Occupational Therapy Interventions to Optimize Functional Use of the Upper Extremity After Peripheral Nerve Injury: A Systematic Review
Shayleigh Clarkson, Allison Fisher, Sean McFadden, Payton Swanson, Molly Whitlow, and Stacy Smallfield
PURPOSE: Peripheral nerve injuries are a distinct group of injuries that are commonly caused by motor vehicle accidents, falls, industrial accidents, household accidents, and penetrating trauma (Kamble et al., 2019). A peripheral nerve injury can affect an individual’s daily occupations and routines due to unrelenting pain, loss of sensation, and/or burning sensations. Peripheral nerve injuries can result in motor loss and subsequent muscle imbalance which can create functional loss (Chae et al., 2020). The purpose of this systematic review was to provide occupational therapists with evidence supporting the use of interventions to increase the functional use of the upper extremity after peripheral nerve injury.
DESIGN: We conducted a systematic review and included studies relevant to peripheral nerve injury, functional use of the upper extremity, and interventions within the scope of occupational therapy. All articles included were published within the last decade.
METHOD: We reviewed 31 titles and abstracts from MEDLINE, CINAHL, Embase, and Scopus databases and retrieved 11 full-text articles. Six met inclusion criteria. To determine the strength of evidence, we used the U.S. Preventative Services Task Force levels of certainty and grade definitions.
RESULTS: Three themes emerged: mirror therapy, sensory re-education, and the use of an orthosis. Three level I studies, and one level II study reported on the effectiveness of mirror therapy interventions. These studies provide moderate strength of evidence supporting the use of mirror therapy for improving upper limb function after peripheral nerve injury. One level II study reported on the effectiveness of sensory re-education interventions. Based on this study, sensory re-education is another supported intervention for improving functional outcomes of the upper limb after a peripheral nerve injury. However, this is based on low strength of evidence. One level IV study reported on the effectiveness of orthosis interventions. Using a volar wrist orthosis to enhance upper limb functional use is supported for treatment of Carpal Tunnel Syndrome but is found to be disadvised for ulnar nerve injuries, based on low strength of evidence provided by this study. More evidence is needed to determine the effectiveness of this intervention.
CONCLUSION: Based on moderate level of evidence, mirror therapy is a recommended intervention for improving functional outcomes of the upper limb after a peripheral nerve injury. These findings suggest that occupational therapists should be well-educated and trained in mirror therapy procedures and protocols in order to provide best practice to increase functional use of the upper limb after peripheral nerve injury. Sensory re-education is another recommended intervention to improve functional outcomes of the upper limb after a peripheral nerve injury that can be considered on a case-by-case basis. Due to limited literature, future research in the area of peripheral neuropathy interventions within the scope of occupational therapy should focus on increasing sample size using high quality study designs and developing a more standardized mirror therapy protocol.
Clancy Hesseltine, Josiah Heun, Murphy Porter, Sam Wyrick, Stacy Smallfield, and Molly Whitlow
PURPOSE: An estimated 5.8 million people in the United States live with dementia. By the year 2060, this number is expected to climb as high as 14 million people (CDC, 2019). Performance and participation in activities of daily living (ADLs) is a primary goal of occupational therapy. Exercise intervention is an occupational therapy approach for individuals with dementia that will increase ADL performance (Giebel et al., 2015). The present study examined the effects of physical exercise to maintain or improve activities of daily living performance for adults with dementia.
DESIGN: This systematic review of systematic reviews examined whether physical activity interventions maintained or improved ADL performance among older adults with dementia.
METHOD: Inclusion criteria for this study were systematic reviews and meta-analyses written in English and published from 2012-2024 with participants that were adults over eighteen years old who had dementia at the time of data collection, used physical exercise as an intervention measure, and reported an ADL outcome measure. The exclusion criteria for this study were reviews containing greater than or equal to half of studies identical to another systematic review. We screened 337 titles and abstracts from four literature databases: CINAHL, Pubmed, Cochrane Library and Scopus. We retrieved and reviewed 33 full-text articles. Two researchers reviewed each abstract, which led to full-text reviews of papers that appeared to meet the inclusion criteria. Two reviewers then read each full-text article to determine inclusion. Disagreements were resolved through consensus. Seven articles met inclusion criteria. We examined the effects of exercise frequency, duration, and intensity (high intensity included strength training, dance, brisk walking; low intensity exercise included yoga, Tai Chi, walking). The US Preventative Services Task Force levels of certainty and grade definitions were used to describe the strength of evidence.
RESULTS: This study demonstrated a general improvement in ADL performance when low-intensity or high-intensity exercise were used. Four studies had positive outcomes related to ADLs and three reported mixed outcomes. There was strong evidence supporting routine use of low-intensity, long duration exercise (> 30 mins per session), over less frequent (≤ 3 times per week), and a longer intervention period ( > 8 weeks) to improve or maintain ADL performance among adults with dementia. There was less evidence supporting high-intensity, short duration (≤ 30 mins per session), over a more frequent (> 3 times a week), and shorter intervention period (≤ 8-week).
CONCLUSION: This study found strong support for low-intensity, long duration, less frequent exercise over a longer period of time to improve ADL performance among adults with dementia. This systematic review may guide practitioners in making physical activity dosage recommendations to improve performance in ADLs. Future research could address how dementia severity and medical comorbidities interact with exercise characteristics and ADL performance.
Centers for Disease Control and Prevention. (2019, August 20). Minorities and Women Are at Greater Risk for Alzheimer's Disease. U.S. Department of Health and Human Services. https://www.cdc.gov/aging/publications/features/Alz-Greater-Risk.html
Giebel, C. M., Sutcliffe, C., & Challis, D. (2015). Activities of daily living and quality of life across different stages of dementia: a UK study. Aging & Mental Health, 19(1), 63–71. https://doi.org/10.1080/13607863.2014.915920
Effective Occupational Therapy Interventions to Decrease Picky Eating in Children: A Systematic Review
Savannah L. Jacobsen, Josie Cox, Alli Bos, Cherokee Ferguson, Stacey Smallfield, and Molly Whitlow
PURPOSE: Picky eating is related to the lack of consumption in food variety by children when shown different foods (Wolstenholme et al., 2020). A 2015 study reported that almost half of children experience a period of picky eating at some point during early childhood, including almost 15% of children for whom picky eating does not resolve by age 6 (Cardona et al., 2015). The purpose of this systematic review is to identify interventions within the scope of occupational therapy that increase food acceptance in children under the age of seven years who demonstrate picky eating characteristics and who have no underlying health conditions.
DESIGN: This systematic review included articles relevant to children under the age of 7 with no underlying health conditions, addressed unfamiliar food introductions or picky eating interventions, and assessed food consumption and variety. Level I evidence published in 2012 to 2023 in peer-reviewed journals was included.
METHOD: We reviewed the title and abstract of 738 articles from four different literature databases; each title and abstract was reviewed by two researchers to build consensus about which articles would be considered for full-text review. Then we reviewed the full text of 102 articles that appeared to meet or might meet the study’s inclusion criteria, all of which were reviewed by at least two researchers. Twelve articles met the inclusion criteria of this study. We used the U.S. Preventive Services Task Force levels of certainty and grade definition to describe the strength of evidence across these 12 studies.
RESULTS: We categorized articles into three different themes: taste exposure, nutrition education, and flavor change. Nine articles provided strong support for occupation-based interventions involving taste exposure for improving food acceptance and variety. These interventions consisted of screen-based modeling, offering unfamiliar food at snack times, making the foods into small pieces to eat, and using rewards or praise. There was moderate evidence supporting nutrition education and flavor change; these interventions included picture books, school based nutritional education, flavor change of vegetables, and changing the form of vegetables, respectively.
CONCLUSION: Overall, this systematic review identifies several strategies within the scope of occupational therapy practice that may improve food consumption and variety in picky eaters aged seven and under. Eating is a chief activity of daily living and essential to life, and occupational therapy services can address picky eating by using interventions tailored to the individual. Occupational therapy practitioners can use taste exposure to effectively increase food consumption. Since there is moderate evidence to support interventions involving nutrition education and flavor change, practitioners should consider recommending these interventions on a routine basis. Future research could refine protocols’ intervention activities, frequency, and duration.
Cardona Cano, S., Tiemeier, H., Van Hoeken, D., Tharner, A., Jaddoe, V. W., Hofman, A., Verhulst, F. C., & Hoek, H. W. (2015). Trajectories of picky eating during childhood: A general population study. The International Journal of Eating Disorders, 48(6), 570–579. https://doi.org/10.1002/eat.22384
Wolstenholme, H., Kelly, C., Hennessy, M., & Heary, C. (2020). Childhood fussy/picky eating behaviours: A systematic review and synthesis of qualitative studies. International Journal of Behavioral Nutrition and Physical Activity, 17(2), p.1-2. [CJ1] [JL2] https://doi.org/10.1186/s12966-019-0899-x
Occupational Therapy Interventions for ADLs in Adults Post-TBI with Visual Symptoms: A Systematic Review
Connor Jarman BS; Olivia Vander Haar BMS; Lauren Wobken BS; Stacy Smallfield DrOT, MSOT, OTR/L, BCG, FAOTA; and Molly Whitlow PhD, MPH
PURPOSE: Traumatic brain injury (TBI) is a leading cause of death and injury in the United States. In fact, it is estimated that 1.5 million Americans experience them every year (CDC, 2022). Visual impairments may be a symptom following TBI (Richman, 2014). This affects an individual’s ability to perform activities of daily living (ADLs) such as dressing, hygiene, and functional mobility, including the reading required for these activities. The purpose of this systematic review was to synthesize the evidence and intervention options within the scope of occupational therapy for adults post-TBI experiencing visual symptoms.
DESIGN: We conducted a systematic review of the literature from 2002 to 2022 that included adults 18 years and older post TBI, had a measurable ADL outcome, and were within the scope of occupational therapy.
METHOD: We reviewed 163 articles and abstracts from CINAHL, Cochrane, PubMed, and Scopus databases. Eighty-seven articles were retrieved for full review and seven met inclusion criteria. U.S. Preventative Task Force levels of certainty and grade definitions were used to describe the strength of evidence.
RESULTS: Articles were themed by intervention type: oculomotor and compensatory scanning training, and training in device use. Five articles ranging from Level I-III evidence focused on oculomotor and compensatory scanning training and provide moderate strength of evidence to improve ADL performance post-TBI. Oculomotor and compensatory scanning training dosages ranged from 20 to 90 minutes sessions 1-2 times a week, for 4 to 11 weeks. Two articles, one each of Level II and III evidence, addressed training in device use, providing low strength of evidence to improve ADL performance post-TBI. These devices may include the BrainPort Vision Pro, prisms, a dichoptic device, or a cheiroscope with 4-10 hours of training.
CONCLUSION: Based on moderate strength of evidence, we recommend routine use of oculomotor and compensatory scanning training for individuals experiencing visual symptoms post-TBI. Device use training should be done on a case-by-case basis due to low strength of evidence. Many of the interventions in this systematic review were exercise- rather than occupation-based. Rote eye exercises without link to occupation may be considered outside the occupational therapy scope of practice, therefore integration with occupation and collaboration with an eye care professional is important.
Practitioners should consider collaborating with researchers to design occupation-based interventions that can be tested with larger sample sizes to determine effective interventions to improve ADL performance in adults post-TBI experiencing visual symptoms. Professional development can ensure occupational therapists have advanced training and education in oculomotor and compensatory scanning.
IMPACT STATEMENT: Current research supports oculomotor and compensatory scanning training for adults post-TBI experiencing visual symptoms. Future research should continue to explore occupation-based interventions for this population to maximize visual function for performance of everyday activities.
Centers for Disease Control and Prevention. (2022, January 6). Multiple cause of death data on CDC wonder. Centers for Disease Control and Prevention. https://wonder.cdc.gov/mcd.html
Richman, E. (2014, March). Traumatic brain injury and visual disorders: What every ophthalmologist should know. American Academy of Ophthalmology; EyeNet Magazine. https://www.aao.org/eyenet/article/traumatic-brain-injury-visual-disorders-what-every-2
Effectiveness of Functional Cognition Intervention for Adults with Traumatic Brain Injuries: A Systematic Review
Lauren McCormick, Madison Otte, Delaney Hill, Emily Leahy, Stacy Smallfield, and Molly Whitlow
Purpose: An estimated 5.3 million Americans are living with a permanent disability due to having a traumatic brain injury (TBI) (CDC, 1999). A common deficit seen in this population includes impaired functional cognition, which is the ability to use and integrate thinking and processing skills to complete complex instrumental activities of daily living (IADLs) (Giles et al., 2017). Occupational therapy practitioners support individuals post-TBI by creating and implementing occupation-based interventions during rehabilitation to optimize functional cognition and improve individuals' ability to complete IADLs. This study aims to identify the effectiveness of interventions within the scope of occupational therapy practice to improve functional cognition in adults with post-TBI.
Design: This systematic review included randomized controlled trials published in peer-reviewed journals between 2010 and 2022, which addressed adults with TBI, and implemented functional cognition interventions which were within the scope of occupational therapy practice.
Method: Results from four literature databases produced 1154 articles. Duplicate articles were removed (n=19). Teams of two researchers screened the titles and abstracts of each of the remaining 1135 articles to determine eligibility for full-text review. Next, the full text of 289 articles were reviewed to determine if they met the study’s inclusion criteria; eight articles were included in the systematic review. The U.S. Preventative Services Task Force levels of certainty and grade definitions were used to describe the strength of evidence.
Results: The eight studies included in this systematic review were categorized into two themes: simulated electronic-based interventions and metacognitive strategy training. Three articles addressed simulated electronic-based interventions, which examined the effectiveness of Cognitive Symptom Management and Rehabilitation Therapy (CogSMART) and virtual reality training (VTR). All three articles supported the use of simulated electronic-based interventions, though the strength of evidence is classified as moderate, given their methodological limitations, which included small sample sizes and differences in participant characteristics at baseline. Five articles addressed metacognitive strategy training, of which four supported its effectiveness. This evidence is classified as moderate, in light of methodological limitations, including small sample sizes and heterogeneity of the interventions.
Conclusion: Occupational therapists have a critical role in selecting and implementing intervention strategies that will aid in rehabilitating functional cognition. Based on the findings of this review, occupational therapy practitioners should consider routinely implementing metacognitive strategy training and simulated electronic-based interventions to enhance functional cognition in adults following a TBI. Occupational therapy educational programs should address these interventions in occupational curricula. Additional research is warranted to address the heterogeneity of outcome measures and interventions.
Center for Disease Control and Prevention. (1999). Report to Congress: Traumatic brain injury in the United States. U.S. Department of Health and Human Services. https://www.cdc.gov/traumaticbraininjury/
Giles, G. M., Edwards, D. F., Morrison, M. T., Baum, C., & Wolf, T. J. (2017). Screening for functional cognition in postacute care and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. The American Journal of Occupational Therapy, 71(5), 7105090010. https://doi.org/10.5014/ajot.2017.715001
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