Addressing ADL ability in people with poststroke cognitive impairments: A Danish survey of clinical practice

Figures & data

Figure 1. Flowchart of survey respondents.

Table 1. Characteristics of survey respondents and their workplaces.

Questions (Questionnaire section B − C)	Hospital-based OTs n = 72	Municipality-based OTs n = 100
B) Information on respondents’ education and clinical experience
What is your highest educational level? n (%)
Diploma or Professional Bachelor’s degree in Occupational Therapy	65 (90,3)	89 (89.0)
Master’s degree (≤ 120 ECTS)	6 (8.3)	8 (8.0)
Other	1 (1.4)	3 (3.0)
How many years in total have your worked as an OT? median (range)	11 (0 − 38)	12.5 (1 − 35)
How many years have you worked in stroke rehabilitation? median (range)	9 (0 − 35)	10 (0 − 34)
C) Information about respondents’ workplace
Where is your workplace located? n (%)
Capital Region of Denmark (population size: 1,891,871)	23 (31.9)	36 (36.0)
Region Zealand (population size: 849,857)	10 (13.9)	18 (18.0)
Region of Southern Denmark (population size: 1,237,413)	18 (25.0)	20 (20.0)
Central Denmark Region (population size: 1,358,879)	16 (22.2)	14 (14.0)
North Denmark Region (population size: 594,634)	5 (6.9)	12 (12.0)
How would you describe your workplace in terms of type of rehabilitation setting for stroke survivors?* n (%)
Acute stroke unit	33 (45.8)
Inpatient stroke rehabilitation unit	51 (70.8)
Outpatient stroke rehabilitation unit	2 (2.8)
Inpatient municipality rehabilitation centre	N/A	34 (34.0)
Outpatient municipality rehabilitation centre	N/A	45 (45.0)
Home-based rehabilitation	N/A	51 (51.0)
Other (e.g. neurointensive care unit, care home, private municipality rehabilitation centre)	5 (6.9)	5 (5.0)
How many OTs work with stroke survivors at your workplace? n (%)
≤ 5	9 (12.5)	68 (68.0)
6-10	38 (52.8)	23 (23.0)
11-15	12 (16.7)	6 (6.0)
≥ 16	13 (18.1)	3 (3.0)
How many stroke survivors do you provide services to on a typical working week? n (%)
≤ 5	21 (29.2)	43 (43.0)
6-10	32 (44.4)	45 (45.0)
11-15	12 (16.7)	12 (12.0)
16-20	5 (6.9)	0 (0.0)
≥ 21	2 (2.8)	0 (0.0)
How much of your time do you spend on assessing stroke survivors on a typical working day? n (%)
< 25 %	37 (51.4)	81 (81.0)
25-49 %	23 (31.9)	19 (19.0)
50-74 %	9 (12.5)	0 (0.0)
≥ 75 %	3 (4.2)	0 (0.0)
How much of your time do you spend on delivering intervention to stroke survivors on a typical working day? n (%)
< 25 %	17 (23.6)	28 (28.0)
25-49 %	27 (37.5)	40 (40.0)
50-74 %	25 (34.7)	27 (27.0)
≥ 75 %	3 (4.2)	5 (5.0)
Which is the duration of a typical rehabilitation stay for stroke survivors at your workplace? n (%)
< 1 week	16 (22.8)	0 (0.0)
1-2 weeks	20 (27.8)	1 (1.0)
3-4 weeks	17 (23.6)	2 (2.0)
≥ 5 weeks	19 (26.4)	N/A
5-6 weeks	N/A	3 (3.0)
7-8 weeks	N/A	6 (6.0)
9-12 weeks	N/A	34 (34.0)
≥ 13 weeks	N/A	54 (54.0)
Do you work in interdisciplinary teams? n (%)
Yes	70 (97.2)	97 (97.0)
Which other professional groups are in these interdisciplinary teams?* n (%)
Physician	66 (94.3)	11 (11.3)
Physical therapist	70 (100.0)	96 (99.0)
Nursing staff	68 (97.1)	63 (64.9)
Speech and language therapist	67 (95.7)	46 (47.4)
Neuropsychologist	60 (85.7)	34 (35.1)
Dietitian	41 (58.6)	45 (46.4)
Support worker	3 (4.3)	19 (19.6)
Social worker	27 (38.6)	20 (20.6)
Other (e.g. hospital porter, music therapist, optometrists, professionals with coordinating roles)	4 (5.7)	8 (8.2)
Does your workplace have OT students in internship? n (%)
Yes	64 (88.9)	60 (60.0)
Does your workplace participate in research activities of relevance for your clinical practice with stroke survivors? n (%)
Yes	44 (61.1)	14 (14.0)
No	20 (27.8)	81 (81.0)
Do not know	8 (11.1)	5 (5.0)

* The question allowed for multiple answers or free text.

Abbreviations: N/A: non-applicable; OT: occupational therapy.

Table 2. Sources of knowledge.

How often do you make use of following sources of information to get relevant knowledge for your work with stroke survivors?	Never; n (%)		Sometimes; n (%)		Often; n (%)		Each time; n (%)
	Hospital-based OTs n = 72	Municipality-based OTs n = 100	Hospital-based OTs n = 72	Municipality-based OTs n = 100	Hospital-based OTs n = 72	Municipality-based OTs n = 100	Hospital-based OTs n = 72	Municipality-based OTs n = 100
Own experience	0 (0%)	0 (0%)	2 (2.8%)	5 (5%)	20 (27.8%)	33 (33%)	50 (69.4%)	62 (62)
Discussions with colleagues	0 (0%)	0 (0%)	12 (16.7%)	16 (16.0%)	50 (69.4%)	68 (68.0%)	10 (13.9%)	16 (16.0)
Discussions with R&D OT	14 (19.4%)	39 (39.0)	43 (59.7%)	50 (50%)	14 (19.4%)	10 (10.0%)	1 (1.4%)	1 (1.0%)
Danish clinical guidelines	12 (16.7%)	15 (15.0%)	44 (61.1%)	62 (62.0%)	13 (18.1%)	21 (21.0%)	3 (4.2%)	2 (2.0%)
International clinical guidelines	50 (69.4%)	79 (79.0%)	17 (23.6%)	18 (18.0%)	4 (5.6%)	3 (3.0%)	1 (1.4%)	0 (0%)
Local clinical guidelines	16 (22.2%)	45 (45.0%)	31 (43.1)	40 (40.0%)	20 (27.8%)	10 (10.0%)	5 (6.9%)	5 (5.0%)
Research articles	21 (29.2%)	27 (27.0%)	46 (63.9%)	65 (65.0%)	5 (6.9%)	8 (8.0%)	0 (0%)	0 (0%)
Database searching	44 (61.1%)	74 (74.0%)	26 (36.1%)	23 (23.0%)	2 (2.8%)	3 (3.0%)	0 (0%)	0 (0%)
Courses	1 (1.4)	5 (5.0%)	31 (43.1%)	49 (49.0%)	35 (48.6%)	37 (37.0%)	5 (6.9%)	9 (9.0%)
Events	16 (22.2%)	13 (13.0%)	47 (65.3%)	68 (68.0%)	7 (9.7%)	18 (18.0%)	2 (2.8%)	1 (1.0%)
Books	2 (2.8%)	1 (1.7%)	56 (77.8%)	63 (63.0%)	13 (18.1%)	32 (32.0%)	1 (1.4%)	4 (4.0%)
Other* (e.g. Danish Association of Occupational Therapists, social media, supervision)	59 (81.9%)	84 (84.0%)	9 (12.5%)	13 (13.0%)	3 (4.2%)	3 (3.0%)	1 (1.4%)	0 (0%)

Table 3. Clinical practice patterns based on a vignette.

TIDieR items	Questions (questionnaire section D)	Hospital-based OTs	Municipality-based OTs
WHY	Which occupational therapy theoretical framework(s) guide(s) your clinical reasoning?* n (%)	n = 72	n = 100
	CMOP-E, CPPF, CMCE (Enabling occupation)	37 (51.4)	46 (46.0)
	OTIPM, TMO (Powerful practice)	47 (65.3)	58 (58.0)
	MoHO	20 (27.8)	27 (27.0)
	Other (e.g. A-ONE**, OCS**, MOCA**, Guidet Interaction Therapy**, hand assessment**, ICF, ADL observation**)	5 (6.9)	5 (5.0)
	Don’t know	1 (1.4)	7 (7.0)
WHAT	Would you assess the overall quality of the stroke survivor’s dressing performance in terms of independence, effectiveness, and safety? n (%)	n = 71	n = 100
	Yes	71 (100.0)	100 (100.0)
	Which methods would you use to assess the overall quality of the stroke survivor’s dressing performance?* n (%)	n = 71	n = 100
	Interview	48 (67.6)	82 (82.0)
	Observation	71 (100)	99 (99.0)
	Would you use standardised instruments to assess the overall quality of the stroke survivor’s dressing performance? n (%)	n = 71	n = 100
	Yes	36 (50.7)	44 (44.0)
	Which standardised assessment instruments would you use to assess the overall quality of the stroke survivor’s dressing performance?* n (%)	n = 36	n = 44
	AMPS	28 (77.8)	35 (79.5)
	ADL-I	2 (5.6)	9 (20.5)
	A-ONE	7 (19.4)	2 (4.5)
	COPM	3 (8.3)	2 (4.5)
	ADL-taxonomy	0 (0.0)	4 (9.1)
	FIM	1 (2.8)	0 (0.0)
	KF-NAP**	1 (2.8)	0 (0.0)
	MOCA**	1 (2.8)	0 (0.0)
	OCS**	1 (2.8)	0 (0.0)
	PSFS	0 (0.0)	1 (2.3)
	Would you assess which cognitive impairments underlie the stroke survivor’s dressing problems? n (%)	n = 71	n = 100
	Yes	64 (90.1)	100 (100.0)
	Which methods would you use to assess which cognitive impairments underlie the stroke survivor’s dressing problems?* n (%)	n = 64	n = 100
	Interview	45 (70.3)	82 (82.0)
	Observation	61 (95.3)	99 (99.0)
	Would you use standardised instruments to assess which cognitive impairments underlie the stroke survivor’s dressing problems?* n (%)	n = 64	n = 94
	Yes	28 (43.7)	32 (34.0)
	Which standardised assessment instruments would you choose to assess which cognitive impairments underlie the stroke survivor’s dressing problems?* n (%)	n = 28	n = 32
	OCS	10 (35.7)	9 (28.1)
	AMPS**	6 (21.4)	11 (34.4)
	MOCA	6 (21.4)	10 (31.3)
	A-ONE	9 (32.1)	0 (0.0)
	DLOTCA	0 (0.0)	2 (6.3)
	COPM**	0 (0.0)	1 (3.1)
	KF-NAP	1 (3.6)	0 (0.0)
	CT-50	0 (0.0)	1 (3.1)
	OTIPM**	0 (0.0)	1 (3.1)
	Which intervention model(s) would you choose to address the dressing problems?* n (%)	n = 72	n = 100
	Restorative model (improves body functions through activity)	64 (88.9)	73 (73.0)
	Acquisitional model (improves occupational skills)	56 (77.8)	61 (61.0)
	Compensatory model	12 (16.7)	37 (37.0)
	Exercises	5 (6.9)	8 (8.0)
	Other	0 (0.0)	2 (2.0)
	Description of the intervention plan	n = 68	n = 89
	Valid, n (%)	61 (89.7)	63 (70.7)
WHO PROVIDED, HOW	Modes of delivery*, n (%)	n = 70	n = 100
	Individual sessions provided by an OT	69 (98.6)	96 (96.0)
	Individual sessions provided by another professional group under OT supervision	29 (41.4)	35 (35.0)
	Self-training under OT supervision	17 (24.3)	28 (28.0)
	Group-based sessions provided by an OT	1 (1.4)	2 (2.0)
	Group-based sessions provided by another professional group under OT supervision	0 (0.0)	1 (1.0)
	Other	1 (1.4)	3 (3.0)
	Involvement of family members, n (%)	n = 70	n = 99
	Yes	41 (58.6)	79 (79.8)
WHEN AND HOW MUCH	Frequency of intervention, n (%)	n = 69	n = 96
	1-2 sessions/week	17 (24.6)	70 (72.9)
	3-4 sessions/week	31 (44.9)	15 (15.6)
	5-7 sessions/week	16 (23.2)	7 (7.3)
	Other	5 (7.2)	4 (4.2)
	Duration of intervention sessions, n (%)	n = 69	n = 96
	≤15 minutes	2 (2.9)	0 (0.0)
	16-30 minutes	12 (17.4)	17 (17.7)
	31-45 minutes	39 (56.5)	40 (41.7)
	46-60 minutes	16 (23.2)	35 (36.5)
	>60 minutes	0 (0.0)	4 (4.2)
	Length of intervention, n (%)	n = 70	n = 98
	1-2 weeks	40 (57.1)	4 (4.1)
	3-4 weeks	22 (31.4)	30 (30.6)
	5-6 weeks	6 (8.6)	16 (16.3)
	7-8 weeks	2 (2.9)	21 (21.4)
	>8 weeks	0 (0.0)	N/A
	9-12 weeks	N/A	21 (21.4)
	≥13 weeks	N/A	6 (6.1)
	Schedule of the intervention sessions, n (%)	n = 69	n = 96
	When is relevant for the stroke survivor	50 (72.5)	85 (88.5)
	When it fits into the OT’s schedule	13 (18.8)	6 (6.3)
	Other (e.g. both response options)	6 (8.7)	5 (5.2)
WHERE	Location, n (%)	n = 69	n = 96
	Stroke survivor’s room in hospital/at the rehabilitation centre	52 (75.4)	26 (27.1)
	Bathroom in hospital/at the rehabilitation centre	57 (82.6)	24 (25.0)
	Therapy kitchen in hospital/at the rehabilitation centre	9 (13.0)	2 (2.1)
	Therapy room in hospital/at the rehabilitation centre	4 (5.8)	7 (7.3)
	Other	1 (1.4)	1 (1.0)
	Stroke survivor’s home	N/A	72 (75.0)
WHAT	Would you document the outcome of the dressing intervention?	n = 69	n = 96
	Yes	69 (100.0)	96 (100.0)
	Which methods would you use to document the outcome of the dressing intervention? n (%)	n = 68	n = 95
	Interview	32 (47.1)	68 (71.6)
	Observation	68 (100.0)	95 (100.0)
	Would you use standardised instruments to document the outcome of the dressing intervention? n (%)	n = 68	n = 93
	Yes	22 (32.4)	37 (39.8)
	Which standardised instruments would you use to document the outcome of the dressing intervention?* n (%)	n = 22	n = 37
	AMPS	17 (77.3)	28 (75.7)
	ADL-I	3 (13.6)	7 (18.9)
	COPM	3 (13.6)	5 (13.5)
	ADL-taxonomy	3 (13.6)	3 (8.1)
	A-ONE	3 (13.6)	0 (0.0)
	ADL observation (unspecified)	1 (4.5)
	IPPA		1 (2.7)
	EQ-5D-5L		1 (2.7)
	When would you document the outcome of the dressing intervention? n (%)	n = 68	n = 93
	When there has been a change according to the OT	35 (51.5)	31 (33.3)
	At fixed timepoints (e.g. weekly, each other week, monthly)	11 (16.2)	26 (28.0)
	At end of the rehabilitation stay	2 (2.9)	11 (11.8)
	Other (e.g. daily, after each intervention session, or all response options)	20 (29.4)	25 (26.9)
WHY	Would you expect the dressing intervention to also have an impact on other PADL tasks?	n = 70	n = 99
	Yes	64 (91.4)	86 (86.9)
	No	3 (4.3)	6 (6.1)
	Don’t know	3 (4.3)	7 (7.1)

* The question allowed for multiple answers or free text.

^** Authors’ comments: While the OTs report these results, A-ONE, OCS, MOCA, Guided Interaction Therapy [30], hand assessment, and ADL observation are not occupational therapy theoretical frameworks. MoCA, OCS, KF-NAP [31] are not suitable for assessment of the overall quality of ADL performance. AMPS and COPM are not suitable for assessment of cognitive function. OTIPM is not an assessment instrument.

Abbreviations: COPM: Canadian Occupational Performance Measure; CT-50: CT-50 Cognitive Test; DLOTCA: Dynamic Lowenstein Occupational Therapy Cognitive Assessment; FIM: Functional Independence Measure [32]; IPPA: Individually Prioritised Problems Analysis [33]; KF-NAP: Kessler Foundation Neglect Assessment Process; OT: occupational therapist; N/A: non-applicable; PSFS: Patient-Specific Functional Scale [34].

Table 4. Suggested intervention strategies/techniques.

Suggested intervention strategies/techniques, n (Hospital-based OTs, n; Municipality-based OTs, n)	Examples
Use a verbal approach: instructions, guiding, discussions, reflections, n = 62 (25; 37)	Provide verbal assistance to scan the workspace. Provide verbal cues, if necessary, but refrain from providing the solution itself (red.).
Use a tactile or physical approach: stimulation, cues, unspecified guiding, Guided Interaction Therapy, assistance, n = 50 (29; 21)	While the patient is in lying position, start off by stimulating the entire left side of the body. When the stroke survivor (red.) gets stuck, guide her to the next step by placing a relevant object in her hand. Guide the left hand as needed; allow the patient to take over as much as possible. The stroke survivor (red.) would probably benefit of Guided Interaction Therapy (red.) Provide verbal guiding; if it doesn’t help, move on to physical guiding.
Activate the most affected upper limb, n = 42 (30; 12)	Minimise the use of the less affected arm/hand, for example by applying elementary guiding (Guided Interaction Therapy, red.) focused on providing tactile information. Remind the stroke survivor (red.) to use her left hand during the dressing practice; you may choose to guide her physically during the task. Focus on activating the left upper limb, either by physical or verbal guiding.
Teach compensatory strategies, n = 34 (21; 13)	The stroke survivor uses clothing tag/label (…) as cue the garments’ position in space (red.).
Use a pre-specified starting position, n = 31 (21; 10)	Sitting on the edge of bed with a table in front.
Provide unspecified type of support, n = 30 (17, 13)	Provide the necessary support to follow the steps. Guide the patient in searching for objects on the left side.
Place yourself and objects on the neglected side, n = 30 (14; 16)	Talk to the stroke survivor (red.) from her left side; her clothes should be placed on her left side, too.
Teach unspecified visual scanning techniques of the neglected side of the workspace or body, n = 24 (13; 11)	Provide ADL training in the bathroom, focusing on increasing the ability to direct attention towards the left side. Verbally encourage the stroke survivor (red.) to direct her visual attention towards the affected side. Inform the stroke survivor (red.) that you are training her ability to direct attention towards the left side and let her know when it is needed that she takes more time to scan the left side of her body or space.
Use mirror for visual feedback, n = 21 (6; 15)	The stroke survivor (red.) gets verbal assistance to adjust the clothes on the left side of the body, as she often forgets it; a big mirror is used for this.
Teach routines, n = 17 (5; 12)	The stroke survivor (red.) is learning a routine for how she successfully can put on a sweater. Support the patient in learning the correct sequence of task steps. The number of steps must be adjusted according to the patient needs.
Provide support to plan for how to perform the task, discuss problems when they arise, evaluate the task performance, reflect on solutions, and provide feedback during training, n = 12 (5; 7)	In general, discuss problems when they arise It is important to tell the stroke survivor what you observed during the training session (red.) to give her a better understanding of the problems.
Providing written instruction: checklists, pictures, n = 11 (4; 7)	A list of the component steps describing how a T-shirt should be put on is made in collaboration with the patient. Take pictures showing the dressing procedure that must be followed.
Encourage the stroke survivor to find solution herself, n = 8 (3; 5)	Allow the stroke survivor (red.) to try herself; ask questions that will help her reflect on what she is doing and sit on your hands. Allow for independent problem solving during
Perform many repetitions, n = 6 (4; 2)	The stroke survivor (red.) follows written instructions and practice the same dressing routine each time. Through repetitions and overlearning, she will in time learn how to get dressed again Practice task steps according to the principles of repetitive training and errorless learning.
Allow the stroke survivor to take enough time, n = 6 (3; 3)	Allow the stroke survivor (red.) to take enough time to complete the task herself/to locate the blouse herself.
Use errorless learning techniques, n = 5 (2; 3)	Practice task steps according to the principles of repetitive training and errorless learning. Provide training using errorless learning - for example when the stroke survivor (red.) searches for things she needs, it should go be too long time before she finds them.
Use bimanual activities as an active therapeutic component, n = 4 (4; 0)	Focus on object manipulation and bimanual tasks.
Train in a quiet environment, n = 4 (4; 0)	Throughout the training session, it is important not to talk too much to the patient, as she needs to stay focused. The intervention should preferably be delivered in an environment with minimal distractions.
Place objects in both sides of the workspace, n = 3 (3; 0)	Place objects on both right and left side of the workspace.
Encourage the stroke survivor to stop and reflect, n = 2 (2; 0)	Correct the stroke survivor (red.) if she doesn’t put on the blouse properly; ask her to stop and check.
Teach specific visual scanning techniques (the lighthouse strategy) of the workspace, n = 1 (0; 1)	Guide the stroke survivor (red.) verbally to use the lighthouse strategy.

Abbreviations: OT: occupational therapist.

Affolter FD. Perception, interaction and language. 1st ed. Berlin: Springer-Verlag, 2011.

 Google Scholar

Chen P, Chen CC, Hreha K, et al. Kessler foundation neglect assessment process uniquely measures spatial neglect during activities of daily living. Arch Phys Med Rehabil. 2015;96(5):869–876.e1. doi:10.1016/j.apmr.2014.10.023.

 PubMed Web of Science ®Google Scholar

Wessels R, De Witte L, Andrich R, et al. IPPA, a user-centred approach to assess effectiveness of assistive technology provision. Technol Disability. 2000;13(2):105–115. doi:10.3233/TAD-2000-13203.

 Google Scholar

Kowalchuk Horn K, Jennings S, Richardson G, et al. The patient-specific functional scale: psychometrics, clinimetrics, and application as a clinical outcome measure. J Orthop Sports Phys Ther. 2012;42(1):30–42. doi:10.2519/jospt.2012.3727.

 PubMed Web of Science ®Google Scholar