Stroke And Occupational Therapy
Aim: The aim of this review is to explore the extent to a person with stroke performs, participates and engage in their everyday occupations post stroke by reviewing and critiquing both qualitative and quantitative research articles.
Research context: Stroke is a medical condition that occurs when the blood supply to the brain decreases, causing brain cells to damage (Stroke Association,2018). In the UK there are over 100,000 people affected by stroke each year, which results in death or disability (Stroke Association,2018). As a result, a significant proportion of resources are needed for immediate and continuing care, costing the NHS from £3. 4 billion, however, due to an increase in the ageing population the burden of stroke is expected to increase in the future(Stroke Association, 2017). Individuals who are over 65 years of age are more likely to have a stroke, although 25% of strokes occur in people who are under 65 years of age (NHS Choices,2019). The Act FAST campaign is launched by the UK government to help people spot the sign of stroke. This is targeted to individuals who belong to Afro-Caribbean origin as they have a greater risk of having a stroke (GOV. UK,2018). The main effects of stroke include sensory and motor problems, cognitive impairment, perceptual impairment, communication disorders and emotional changes (McKenna et al,2009). These consequences of stroke limit a person’s ability to engage in self-care, productivity and leisure occupations (Hammel,2004), reducing life satisfaction (Clarke et al,2002). According to Borg, Hallber & Blomqvist,(2006) life satisfaction in elderly people who relied on a carer for self‐care was reduced, which was related to a person’s social, physical, mental and financial circumstances. In order to overcome these disruptions faced by stroke patient, they need to re-engage and participate in meaningful occupations to maintain their health and wellbeing (Wilcock,2007). Moreover, being able to recapture an occupation after stroke can help to regain the individual’s identity which therefore, preserves the sense of self, influencing positive wellbeing(Eriksson & Tham,2009). The main purpose of occupational therapy is to restore a match beneficial to the individual between their own abilities, demands of their environment and occupations (Creek,2003). Occupational participation is limited after stroke which reduces health and wellbeing, as a result, the therapist provides advice and training on lost performance skills for improvement of participation in society, functional abilities and increased quality of life are important outcomes of occupational therapy (Royal College of Occupational therapy,2017). However, there is little evidence that supports the use of virtual reality and driver education programs interventions to improve occupational performance in instrumental ADLs post stroke (Wolf et al. ,2014).
Methodology: Relevant articles were identified and retrieved from an electronic search of CINAHL, Scopus and ProQuest. These different databases were used to explore a range of journal articles, in order to acquire the most appropriate and quality articles for this review. Formulated keywords used in the database included: stroke, post-stroke, after stroke, occupational participation, occupational performance, occupational engagement, engaging and occupations. These searches were conducted using the Boolean operator to ensure large amount of hits were achieved (De Brun &Pearce-Smith,2009). Truncation was also used which is a use of symbols such as asterisks (*) which was used to reduce search steps and increases the number of articles. The inclusion criteria are everything that is vital in a study, in order to be included in the review(Salkind,2010). The articles published within the last 10 years period from 2009-2019 were set in inclusion criteria to guarantee up-to-date articles. Inclusion criteria also involved publications being in the English language. Exclusion criteria are the factors that would make a study unsuitable to be included in the review(Salkind,2010). Exclusion criteria ensured that non-English articles are not included. The CASP qualitative checklist was used to review and critique articles that conducted qualitative research methodology. Furthermore, Step-by-step guide to critiquing research article by Coughlan, Cronin &Ryan,(2007) was used to critique articles that conducted quantitative research. In order to review the four chosen articles, a literature review grid was created(see appendix), this helped to sort out ideas about the specific areas that could be critiqued.
Critique:
This research study is quantitative research. Quantitative research is a research method covering the phenomena using numerical form, frequencies, and distribution(Flick,2015). A sufficient amount of detail was given of sample selection, suggesting that participants were recruited from the hospital stroke unit between 2006 to 2007. As only the hospital-based population of Swedish individuals were included, the results cannot be generalised to other settings and also to other cultures therefore, it contains cultural bias (Pannucci &Wilkins,2010). This research is a longitudinal study as it helps to learn about cause and effect relationship between satisfaction and participation in occupations following 5 years prior stroke. In a longitudinal study participants are studied over time to collect data with continuous monitoring (British medical Journal,2019). However, one of the disadvantage of the longitudinal study was that the sample size decreased from 349 to 121, which could be due to withdrawal, changes in contact details, incapability or death, reducing the usable data that can be used to formulate a conclusion. 70 out of 121 responded to the questionnaire, this is considered a good response rate according to Taylor,(2007), however, the researcher did not implement specific strategies such as sending reminders to ensure a higher response rate. Higher response rate is need in quantitative research to increase sample size thereby providing generalised results.
Although oral and written consent was gained to take part in the study, it does not mention clearly whether informed consent was gained by patients when data was extracted from the medical records. This is an ethical issue because the patients are not informed of how and where their data will be used, which goes against the data protection act (GOV. UK,2018). The study also does not mention what information was given to participants or if there were any issues with communication. It does not focus on safety or address any issues with confidently, leading to risk for participants and the researcher (Cormack,2000).
The Occupational Gaps Questionnaire was used for data collection. It is not clear, whether the Occupational Gaps Questionnaire (OGQ) was self-reported by the participants in their own time or if the researcher was present when the questionnaire was being completed. This could be a weakness as the issue of researcher bias, may lead to influence of some sort, especially in vulnerable stroke patients (Shuttleworth,2009). As questionnaires are considered as tools that remove bias, however if they are remotely administrated, it becomes difficult to ensure whether they are completed honestly or by the target population(Gillham,2000). As the method of data collection was not made clear for the vulnerable adults it may constitute another ethical issue to arise and also this result may be problematic for replication and rigour (Cormack,2000). The Occupational Gaps Questionnaire requires yes or no answer but does not offer a neutral answer which is neither yes or no. Therefore, participants with no other options may answer anyway. They also found that participants who did not respond to one or more questions from the questionnaire they were excluded from the study, this can be considered as a strength because if this study is carried out again, they will gain the same results ensuring reliability and validity (Taylor,2007). According to Burns & Groves (2007), reliability is the accuracy of the measurement method and when the method is repeated it provides the same results and validity is how well a piece of research measures what they aimed to measure.
The data analysis was undertaken using descriptive statistics to understand the characteristics of the participants which was presented as percentages and results of the OCQ were presented on a bar chart. The bar chart was used to represent categorical data from the OCQ, which is appropriate and provides a clear and better understanding of the results (Ware & Brewer,2013). In addition, McNemar/Chi-square was used to test the relationship between participation restrictions and individuals with no participation restrictions according to age and satisfaction levels of the participants. Using McNemar/chi-square was appropriate because the Occupational Gaps Questionnaire produced categorical data, which is a suitable use for a quantitative study. According to Gitlin et al,(2001) the P value set at 0. 05, is acceptable, because lower the P value, there is greater significance of the results and less likely results are due to chance.
This research study conducted quantitative research. The participants for this study were recruited through convenience and snowball sampling. Snowball sampling is an appropriate method to use for this quantitative study and it involves one participant to nominate other similar people who might be suitable to take part in the study. (Taylor,2007). Convenience sampling is mostly used in larger scale studies (Sim & Wright,2000), therefore it might be an inappropriate method to conduct for this study, as the sample size only consisted of 23 participants. This small sample is also considered small for a quantitative study according to World Health Organisation,(2018) as they suggest that for quantitative methods sample size needs to be big enough for generalisation but small enough to allow intensive study method, therefore, at least 30 participants should be chosen for the study. Furthermore, 70% of the participants were men, therefore, the results would be more biased towards men than women because according to Vaughan & Hogg,(1995) gender differences have effects on use of time and role participation which may confound some of the results. Convenience sampling participants are selected from a group who happen to be available (Taylor,2007). As the participation was voluntary, the individuals may have volunteered because they take part in activities and roles and found the research topic interesting, this makes it likely to produce biased sample as many people are not getting the chance to be sampled (Taylor,2007).
The author has not mentioned any ethical issues concerning about the welfare of the participants. The researcher also did not mention about informed consent; however, it can be presumed that informed consent was gained from every participant as they volunteered to take part in research. Informed consent refers to participants having sufficient information related to the research (Surrena,2011).
The data was collected using the interviews by administrating different instruments such as Activity Configuration, Role Checklist, Life Satisfaction were administered. This is a strength because researchers used different established instruments, which suggests that they have been validated, further increasing the quality of research (McColl et al,2001). Face-to-face interviews were completed which are appropriate to gain insight into a person’s perspectives, however, individuals may have unknowingly altered their responses to show more of a positive and active life experience, reducing the validity and reality of the results. The researchers used Activity Configuration which relies on retrospective recall, which could have produced inaccurate data. Retrospective recall involves events and experiences from past (Flick,2015). The author used Statistical Package for Social Sciences (SPSS) to carry out statistical analysis. SPSS is an established statistical programme, which is used to generate descriptive statistics for each variable, but data is not presented in a lot of detail (Taylor,2007).
This research study conducted qualitative research. Qualitative research study takes place in the natural settings to interpret, phenomena from a person’s perspective (Flick,2015). The sample in this study is described as a non-probability purposive sample and this is a suitable method of sampling for a qualitative study(Juanita,2005). In non-probability purposive sampling not all individuals in the population has a chance of participating in study, but this method produces lower level of generalisation (Juanita,2005). According to Braun & Clarke,(2013) explains that rigour is less likely to be established using purposive sampling, however, Ritchie & Lewis,(2003) explains that rigour in a qualitative study is not necessary, because the main concern is to gain insight on a particular phenomenon.
The sample included seven participants and one carer to provide conversational support for a participant with aphasia, which is a strength because this study can be applied for people with communication difficulties. A participatory design approach was suitable for this qualitative study because it transfers the objective of handling power from researcher to research participant such as the use of focus group to provide personal thoughts and feelings of the participants. Although the sample consisted of seven participants proposing low transferability to the wider stroke population, but Barbour,(2008) explain that in qualitative research small focus group sizes are acceptable. The researchers imposing their own perspective was reduced (Goodley & Lawthom,2006) by engaging the participants in focus groups rather than carrying out a semi-structured interview, increasing the trustworthiness of the study. Focus groups involve a group of people invited to discuss about a specific issue (Flick, 2015). Using focus groups in a qualitative study was a strength as it reduced conformity but elicited individuals to express their experiences and provided a range of opinions, which was in focus with study’s aim. However, according to Barbour,(2008) some participants may have felt intimidated, increasing pressure to agree with dominant views, but this was made clear within the limitations section that participants were familiar with each other and displayed no dominant point.
The researchers are experienced stroke therapists, but the study did contain elements of neutrality, which means the study contains no biases or social influence from the researcher (Krefting,1991) because peer review was undertaken by two independent reviewers which stimulated the condition of a different perspective providing confirmability (Krefting,1991).
Thematic analysis was used to analyse data, this method is appropriate for qualitative research as it indicates recurrent thoughts and feelings (Mays,Popay & Pope,2007). There is sufficient detail on each theme, and includes several direct quotes, which leads to transparency of the research (Dale,2005). Transparency means to establish quality of research and to be explicit and clear on the presentation of the findings (Moravcsik,2013). As well as this there are models and graphical representation of the findings which showed how the themes were arrived, enhancing accessibility. The visual method e. g. photography can be critiqued for the lack of objectivity, but formal analysis was only used from focus groups. However, Gaver et al,(2004) argue that visual methods help to understand lives of participants and should not be quantified. There was also a limitation for the use of disposable camera because participants with limited upper motor movement or who lived alone wasn't able to take the camera home, therefore could not take part in the photography activity, providing limited photographs needed for interoperation.
