineation was made to identify a clinician as a ‘specific cognitive assessment user’ if s/he indicated using tool(s) that in their entirety are designed to measure constructs related to cognition or, a ‘general assessment with cognitive component user’ to identify those who used tool(s) where at least one component is designed to measure cognition (e.g. the FIM). Finally, a ‘best practice cognitive assessment user’ was defined as a clinician who used a standardised, cognition-specific assessment tool(s) at admission and again to monitor cognitive status at another point in time.
A clinician was identified as a ‘cognitive intervention user’ if s/he indicated the use of any intervention that has been described in the scientific literature for the specific treatment of cognitive impairments. This included a very broad category of interventions including those that focussed on ADL or instrumental ADL, based on the principle that during these activities, a clinician typically works not only on the physical functions needed to perform the task but also on cognitive functions (see Table 4). Further delineation was made to identify a clinician as a ‘specific cognitive intervention user’ if s/he used a term that was related specifically to constructs of cognition.
|Intervention||Acute care||Inpatient rehabilitation||Community-based|
|n = 183||n = 253||n = 227|
|Cognitive therapy for memory deficits||1.1||1.2||0|
|Cognitive therapy for attention||0.5||2.8||2.2|
|Cognitive therapy for behaviour||1.1||0.8||0.4|
|Kitchen skills (cooking)||13.1||15.4||2.2|
|Activities of daily living (ADL)||70.5||64.4||36.1|
|Instrumental activities of daily living (IADL)||4.9||9.9||5.7|
|Stop and start cueing||0||0||0|
|Cognition intervention user†||81.4||82.6||49.8|
|Specific cognitive intervention user‡||32.8||45.1||22.0|
Descriptive statistics were used to indicate the prevalence of cognitive-problem identification, prevalence of the various classifications of assessment user and interventions specific to cognition. Additionally, the prevalence of desired use of assessments and interventions was calculated. To study the contribution of potential explanatory variables for three dichotomous outcomes, ‘cognition problem identifier’ (yes/no), ‘standardized specific cognitive assessment user’ (yes/no) or ‘cognition intervention user’ (yes/no), univariate analyses were performed on the clinician and institutional factors (see Table 1). Chi-square analyses were used for categorical variables and analysis of variance for continuous variables. As numerous comparisons were performed, the threshold for significance was set at 0.01 using a Bonferroni correction.
Of the 1072 occupational therapists contacted, 290 were ineligible, 71 untraceable and 48 (7%) refused, with the remaining 663 participating. Of these, 183 answered the acute care vignette, 253 the inpatient rehabilitation vignette and 227 the community-based vignette. The average age was 36.8 years (± 9.02) and 92% were female. The majority held a bachelor’s degree. Table 1 shows clinician and environmental factors and their univariate associations with being a cognitive problem identifier (yes/no), a specific cognitive assessment user (yes/no) and intervention user (yes/no).
Cognition-specific problem identification was variable: 68.9% (126/183) in clinicians reporting on their management of the acute care case, 83% (210/253) for the inpatient rehabilitation case and 31.3% (71/227) for the community-based case (Table 2).
Clinicians indicated using 56 different assessments. Table 3 describes, according to vignette, the prevalence and timing of these (initial, interim, discharge or follow-up) when reported by more than 5% of clinicians. The majority of clinicians mentioned using standardised specific cognitive assessments. In addition, many also used non-standardised assessments (Table 3).
|Type of assessment||Timing of assessment|
|Acute care||Inpatient rehabilitation||Community-based|
|n = 183||n = 253||n = 227|
|Initial %||Interim %||Discharge %||Anytime†%||Initial %||Interim %||Discharge %||Anytime†%||Initial %||Interim %||Discharge %||Anytime†%|
|Specific cognition-related assessment||–||–||–||–||–||–||–||–||–||–||–||–|
|Mini-Mental State Examination (MMSE)||30.6||13.7||8.7||36.1||26.5||10.3||9.9||28.1||18.5||7.5||4.8||21.1|
|Neurobehavioural cognitive status examination (Cognistat)||10.9||8.7||4.9||16.4||15.8||7.1||6.3||19.4||10.1||7.5||3.1||16.3|
|Cognitive Competency Test (CCT)||10.9||16.4||8.2||23.5||12.6||14.2||10.3||25.3||10.1||12.3||4.4||18.9|
|Protocole d’Examen Cognitif de la Personne Âgée/ Cognitive Assessment for the Elderly (PECPA/CASE)||8.7||4.9||4.9||10.4||12.3||4.7||7.5||14.2||2.2||1.8||1.3||2.2|
|Trail Making Test||1.6||1.6||1.1||3.3||4.3||4.0||4.7||7.1||5.3||3.5||2.6||7.0|
|General assessment with a cognitive component||–||–||–||–||–||–||–||–||–||–||–||–|
|Functional Independence Measure (FIM)||8.7||1.1||6.6||8.7||18.6||3.6||15.4||19.8||4.0||0.9||3.1||4.0|
|Assessment of Motor and Process Skills (AMPS)||2.7||2.7||2.2||4.4||6.7||6.3||7.5||9.1||4.4||3.1||3.1||6.2|
|Chessington OT Neurological Assessment Battery (COTNAB)||1.6||1.1||0.5||3.3||5.1||4.0||3.2||7.9||0.9||2.6||0.9||2.6|
|Activities of daily living (ADL)||50.8||37.7||32.8||61.7||55.3||45.5||40.3||60.9||37.0||23.3||18.1||43.6|
|Instrumental activities of daily living (IADL)||7.1||9.8||10.9||18.6||11.1||14.2||15.8||22.9||14.5||12.3||7.9||18.5|
|Standardised cognitive assessment user‡||55.7||39.9||31.7||69.9||71.1||43.5||47.8||77.1||44.9||31.3||21.1||57.7|
|Specific cognitive assessment user§||50.3||38.3||24.6||65.6||61.3||36.4||35.6||70.8||39.6||26.9||15.9||52.4|
|General assessment with a cognitive component user¶||5.5||1.6||7.1||4.4||9.9||7.1||12.3||6.3||5.3||4.4||5.3||5.3|
|Non-standardised cognitive assessment user††||63.4||47.0||42.6||74.9||68.4||57.7||50.6||76.3||51.1||36.1||23.8||59.0|
|Cognitive assessment user‡‡||89.1||66.7||60.7||96.7||89.7||75.5||72.3||92.9||80.2||58.1||37.9||89.4|
The frequency of administration of cognition-based assessments decreased after initial assessment: 32.8%, 44.3% and 24.2% of clinicians responding to the acute, inpatient rehabilitation and community-based vignettes respectively were deemed ‘best practice cognitive assessment users’, in that they reported using a standardised assessment at admission and then again during the course of stroke care.
When asked about assessment practices in an ideal world, 14.2%, 9.9% and 7% of clinicians responding to the acute, rehabilitation and community-based vignettes respectively named a cognition-specific standardised assessment tool they would ideally wish to use. The Assessment of Motor and Process Skills (AMPS) (Fisher, 1995) was the most frequently mentioned, and 10.4%, 8.3% and 6.6% of clinicians working in an acute, inpatient rehabilitation and community-based setting respectively wanted to implement its use. Only one clinician of 181 responding to the acute vignette and two clinicians of 254 responding to the rehabilitation vignette indicated the desire to evaluate executive function, by naming the Behavioural Assessment of Dysexecutive Syndrome (BADS) (Wilson, Alderman, Burgess, Emslie & Evans, 1996) and the Executive Interview (EXIT-25) (Royall et al., 1992).
Approximately 80% of occupational therapists working in acute care and inpatient rehabilitation and nearly 50% of occupational therapists working in the community indicated that they would use a cognitive intervention with the patient depicted in the vignette, using the broadest sense of the construct. The majority indicated a functionally based treatment designed to improve performance in ADL (see Table 4).
Of the clinicians working in acute, inpatient rehabilitation and community-based settings, 8.2%, 5.9% and 4% respectively indicated a desire to introduce a cognition-specific intervention for the patient depicted in the vignette.
Clinician and environmental factors
Younger clinicians were more likely to identify a cognitive problem and to mention the use of cognitive interventions (Table 1). Working in a research environment and the presence of a stroke unit were univariately associated with increased assessment and intervention use for the vignette representing the patient receiving inpatient rehabilitation.
The prevalence of problem detection relating to cognition was quite high in response to the acute care and inpatient rehabilitation vignettes, but much lower in the community-based vignette. This finding may be in part explained by the fact that the first two vignettes had clear cues relating to cognitive impairment. For example, the acute care vignette stated ‘P was found to be alert, oriented and awake to person and time, but not place’ while the inpatient rehabilitation vignette stated ‘J provides some accurate and basic information, but is easily distracted…’ In contrast, the cues in the community-based vignette were more subtle with statements such as ‘C wants to resume driving the family car ... C has difficulty expressing ideas and is often searching for words, making the conversation difficult.’ Another plausible explanation is that clinicians working in the community may be less inclined to focus on standardised assessment, either because it is a less common practice to use standardised tools in community practice, or, because of a belief that cognitive status is no longer changing once a patient is back in the community.
Encouragingly, a high percentage of clinicians used cognition-specific standardised tools. The majority also indicated the use of non-standardised tools. A wide range of assessment practices were evident and this finding was similar to the wide range used in the assessment of older adults (Douglas et al., 2007). Unfortunately, the use of numerous tools increases the complexity of communication within the discipline and with members of other disciplines. From a quality assurance perspective, the lack of commonality makes it difficult to identify the effectiveness of occupational therapy interventions (Canadian Association of Occupational Therapists, 2007) across settings and across the continuum of care. This diversity may be explained in part by the fact that none of the Canadian or American best practice guidelines available when this study began in 2005 recommended specific tools.
Of the numerous standardised tools used by clinicians, the MMSE was the most frequently mentioned. The Australian survey by Koh (2008) also found a high prevalence of use of the MMSE. This finding is encouraging given that it coincides with best practice guidelines that indicate the need for patients to be screened early on post-admission. However, guidelines also suggest that if the screening raises any concerns, the patient should have a thorough cognitive assessment, followed by periodic reassessment to monitor responsiveness to treatment or deterioration in cognitive status. In the present survey, few clinicians indicated that they would reassess cognitive functioning after baseline assessment. The low prevalence of repeat assessment is disconcerting. If clinicians are not reassessing patients, they may miss an opportunity to adjust intervention as the patient’s status changes (Salter et al., 2009). Another interesting finding was that of those who reported performing repeat assessments, many indicated they would use the MMSE. The MMSE is not appropriate to monitor cognitive changes post-stroke as it has been shown to have a ceiling effect, is not responsive to change and repeat administration impacts negatively on its validity (Folstein et al., 1975; for a review see http://www.strokengine-assess.ca). While there is no one gold standard for the assessment of post-stroke cognitive impairment, in 2008, the Canadian best practice guidelines suggested that the MoCA (Nasreddine et al., 2005; for a review see http://www.strokengine-assess.ca) is a better choice psychometrically as compared with the widely used MMSE.
Stroke often has impact on executive functioning (Hachinski et al., 2006). Surprisingly, tests of executive function such as the BADS (Wilson et al., 1996), the EXIT-25 (Royall et al., 1992) and the Frontal Assessment Battery (Dubois, Slachevsky, Litvan & Pillon, 2000) were rarely mentioned. This is an area of practice that needs to be improved upon, especially given the impact of impairments of executive function on resumption of community living. Clinicians need to make better use of the numerous assessments of executive function available, especially when evaluating individuals who wish to resume cognitively demanding tasks such as driving. Encouragingly, the 2010 Australian Clinical Guidelines for Stroke Management (National Stroke Foundation, 2010) specifically detail the assessment and intervention practices related to cognition as well as executive function, with a recommendation that executive functioning be formally assessed.
The prevalence of use of general cognitive interventions was high if one includes the cognitive training that is incorporated into practising ADL skills. This high prevalence of general training of cognition during ADL or instrumental ADL tasks was also seen in the Australian study (Koh, 2008). However, when the definition was refined to indicate cognition-specific interventions, the prevalence was low.
When referring to cognition-related interventions, respondents occasionally used terms like ‘memory’ and ‘orientation’ to describe their practices. While this reveals the cognitive constructs that clinicians are focusing on, it provides no indication of the therapeutic approaches used. Research on cognitive intervention effectiveness post-stroke has been sparse to date (see http://www.strokengine.ca for a structured review). This may, in part, explain why clinicians rarely indicated using specific interventions such as cueing, computer-remediation, memory aids, etc.
When desired practices in an ideal world were explored, few clinicians indicated a desire to use standardised assessments or to introduce new interventions specific to cognition. This finding suggests that gaps in best practice management such as the lack of use of standardised tools that measure executive function are not necessarily associated with a lack of time or resources.
This study’s findings suggest that there is room for improvement in occupational therapy assessment and intervention practices related to cognitive deficits post-stroke. That being said, there is a growing body of research suggesting that gaps in best practice are not easily closed (Davis et al., 2003). Encouragingly, a systematic review of knowledge translation strategies specific to rehabilitation clinicians did suggest, albeit with limited evidence, that multi-modal interventions (interactive lectures, web-based support and local champions) are more effective in inciting change in practice than uni-modal interventions. (Menon, Korner-Bitensky, Kastner, McKibbon & Straus, 2009). Tools such as the PERFECT (Professional Evaluation and Reflection on Change Tool) (Menon et al., 2010a) are also available to occupational therapists who would like to explore their current practices, changes in practices and the facilitators and barriers to both actual and desired changes.
As pointed out by Menon, Korner-Bitensky and Straus (2010b), for the first time in the history of rehabilitation we have extensive knowledge of best practices in stroke rehabilitation coupled with evidence on the effectiveness of knowledge translation strategies aimed at increasing these practises. This should enable a more rapid and successful movement of new knowledge into clinical practice.
An encouraging finding is that younger clinicians and those working on a stroke unit were more likely to introduce standardised assessments of cognition and interventions specific to cognition. There has been widespread emphasis internationally on training the new generation of occupational therapists to be critical consumers of research evidence. The finding that better patient management was seen in clinicians working on a stroke unit is also positive. There is strong evidence that patients who are treated on a stroke unit have better outcomes, as can be explained in part by better assessment practices and a greater likelihood of best practice intervention use (National Stroke Foundation, 2010).
Concern has been raised regarding the use of vignettes to elicit clinician practice behaviours. However, vignettes have been shown to be a valid means of determining actual practice because they provide a consistent case on which to base practice variations (Jones et al., 1990). Another potential concern in a survey of clinician practices is the potential bias resulting either from a failure to achieve a representative sample because of the sampling frame used or because of high refusal rates, potentially in those who differ greatly in their practice behaviours from participants. In Canada, clinicians are not permitted to work without being registered annually with their professional order or licensing body; therefore, the sampling frame used for recruiting clinicians represented all registered occupational therapists. By random sampling and by over-sampling in provinces with fewer clinicians, we were able to ascertain practices even in more rural or under-staffed regions. Furthermore, the exceptionally high participation rate of 93% suggests that our findings can be generalised with confidence to occupational therapists working in stroke rehabilitation in Canada. What is less clear is whether these results are applicable to clinicians working in other countries. It is likely that similar results would be found in countries where stroke rehabilitation is offered across a similar continuum of care and indeed, the study by Koh (2008) found similar patterns of post-stroke assessment use in Australian occupational therapists.
This study found that cognition-related problem identification, assessment use and intervention use were relatively high among occupational therapists working in stroke rehabilitation, but varied greatly from one clinician to another and dropped off substantially once the patient was receiving community-based rehabilitation. Executive function, a critical component of post-stroke assessment and intervention, was rarely addressed. Reassessment of patients was rare, raising concern that monitoring of change in cognitive status post-stroke is not usual practice. This study also found that interventions were most often general in nature and this may be due to the lack of randomised trials available to help guide clinical practice specific to cognition. Impairments in cognition impact severely on post-stroke recovery and thus the study of various interventions and their relative effectiveness warrants greater research attention. This knowledge will help maximise the effectiveness of occupational therapy clinical practice specific to cognition post-stroke.
We acknowledge the support of Dr Julie Lamoureux for statistical analysis, our large and dedicated team of interviewers and the clinicians who participated. We also acknowledge the investigators of this project for their collaboration: S. Wood-Dauphinee, R. Teasell, J. Hanley, J. Desrosiers, F. Malouin, A. Thomas, M. Harrison, F. Kaizer and E. Kehayia. Funding was provided by the Canadian Stroke Network. Additional funding was provided by the Réseau provincial de recherche en adaptation réadaptation (REPAR), Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain Montreal (CRIR) and to N. Korner-Bitensky through a senior career award from the Fond de la Recherche en Santé du Québec.
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