Efficacy Studies of Home-Based Occupational Therapy Services Following Stroke: A Scoping Review

Abstract The aim of this scoping review was to review and assess recent studies on the efficacy of home-based occupational therapy interventions for adults post-stroke. The number of efficacy studies is limited. The few studies available suggest that occupational therapy delivered in home settings may improve outcomes for stroke patients. There is also limited use of occupation-based assessments, interventions, and outcome measures in studies addressing home-based occupational therapy. Methodologies should be improved to include contexts, caregiver training, and self-efficacy. Further high-quality studies are needed on the efficacy home-based occupational therapy services.


Background
Stroke or cerebrovascular accident (CVA) is a leading cause of death and disability in the United States (Benjamin et al., 2017), with stroke-related costs averaging $46 billion annually (Centers for Disease Control & Prevention, 2020).As the older adult population continues to grow, the number of stroke survivors is expected to increase substantially.Stroke frequently results in motor, sensory, and cognitive impairments that negatively impact an individual's ability to engage in functional tasks and activities of daily living (ADLS) (Zhou et al., 2013).Occupational therapy is a key component of post-stroke rehabilitation.Occupational therapists work with stroke patients to address physical, psychosocial, and cognitive deficits and promote recovery through engagement in occupation to ultimately increase independence in all aspects of daily living (Nilsen & Geller, 2015).Research indicates that occupational therapy increases upper extremity functioning, improves cognitive performance, and leads to functional recovery and enhanced quality of life for CVA patients (Gillen et al., 2015;Hatem et al., 2016;Mutai et al., 2016;Steultjens et al., 2003).
Among stroke patients, occupational and physical therapy rehabilitation services are typically initiated in the hospital (Freburger et al., 2018a).After the hospital stay, stroke survivors may be discharged home, to an inpatient rehabilitation center, long-term acute care, skilled nursing facility, or to an outpatient setting (Nguyen et al., 2015).Of note, not all patients receive therapy services after hospital discharge, and research suggests that the majority of those who are discharged home do not get these muchneeded services.For example, Freburger et al. (2018b) found that only 31% of stroke patients who were discharged home received occupational and physical therapy services, 11% received outpatient therapy services, while 59% received no therapy.There are a number of advantages to therapy services being provided in the home as compared to inpatient or outpatient services, such as the potential for lower costs, increased satisfaction with services, and patient preference (Hillier & Inglis-Jassiem, 2010;Landers et al., 2016;Lincoln et al., 2004Lincoln et al., , 2004;;Medicare Payment Advisory Commission, 2019).The low rate of home therapy is concerning given that home-based therapy services have been found in a systematic review to lead to more functional benefits for patients post-stroke as compared to center-based services (Hillier & Inglis-Jassiem, 2010).
Many CVA patients are discharged from the hospital early to control costs.These clients are often referred to home health for continued services.However, there is a paucity of research demonstrating the efficacy of home-based occupational therapy and physical therapy services.In 2012, the Affordable Care Act initiated the Hospital Readmission Reduction Program (HRRP).The goal of the HRRP is to reduce preventable events and decrease overall hospital readmission rates (McIlvennan et al., 2015).The program prescribes penalties and reduced payments for hospitals that have unplanned readmissions within 30 days of discharge from the hospital (Medicare Payment Advisory Commission, 2019).Providers, payors, and stakeholders have a critical need for access to clear evidence regarding the needs of patients being discharged home from acute care hospitals and efficacy of occupational therapy and physical therapy interventions provided in the home.Policy makers, providers, and payors need evidence to inform decision making, to generate protocols and models for treatment, to prioritize treatment based of the most efficient and cost-effective care, and to guide the allocation of resources within the Medicaid (TennCare) program.
The current review focuses on efficacy studies in recognition that intervention research is generally placed on a continuum and that efficacy research assessing intervention impact under ideal conditions such as randomized controlled trials with homogenous populations.Different from efficacy studies on intervention research, studies on the effectiveness of intervention are aimed to evaluate the performance of an intervention in heterogeneous populations under the real-world conditions (Streiner, 2002).Efficacy studies "provide tests of whether a technology, treatment, procedure, or program does more good than harm when delivered under optimum conditions" and "effectiveness trials provide tests of whether a technology, treatment, procedure, or program does more good than harm when delivered under real-world conditions" (Flay, 1986, p. 451).As a result, efficacy studies have higher internal validity by testing the interventions in homogenous populations, and effectiveness studies have higher reliability and test whether the performance of an intervention are reproducible across the heterogenous populations.Furthermore, efficacy studies provide important initial exploratory evidence and preliminary findings prior to the real-world evidence that are further generated from additional effectiveness studies.Given the paucity of intervention research in the area of home-based occupational therapy post-stroke, we deemed it appropriate to first review and assess the spectrum of efficacy studies to date in this arena.
The purpose of this scoping review was to review and assess the types of available research to date examining the efficacy of home-based occupational therapy services after hospital discharge for adult stroke patients.
In particular, we sought to map out the state of basic efficacy research on home-based occupational therapy post-stroke and to identify strengths, weaknesses, and gaps in the literature.While preliminary research on home-based occupational therapy services for patients with stroke has demonstrated promising results (Ávila et al., 2015;Rowe & Neville, 2018), there is an important need to understand the spectrum of home-based occupational therapy services provided post-stroke and to identify and analyze knowledge gaps in the current literature.

Method
Arksey and O'Malley's scoping review framework and the revised recommendations of Levac et al. (2010) were used to guide this review with application of the following stages: 1) identify the research question; 2) identify the relevant studies; 3) select studies; 4) chart the data; and 5) assemble, summarize, and report the results (Arksey & O'Malley, 2005).A university librarian assisted in developing the search strategy.Because the primary question guiding this scoping review focuses on efficacy studies, we used published recommendations to guide us when operationalizing the inclusion and exclusion criteria (Flay, 1986;Gartlehner et al., 2006).A review protocol was not developed.As this was a scoping review, approval by the university's Institutional Review Board was not required.

Research questions
The questions guiding this review were: 1) What is the extent of the recent literature examining the efficacy of home-based occupational therapy services after hospital discharge for adult stroke patients, and what empirical and methodological gaps exist within this literature?2) What types of occupational therapy home-based interventions were delivered in the included studies? 3) What treatment doses were used, and 4) What were the primary outcomes of interest?

Search strategy
We identified relevant peer-reviewed papers using a systematic search strategy in January of 2023 using the following computerized bibliographic databases: Clinicaltrials.gov,Cochrane Library, Cumulative Index of Nursing and Allied Health Literature (CINAHL), EMBASE, SCOPUS, PsycINFO, Medline Ovid, Proquest, and OTSeeker.The MESH search terms used in the abstract and titles were occupational therapy, stroke, cerebrovascular accident, home-based, and home.

Inclusion and exclusion criteria
The criteria for article inclusion were: (1) intervention studies focused on home-based occupational therapy services; (2) the study sample included only individuals post-stroke; (3) the interventions were delivered solely by an occupational therapist; (4) written in English; (5) published since 2011, and (6) primary studies (including randomized controlled trials (RCTs), qualitative studies, case series), and trial registry records.In order to focus on the most current research, the database searches were limited to the past 10 years.Studies were excluded if a professional other than an occupational therapist (i.e.physical therapist) was involved in the intervention implementation, or it was not evident that an occupational therapist implemented the intervention.In addition, intervention studies that clearly met validated criteria distinguishing them as effectiveness rather than efficacy trials were excluded (Gartlehner et al., 2006).Systematic-reviews, meta-analyses, book reviews, editorials, and opinion pieces were also excluded.Since, scoping reviews should summarize the full range of literature within a defined set, regardless of its quality (Arksey & O'Malley, 2005;Levac et al., 2010), no assessment of study quality took place.

Results
In the initial search of databases, 674 titles and abstracts were retrieved after duplicate removal.If the study relevance was not clear, the full text was reviewed.Of the initial 674 articles screened, 133 were identified as relevant and entered into EndNote.For the second level of screening, the references were exported to Rayyan, a web-tool that allows for blinded abstract screening and selection.The full-text articles were then uploaded to Rayyan.
The next step involved a detailed review of the full text of each article.This step eliminated 118 articles, leaving 15 peer-reviewed articles that focused on home-based occupational therapy services among stroke patients and met the inclusion criteria for this review.We also reviewed the reference lists of relevant articles to identify additional references, but none were identified.Relevant article content was then extracted into a data charting spreadsheet (Arksey & O'Malley, 2005), including the journal name, authors, year of publication, location, study aim, sample, design, outcome measure(s), and results.The reporting process used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension for scoping reviews (Figure 1) (Moher et al., 2009;Tricco et al., 2018).
The included articles, 14 of which were quantitative in design, and one that was mixed methods in design, are shown in Table 1 and marked with an asterik (*) in the reference list.Of the 674 articles initially identified, all 15 included were from database searches.The sample sizes of the studies ranged from one to 80 subjects and included both male and female   were efficacy studies and none met the criteria distinguishing them as effectiveness studies (Gartlehner et al., 2006).See Table 2 for the other characteristics of the included studies.

Efficacy
The paucity of efficacy research on home-based occupational therapy services after stroke was reflected in this scoping review by our identification of only 15 total eligible efficacy studies.The designs for these eligible studies varied widely, but of note, few (N =, 33%) employed best methods for efficacy research, such as randomized clinical trials.All 15 studies had positive results with significant improvement noted in at least one of each of the studies' outcome measures.

Types of interventions
Occupational therapy delivered in a telerehabilitation service delivery model using game-based interventions was reported in two of the 15 studies as shown in Tables 2 and 3.For example, a game-based, in-home telerehabilitation exercise program was found to be a feasible approach to promote the attainment of individualized functional goals post-stroke (Proffitt & Lange, 2015), and another telehealth occupational therapy intervention using virtual reality gaming was successful in increasing client hand strength and motivation (Pareto et al., 2011).
In one study, electrical stimulation was combined with purposeful activities, and the combination led to greater improvements in motor function and goal achievement after stroke as compared to a standard stretching and exercise program (Minami et al., 2021).In another study, the use of assistive technology devices when performing activities resulted in increases in satisfaction, performance, and goal attainment for individuals post-stroke (Lim et al., 2022).
Mirror therapy was used in two studies.In the first, a case report of a home-based mirror therapy revealed significant improvements in sensation and hand function, as well as decreased pain for the participant.Graded motor imagery and mirror therapy combined resulted greater increases in scores for motor function of the upper limb as compared to a control group.However, there was no difference between the two groups for the other functional results measured (Nilsen & DiRusso, 2014).Geller et al., 2022 compared home-based unimanual mirror therapy, bimanual mirror therapy, and traditional occupational therapy home programs, all which involved the implementation of functional tasks, and found that all groups demonstrated significant improvements over time, with confidence interval data indicating that unimanual mirror therapy might be more beneficial for clients who have moderate or severe upper extremity impairment.
As shown in Table 3, ten of the studies in this scoping review used occupation-based interventions.For example, a pilot RCT conducted by Zhang et al. (2022) revealed that an occupation-based telehealth coaching program improved the participation, performance of IADLs, and intrinsic motivation of stroke survivors.In another randomized control trial examining a home-based restorative and compensatory upper extremity apraxia therapy program, the intervention involved the implementation of functional and cognitive strategies during activities of daily living (ADLs).The investigators reported statistically significant differences in the treatment and control groups with the treatment group scoring higher on ideomotor apraxia, and gesture imitation, recognition, and comprehension scores.However, there were no differences in the groups regarding functionality and quality of life (Aguilar-Ferrándiz et al., 2021).
A study that used an intervention approach of physical, cognitive, and social activities that were functional in nature found significant improvements in the participants' functional independence and cognitive skill scores after the intervention (Ávila et al., 2015).Lim et al. (2022) examined the effect of meaningful therapeutic activities carried out in the various contexts in which the participants engaged and found statistically significant improvements in the participants' satisfaction and occupational performance.In the Minami et al. (2021) study, participants who received electrical stimulation while engaging in purposeful occupational activities demonstrated significantly improved motor function and achievement of their goals.Occupation-based community rehabilitation involving task-specific training, environmental modifications, and patient education, was found to have a positive effect on quality of life and activities of daily living for post stroke (Moon et al., 2022).A stroke-specific occupation-based self-management program was found to improve occupational performance and satisfaction (Nott et al., 2021).The final study that used an occupation-based intervention was a pilot study conducted by Simpson et al. (2016).This study examined the effect of a handwriting intervention that involved tasks that were specific to the needs of the client, such as writing notes and postcards to family members.Although the intervention was found to be feasible and acceptable, there were no significant differences in legibility scores pre and post intervention.

Treatment dosage
The frequency of sessions ranged from one to seven per week (mean = 3.1, mode = 2,3), and the number of minutes per intervention session ranged from 20 to 90 min (mean = 44.5, mode 30).The duration of the therapy sessions ranged from 4 to 12 wks (mean = 7.4, mode = 4,8).Independent practice without supervision of the occupational therapist was recommended for three hours per week in only one study.
There were significant differences in efficacy across studies.Some studies showed clinical improvements in performance skills (Aguilar-Ferrándiz et al., 2021;Ji et al., 2021;Minami et al., 2021;Pareto et al., 2011;Takekawa et al., 2012) targeting upper limb movements and two studies addressed the feasibility of interventions to improve performance skills (Nilsen & DiRusso, 2014;Proffitt & Lange, 2015) of gross motor function.Although these studies demonstrated improved motor function, two of the three studies which included self-care measures saw little to no change in selfcare performance or quality of life (QOL) (Aguilar-Ferrándiz et al., 2021;Ji et al., 2021).Minami et al., 2021 did show an improvement in self-efficacy after the e-stim with functional task portion of the trial, but the interventions used during electrical stimulation were occupation-based.Studies using occupational performance and self-efficacy interventions (Ávila et al., 2015;Geller et al., 2022;Lim et al., 2022;Minami et al., 2021;Moon et al., 2022;Nott et al., 2021;Rowe & Neville, 2018;Simpson et al., 2016;Zhang et al., 2022) all showed significant improvement in self-care and QOL measures regardless of treatment dosage or treatment duration.
Many of the occupational therapy interventions included in the reviewed studies did not address ADLs or IADLS, nor did they involve caregivers or consider the home context.Only one article included an intervention that incorporated assistive technology.(See Table 2).

Discussion
Results from this scoping review reveal that there is a paucity of efficacy research on home-based occupational therapy services, and the study designs for the eligible studies varied widely.Furthermore, the published studies included in this scoping review reveal wide heterogeneity in the specific outcome measures assessed and home-based occupational therapy interventions and dosages (i.e.exposure levels) employed, making direct comparison, systematic review, or meta-analysis difficult.Only two of the studies reviewed included interventions that addressed cognitive skills, and there were no studies that investigated the provision and efficacy of occupational therapy interventions for depression for individuals post-stroke.This is concerning because stroke patients who have unmanaged depression are more likely to have functional limitations with activities of daily living (Hackett & Pickles, 2014;Schmid et al., 2011).Many of the occupational therapy interventions included in the reviewed studies did not address ADLs or IADLS, nor did they involve caregivers or consider the home context.Only one article included an intervention that incorporated assistive technology.It is noteworthy that one-third of the study interventions were not occupation-based.
The lack of focus on occupation and occupation-based outcome measures may be related to the continued emphasis of the medical model in healthcare settings and educational programs where clients are classified by disease states and treatment protocols focus on symptom management and mediation.This may explain why clinical trials continue to emphasize performance skills and client factors as outcome measures instead of focusing on QOL, self-care, and self-efficacy.Another factor which may influence the choice of outcome measures is ease of use of assessment tools.Measures like grip strength, tone, and muscle testing are easy to use, have high reliability, and are repeatable over time.Assessments that include caregiver training, QOL, and self-management are more difficult to complete and are difficult to quantify in scientific literature.Quality evidence of this type often involves qualitative analysis and is considered a lower level of evidence in research.
Caregiver training and support are important aspects of successful reintegration into the home environment (Govender et al., 2019), and caregiver burden can be reduced in cases where occupational therapy interventions focus on client-centered functional activities of daily living (Hedman et al., 2019;LeLaurin et al., 2020).However, only one study included caregivers as study participants (Zhang et al., 2022).The most common outcome measures were quantitative measures for strength and range of motion, even though occupational performance is a critical aspect of successful return to the home setting.Quality of life measures were included in five studies, but these revealed little change as a result of occupational therapy intervention.Of note, none of the studies included in our scoping review assessed 30-day hospital readmissions for patients post-stroke, an outcome measure of particular interest to payors.
The Occupational Therapy Practice Framework: Domain and Process-Fourth Edition (OTPF-4) identifies contexts as a broad construct defined as the environmental and personal factors specific to each client (person, group, population) that influence engagement and participation in occupations (American Occupational Therapy Association, 2020), but the home-based studies included in this review rarely included assessment of the home context.The home setting is an important context for occupational engagement, and successful performance in this context is essential for the client in achieving satisfaction and quality of life.Although practitioners understand the importance of context, there is little scholarly investigation on the importance of context for clients with stroke in home health settings.The OTPF-4 describes the importance of occupations and occupational engagement for optimal functioning of the client.Though the majority of the studies included addressed occupations or occupational engagement, many emphasized motor function.Further, the OTPF-4 identifies contexts as an important aspect of performance.These contexts, ranging from personal to environmental, are consistent with multiple frames of reference (e.g.Model of Human Occupation, Person-Environemnt-Occupation Model, Occupational Adaptation, and Ecology of Human Performance), yet they were rarely considered in the design or implementation of the study protocols (Dunn et al., 1994;Kielhofner, 2008;Law et al.,1996;Schkade & Schultz, 1992).Clearly there continues to be a need for studies that address this aspect of client performance.
A number of studies instead chose to include outcome measures focused on performance skills and client factors in general, and motor skills in particular.This is consistent with the mindset of clinical practitioners working within the medical model.The hierarchical medical model works well as a business system and has clear application in hospitals, rehab facilities, and skilled nursing centers where the physicians and nurses have responsibility for the patient's care (IGI Global, 2019).However, the emphasis on body systems and disease processes does not adequately address the environment and contexts in which the client must perform (Farre & Rapley, 2017).Strength and ROM are quantitative measures of performance and are readily measured using standardized tools and assessments.Although most of these studies look at performance measures, there continues to be a limited number of studies focused on outcome measures such as quality of life and self-care, that are of great interest to providers and payors (Agency for Healthcare Research and Quality, 2019).
Occupational therapists incorporate occupations as a means and an end for interventions.This holistic use of activities that have meaning to the client has demonstrated superior results compared to exercise (de Vreede et al., 2005;Guzelkucuk et al., 2007).Despite evidence to support the use of activities as interventions, few studies incorporated ADL and IADL activities in their interventions or in their outcome measures.In fact, one third of the researchers did not use interventions that focused on occupational performance and engagement.This is also consistent with practitioner survey data indicating that strength and range of motion were listed as two of the three most commonly used interventions for more than half of the respondents (Donoso Brown & Fitcher, 2017).
Home interventions involving telerehabilitation were included and the results were promising (Pareto et al., 2011;Takekawa et al., 2012); however, the outcome measures were different in each study, with only two of the three telerehabilitation studies using an occupation-based outcome measure (Pareto et al., 2011;Zhang et al., 2022).Occupational therapy telerehabilitation has been found to result in positive therapeutic effects (Hung & Fong, 2019), and delivering telerehabilitation home-based occupational therapy interventions to individuals post-stroke is a convenient and potentially cost-effective approach.Yet, additional evidence is needed to demonstrate the efficacy of occupational therapy telerehabilitation interventions for stroke patients in the home setting.
It is noteworthy that there were no studies that investigated visual issues despite the fact that fifty to sixty percent of adults with stroke experience some form of visual deficits (Rowe, 2016).Visual deficits can include abnormal eye movements, central vision loss, visual field loss, and visual perceptual abnormalities.Any of these issues can impact a person's ability to complete mobility, self-care, and other valued occupations.Further investigation examining the efficacy of home-based interventions for visual deficits post-stroke is clearly needed.

Limitations
Limitations of this scoping review include the quantity and quality of research reviewed and restricting the scope of the review to English-language articles.New studies examining the efficacy of home-based occupational therapy services may have been initiated or completed since the date of the final search.Additionally, we did not include studies with occupational therapy interventions delivered in conjunction with other disciplines, such as physical therapy.Because this was a scoping review, the methodological quality of the included studies was not examined.Despite these limitations, we searched a broad range of electronic databases and followed a rigorous scoping review methodology (Arksey & O'Malley, 2005;Levac et al., 2010).The best way to assess the overall efficacy of home-based occupational therapy services post-stroke is through a systematic review and a meta-analysis.However, this was not feasible because of the heterogeneity of the outcomes and because the literature in this area is sparce.

Implications for occupational therapy practice
According to this scoping review, there are a limited number of efficacy studies on home-based occupational therapy services, which is of critical importance and is needed to influence policy makers and payors in their coverage of occupational therapy services.This evidence is also critical for effective quality improvement efforts to increase utilization.The limited number of studies may be due to the difficulty controlling for extraneous environmental variables in the home setting or controlling other services received such as physical therapy.Another challenge may be difficulty with subject recruitment (Simpson et al., 2016).Due to challenges with quantitative designs, researchers should consider supplementing quantitative designs with qualitative approaches.Also, researchers should not stop with feasibility studies.To influence payment policy and utilization of occupational therapy services post-stroke, high-quality efficacy studies employing best practice study designs such as pragmatic randomized controlled trials are especially needed.The lack of consistency in outcome measurements and limited emphasis on occupational performance and engagement are issues that need to be addressed in future research.In addition, high quality studies should examine the efficacy of home-based occupational therapy interventions that incorporate the home context and address ADLs, caregiver support for carryover of interventions, psychosocial and cognitive issues, and occupational engagement.There is a particularly critical need for further research into the efficacy of home health occupational therapy services, as recent literature is limited in quantity and methodological rigor.Additional research is also needed that addresses occupation-based practice that illustrates the distinct value of occupational therapy and distinguishes occupational therapy interventions from those used by physical therapy.

Conclusion
We conducted a scoping review of home-based occupational therapy interventions for patients post-stroke.Although the studies included in this scoping review had varied study designs and outcome measures, and most investigations revealed positive therapeutic effects, efficacy evidence is lacking.These critical evidence gaps in research examining efficacy need to be addressed to encourage broader utilization of home-based occupational therapy services following hospital discharge in stroke survivors.

Table 1 .
Summary of methods employed for qualifying studies.

Table 3 .
continued participants ranging in age from early 40s to 86 years.All 15 studies (100%)

Table 2 .
characteristics of included studies.

Table 3 .
Description of interventions and main findings of qualifying studies.