555876

research-article2014

CRE0010.1177/0269215514555876Clinical RehabilitationTomori et al.

CLINICAL
REHABILITATION

Article

Comparison of occupation-based
and impairment-based occupational
therapy for subacute stroke: a
randomized controlled feasibility
study

Clinical Rehabilitation
2015, Vol. 29(8) 752762
The Author(s) 2014
Reprints and permissions:
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DOI: 10.1177/0269215514555876
cre.sagepub.com

Kounosuke Tomori1, Hirofumi Nagayama1, Kanta

Ohno2, Ryutaro Nagatani1, Yuki Saito3, Kayoko
Takahashi4, Tatsunori Sawada5 and Toshio Higashi6

Abstract
Objective: To compare occupation-based and impairment-based approaches in occupational therapy
and determine the feasibility of patient recruitment and retention.
Design: A multicenter, randomized, controlled pilot trial with a single blind assessor.
Setting: Ten subacute rehabilitation units in Japan.
Participants: Fifty-four patients with subacute stroke.
Interventions: The experimental group used the iPad application, Aid for Decision-making in Occupation
Choice, to establish occupation-based goals, and evaluation and intervention were conducted mainly
through real occupations. The control group was evaluated according to patients generic abilities and
activities of daily living (ADL), and the intervention mainly involved the impairment-based approach.
Main outcome measures: Short Form-36, Functional Independence Measure, Brunnstrom recovery
stages, The Client Satisfaction Questionnaire, and length of hospital stay.
Results: Of the 1465 potential participants, 54 (3%) subacute stroke patients were enrolled over 16
months and 68% (n = 36) were retained to the 2-month assessment: experimental group (n = 16);
control group (n = 21). Although there was no significant intergroup difference for any outcomes, the
experimental group had a small effect size advantage on the Short Form-36 General health (d = 0.42)
and Role emotional (d = 0.43) subscales relative to the control group. A sample of 118 subacute stroke
patients per group would be required for a lager study.

1Department

of Occupational Therapy, Kanagawa University

of Human Services, Yokosuka, Kanagawa, Japan
2Graduate Course in Health and Social Care, Kanagawa
University of Human Services, Yokosuka, Kanagawa, Japan
3Department of Occupational Therapy, Koriyama Institute of
Health Science, Koriyama, Fukushima, Japan
4Department of Occupational Therapy, Kitasato University,
Sagamihara, Kanagawa, Japan
5IMS Itabashi Rehabilitation Hospital, Itabashi, Tokyo, Japan

6Department

of Community-Based Rehabilitation Sciences,

Unit of Rehabilitation Sciences, Nagasaki University Graduate
School of Biomedical Sciences, Sakamoto, Nagasaki, Japan

Corresponding author:
Kounosuke Tomori, Occupational Therapy, Kanagawa
University of Human Services, Yokosuka, Kanagawa, 2388522, Japan.
Email: adoc.project@gmail.com

753

Tomori et al.

Conclusions: Results suggest that the occupation-based approach has more potential to improve
General health and Role emotional scores on the Short Form-36 than the impairment-based approach.
Further investigation of study protocol with interventions and recruiting is needed prior to a larger trial.
Keywords
Occupational therapy, occupation-based, impairment-based, activities, Aid for Decision-Making in
Occupation Choice
Received: 18 May 2014; accepted: 25 September 2014

Introduction
The World Health Organization1 has recently
focused attention on activities and participation
with the development of the International
Classification of Functioning, Disability and
Health. Occupational therapy associations24 and
researchers58 have emphasized that occupational
therapy evaluation and intervention should always
be based on an occupation (purposeful and meaningful activities for individual and social context)
rather than the impairments or body structure (the
occupation-based approach).
There are various opinions about occupationbased practice, and Zemke9 states three key points
about the occupation-based approach: 1) assessment
includes occupational interviewing and skilled
observation in the most natural context possible, 2)
treatment uses occupation in the most natural context
possible, and 3) goals focus on facilitating engagement in occupation and participation in community
life, rather than solely on reducing impairments in
the persons body structure and function.
However, the occupation-based approach was
seen as more difficult in a medical-based facility.10
Especially, the occupation-based approach with subacute stroke is controversial because occupational
therapy for this stage of stroke needs to maximize the
recovery of motor and cognitive function and prevent the development of secondary impairment.
Although there was substantial evidence that occupational therapy improves body-function and activities
of daily living (ADL),11,12 research has yet to be carried out about the effect of occupation-based
approach for subacute stroke patients. Thus, the
majority of occupational therapists time was clearly
spent using impairment-focused activities.1316

Recently, we have developed an iPad (Apple)

application, Aid for Decision-making in Occupation
Choice, to promote shared decision-making in occupation-based goal-setting using a systematic process.1719 This application involves the client choosing
from 94 illustrations describing daily activities related
to the category of activities and participation.17 Our
case studies showed that this application could facilitate the use of the occupation-based approach for
subacute stroke patients in rehabilitation units, even if
they had aphasia20 and dementia.21
Before undertaking a larger trial to investigate
the occupation-based approach using Aid for
Decision-making in Occupation Choice for subacute stroke patients, we aimed to determine the
effectiveness of the occupation-based approach for
subacute stroke patients relative to active control
and the feasibility of recruiting and retaining
patients in multicenter rehabilitation units. In this
pilot study, we posed the following questions:
1) Is there a difference between the efficacy of
occupation-based and impairment-based occupational therapy for subacute stroke patients?
2) If so, what is the direction and magnitude of
the difference?
3) How feasible is this study design in subacute
stroke rehabilitation units?

Method
The present study was a multicenter pilot randomized controlled trial with a single blind assessor.
The study was approved by the ethics committee at
the Kanagawa University of Human Services (No.
23-028).

754
The study was conducted in the Kaifukuki (convalescent) rehabilitation wards of 10 subacute
rehabilitation units in Japan.22 Patients for whom
the onset of disabling diseases, including stroke,
traumatic brain injury, other neurological diseases,
and orthopedic diseases such as hip fracture, had
occurred within the previous three months were
eligible for admission to the Kaifukuki rehabilitation wards. The maximal duration of stay following a stroke is 180 days. The duration of
occupational, physical, or speech therapy sessions
was up to three hours per day in total, and the proportion of therapy time was decided according to
the needs of each patient in order to improve ADL
and discharge them.
In order to use the intervention in the current
study, we divided occupational therapy interventions used in the wards into four categories (see
online Appendix): (1) basic function exercises, (2)
simulated occupational practice, (3) real occupational practice using Personal-ADL, and (4) real
occupational practice excluding Personal-ADL.
Based on a preliminary study in Kaifukuki rehabilitation wards (data not shown), (1) and (2) were
conducted to remediate capacities and abilities, and
(3) and (4) were conducted to adapt, educate, or
restore activities.
Participants included patients with hemiparesis,
at the subacute stage of stroke, who were hospitalized in Kaifukuki rehabilitation wards between
August 2012 and November 2013. Participants
were required to meet all of the following criteria:
aged 40; stroke caused by a cerebral infarct or
intracerebral hemorrhage onset; onset of stroke
30 days; no major cognitive deficits (i.e., participants did not have scores 24 on the Mini-Mental
State Examination),23 aphasia, or depression as an
obstacle to daily living; and the patient was
attended to (charged) by a research occupational
therapist who was not involved in study allocation.
In addition, we excluded patients who had cardiac
or progressive disease, were judged by a primary
physician as unable to undergo occupational therapy, or were attended to (charged) by an occupational therapist who did not participate in study. No
formal power calculation was performed because
this was a pilot study.

Clinical Rehabilitation 29(8)

Trial occupational therapists in each facility that
were not involved in assessment and intervention
gave all eligible patients written and verbal information regarding the study purpose and methodology. After being provided with the time required to
decide whether they wished to participate, patients
who wished to do so signed informed consent
forms.
An individual research assistant used the random number generator in Microsoft Excel to generate a randomization sequence, which remained
unknown to any of the staff except the research
assistant. Patients were randomly assigned, using
blocked randomization (block size 4), to either the
experimental group (occupation-based) or the control group (impairment-based), which was stratified according to motor function levels determined
via completion of the Japan Stroke Scale-Motor
function24 (mild > 10 or moderate 10, with lower
scores indicating better functional status.
The trial occupational therapists enrolled the
participants, who were then assigned, according to
the randomization sequence, to the experimental or
control group by the research assistant. Before
each assessment, patients and caregivers were
asked not to inform the assessors about the intervention. All trial occupational therapists received a
16-hour lecture in the use of an occupation-based
approach for patients with subacute stroke. After
the lecture, the research group and trial occupational therapists instructed occupational therapists
that were to intervene with study participants
(patients).
In the experimental group, participants and
occupational therapists began to share and identify meaningful occupations (i.e., activities and
participation according to the ICF) for the participants, using the Aid for Decision-making in
Occupation Choice application.1719 The Aid for
Decision-making in Occupation Choice involves
the choice of 94 illustrations describing daily
occupations related to activities and participation. By choosing illustrations, patients and
occupational therapists decide on goals and prioritized occupations that affect occupational therapy interventions. Our previous study showed
that Aid for Decision-making in Occupation

Tomori et al.
Choice is a useful tool to facilitate the establishment of activity and participation level goals
according to a systematic and flexible strategy.
After setting the activity and participation level
goals, occupational therapists then observed the
participant performing the selected occupations
and assessed occupational performance.
The interventions focused on acquiring occupation through real occupation-based practice (e.g.,
using chopsticks to eat food, cooking, knitting).
During the hospital stay, the majority of the intervention time (more than two-thirds) was allocated
to real occupational practice (both with and excluding Personal-ADL), and as appropriate, the remaining one-third of intervention time was allocated to
basic function exercises and simulated occupational practice (see online Appendix). Physiotherapy
and/or speech therapy was undertaken as usual,
concurrent with occupational therapy.
In the control group, evaluations were focused
on improving the patients impairment (i.e., bodily
functions and structures according to the ICF) and
personal ADL through physical and cognitive testing. The therapists did not use goal-setting tools
such as the Canadian Occupational Performance
Measure25 or Goal Attainment Scaling.26
The interventions focused on restoring capacities (e.g., neuromuscular facilitation, muscle
strength exercises, cognitive training). During the
hospital stay, the majority of the intervention time
(more than two-thirds) was allocated to basic function exercises and simulated occupational practice,
and as appropriate, the remaining one-third of the
intervention time was allocated to real occupational practice (see online Appendix). Physiotherapy
and/or speech therapy practice was undertaken as
usual. This intervention was typical practice for all
occupational therapists that participated in this
study. Thus, in the control group intervention, the
rehabilitation design followed the format of the
ordinary rehabilitation programs offered by the
Kaifukuki wards (data not shown).
For the outcome assessments, we employed the
Short Form-36,27,28 Brunnstrom recovery stages,29,30
and Functional Independence Measure,31 on pre- and
post-interventions (two month period). The Client
Satisfaction Questionnaire32 and duration of stay

755
were assessed at discharge. Assessments were made
by trained occupational therapists or physical therapists that were blinded to patients group
assignment.
The Short Form-36 was used to assess healthrelated quality of life. These scores are standardized to provide a norm-based score with a mean of
50 and standard deviation of 10 (scale range from
0100, with higher scores indicating better health
status).
Brunnstrom recovery stages were used because
the stages reflect underlying motor control based
on clinical assessment of movement quality from
flaccid (palsied) to nearly normal. Higher
Brunnstrom recovery stages indicate better motor
recovery.
The Functional Independence Measure is
widely used to measure activity limitation in terms
of how much help the subject requires in order to
perform basic physical and cognitive activities, via
performance observation. The degree of assistance
required is scored from 1 (total assistance) to 7
(complete independence) and a total score is
expressed by simple summation (the scale ranges
from 18126, with higher scores indicating better
functional status).
The Client Satisfaction Questionnaire contains
8 items. Patients respond to these items using a
4-point Likert scale. Their responses are scored
from 14, and the total possible score ranges from
832. Higher scores indicate greater satisfaction.
We compared baseline characteristics and
between-group outcomes using a two-tailed independent t-test (continuous measures with ordinal
scale data were assessed using the Mann-Whitney
U test) and a chi-square test (for categorical data).
Primary outcomes were assessed two months later.
Intervention effects were tested by examining the
changes in scores (post-test minus baseline) for
each outcome variable. We used a two-tailed independent t-test for between-group comparisons and
a paired t-test (ordinal scale data were analyzed
using Wilcoxons signed rank test) for comparison
of baseline and post-test outcome changes.
We calculated two-tailed 95% confidence intervals and effect sizes (Cohens d), with effect sizes
of 0.3, 0.5, and 0.8 considered small, medium,

756

Clinical Rehabilitation 29(8)

Figure 1. Enrollment of patients.

and large, respectively.33 All outcomes were

assessed according to intention-to-treat analysis.
For all analyses, P < 0.05 was considered statistically significant. SPSS for Mac ver. 21 (IBM) and
R were used for all data analyses.

Results
Figure 1 provides the CONSORT flow diagram
and details of the screening, enrolment, and
delivery of the intervention, whereby 3%
(54/1465) of subacute stroke patients were
enrolled in this study, and 68% (36/54) were
retained up to the two-month assessment. Of the
54 participants, 11 patients in the experimental
group (8 had been discharged early within the
first two months, 2 deteriorated, and 1 was not
suited to the experimental group due to cognitive
dysfunction) and 6 patients in the control group

(4 had been discharged early within the first two

months, 1 deteriorated, and 1 refused) withdrew
immediately before the two-month assessment.
Table 1 shows baseline clinical characteristics.
There were no significant differences between
groups in these characteristics except in sex.
Table 2 shows the outcome results. In the comparison of pre- versus post-intervention outcomes,
Short Form-36 subscale scores for Physical functioning and Physical component summary
increased significantly in both experimental and
control groups. The subscale scores for General
health and Role-emotional increased significantly only in the experimental group, and
Vitality increased significantly only in the control group. The post-intervention outcomes for
Brunnstrom recovery stages and the Functional
Independence Measure also increased significantly
in both the experimental and control groups.

757

Tomori et al.
Table 1. Patients pre-intervention characteristics.
Characteristics

Experimental
(n = 27)

Control
(n = 27)

Total (N = 54)

Age, Mean (SD)

Sex, n (%)
Male
Female
Affected side, n (%)
Right
Left
Double
JSS-M, Mean (SD)
MMSE, Mean (SD)

68.26

10.90

64.19

10.16

66.22

10.64

22
5

81.5%
18.5%

36
18

66.7%
33.3%

14
12
1
10.45
26.89

48.1%
48.1%
48.1%
6.92
2.55

26
27
1
9.88
26.35

48.1%
50.0%
1.9%
6.95
2.86

0.16

0.02

0.50

0.55
0.17

14
13

51.9%
48.1%

12
15
0
9.30
25.81

44.4%
55.6%
0.0%
7.06
3.10

JSS-M: Japan Stroke Scale-Motor function, MMSE: Mini-Mental State Examination.

2 tests,Students t-tests.

Comparing the experimental and control groups,

a small effect size was observed in Short Form-36
General health and Role-emotional scores in
the experimental group. However, we did not
detect a statistically significant difference between
experimental and control group in General health
(P = 0.22, d = 0.42, 95% CI = 4.7 to 20.0) and
Role-emotional scores (P = 0.21, d = 0.43, 95%
CI = 11.7 to 52.1). There were no significant differences in any post-intervention outcomes
between the experimental and control groups.
We focused on Short Form-36 General health
and Role-emotional scores to estimate the
required sample size for the definitive future study.
The difference in Role-emotional changes in
scores between the experimental and control
groups was 20.2 (SD = 47.8) points, and the effect
size (Cohens d) was 0.43. The difference in
General health changes in score between the
experimental and control groups was 7.7 (SD =
18.4) points, and the effect size (Cohens d) was
0.42.
Power was calculated using these results, with
80% power, a two-sided effect, and a type I error
rate of 5%. Assuming a loss to follow-up of 33% at
two months (in this study, the number of participants at recruitment was 24 and the number of primary analysis participants was 16), the study was
powered to detect an effect size of 0.4 and a
20-point difference in the Short Form-36 Role

emotional score, with a minimum sample size of

118 patients per group.

Discussion
Our results have shown that both occupation-based
and impairment-based approaches to occupational
therapy for inpatients with subacute stroke are
effective in improving health-related quality of life
and recovering physical function and self-care.
Guidetti etal.34 reported that new client-centered
self-care interventions improved ADL, life satisfaction, and caregiver burden for inpatients with
strokes; however, there is no significant difference
from the ordinary intervention. Previously, several
studies demonstrated that occupational therapy
focused on improving Personal-ADL after stroke
and focused body function can improve performance.11,12 Detecting marked differences in the
occupation-based approach relative to ordinary
occupational therapy requires ample studies of the
systematic program to a larger study.
Interestingly, although there were no significant
differences between the groups in any outcomes,
Short Form-36 subscale scores for General health
and Role-emotional significantly increased postintervention in only the experimental group, and
small effects were detected in General health and
Role-emotional subscale scores in the experimental group.

Pre

Short Form-36 V2
Physical
25.0
function
(18.3)
Role
30.1
physical
(35.9)
Bodily pain 65.6
(27.7)
General
48.1
health
(20.6)
Vitality
43.4
(27.9)
Social
57.8
functioning (35.0)
Role
45.3
emotional (39.3)
Mental
54.1
health
(29.5)
Physical
18.8
composite (13.6)
Mental
58.3
composite (11.9)
Role
27.5
composite (20.7)

49.1
(31.8)
45.7
(38.6)
62.5
(30.4)
61.9
(18.7)
54.3
(25.9)
53.1
(36.7)
73.4
(33.2)
59.4
(27.1)
32.0
(16.2)
56.3
(14.7)
32.8
(18.7)

Post

24.1
(17.1)
15.6
(47.2)
3.1
(29.2)
13.8
(18.8)
10.9
(21.2)
4,7
(35.0)
28.1
(40.4)
5.3
(26.5)
13.2
(7.5)
2.0
(14.3)
5.28
(29.15)

33.3
(29.6)
31.8
(34.5)
67.1
(27.3)
56.8
(21.3)
51.5
(18.5)
58.3
(28.3)
46.8
(41.2)
61.7
(20.9)
23.1
(15.2)
62.2
(11.1)
25.5
(20.72)

58.1
(24.8)
36.9
(38.1)
66.0
(24.9)
62.9
(20.0)
62.5
(19.2)
51.2
(35.1)
54.8
(40.5)
64.0
(23.8)
36.6
(12.3)
61.1
(12.2)
23.0
(24.3)

Post

24.8
(29.6)
5.1
(49.8)
1.1
(30.8)
6.1
(17.9)
11.0
(22.7)
7.1
(41.8)
7.9
(52.1)
2.4
(27.6)
13.4
(17.6)
1.0
(9.4)
2.5
(29.2)
0.78

0.32

0.37

0.37

0.91

0.96

0.32

0.22

0.87

0.88

0.33

0.26

0.15

0.88

0.19

0.77

0.13

0.41

0.70

0.11

0.42

0.93

(95% CI) d

Experimental
pre vs post

0.03 <0.0001 (33.2 to

14.9)
0.22
0.21 (40.8 to
9.5)
0.07
0.67 (12.4 to
18.7)
0.42
0.01 (23.8 to
3.7)
0.00
0.06 (22.2 to
0.4)
0.06
0.60 (14.0 to
23.3)
0.43
0.01 (49.6 to
6.6)
0.11
0.44 (19.5 to
8.8)
0.02 <0.0001 (17.1 to
9.2)
0.08
0.58 (5.6 to
9.6)
0.30
0.34 (16.7 to
6.1)

(95% CI) d

0.93 (16.5 to
15.1)
0.52 (22.2 to
43.4)
0.84 (22.3 to
18.3)
0.22 (4.7 to
20.0)
0.99 (14.9 to
14.8)
0.85 (23.8 to
28.7)
0.21 (11.7 to
52.1)
0.75 (15.3 to
21.2)
0.96 (9.0 to
8.5)
0.80 (8.9 to
6.9)
0.38 (9.8 to
25.4)

Baseline Experimental vs
control
change score

Change P
score

Control group (n=21)

mean (SD)

Change Pre
score

Experimental group
(n=16)
mean (SD)

Table 2. Pre-post intervention outcomes.

0.70

0.62

0.002

0.70

0.49

0.44

0.04

0.14

0.87

0.65

0.001

0.11

0.13

0.84

0.36

0.43

0.31

1.02

0.23

0.14

0.47

0.86

(Continued)

(38.3 to
11.3)
(27.7 to
17.6)
(12.9 to
15.1)
(14.2 to
2.1)
(21.4 to
0.7)
(11.9 to
26.1)
(31.6 to
15.8)
(14.9 to
10.2)
(21.5 to
5.4)
(3.2 to
5.3)
(10.8 to
15.8)

(95% CI) d

Control
pre vs post

758
Clinical Rehabilitation 29(8)

Pre

Post

0.6
(0.9)

Post

0.61 (9.7 to 0.29 0.0001

5.8)
0.56 (2.3 to 0.1
4.2)
0.32 (13.6 to
41.2)

28.9
(3.5)
115.5
(40.8)

15.7
(14.1)

110.6
(14.2)

0.22 0.046

0.77

4.9 (0.8) 0.4 (0.7)

0.02

0.05 0.046

0.96

0.25

(95% CI) d

(17.37 0.68
to 6.88)

0.16

0.15

0.33

(95% CI) d

Experimental
pre vs post

4.5 (1.4) 0.4 (0.8)

0.73

Baseline Experimental vs
control
change score

Change P
score

4.1 (1.4) 4.5 (1.2) 0.4 (0.6)

Change Pre
score

Control group (n=21)

mean (SD)

4.3 (1.6) 4.6

0.3
4.2 (1.4)
(1.7)
(0.4)
leg
4.3 (1.5) 4.6
0.3
4.5 (1.2)
(1.6)
(0.4)
Functional Independence Measure (total)

93.8
105.9 12.1
94.9
(19.7) (16.1) (9.9)
(23.3)
Client Satisfaction Questionnaire

28.6
(4.2)
Duration of stay

129.3
(40.5)

finger

Brunnstrom
recovery stages
arm
3.8 (1.8) 4.4
(1.7)

Experimental group
(n=16)
mean (SD)

Table 2. (Continued)

0.36

0.21

0.29

(95% CI) d

0.00005 (19.81 0.79

to 8.38)

0.02

0.17

0.01

Control
pre vs post

Tomori et al.
759

760
Shinohara etal.35 reported that occupational
therapy interventions, which is the model of human
occupation based on patient needs for residents
with chronic stroke, tended to improve Short Form36 Role-emotional and General health scores
in a pilot randomized controlled trial. Moreover,
Egan etal.36 reported that community-based occupational therapy, which is a client-centered occupation-based approach guided by the Canadian Model
of Occupational Performance and the Occupational
Performance Process Models, only improved Short
Form-36 Role emotional scores. Our results and
those of previous studies35,36 suggest that Short
Form-36 General health and Role-emotional
scores tended to reflect the efficacy of the occupation-based approach.
Indeed, the definition of occupational therapy is to
promote health and well-being through occupation,
and the primary goal is to enable people to participate
in the ADL.2 Thus, health and daily activities are considered to be closely related to occupational therapy.
In this study, the experimental group evaluation and
intervention centered on identifying activities and
participation that were meaningful to the patient, and
then practicing these activities. We speculate that
improvement areas of Role-emotional and General
health in the experimental group was reasonably
reflected and accepted as a result of the intervention.
Regarding the feasibility of the study design, no
major issues arose with respect to managing the current study, including the multicenter trial and multidisciplinary team approach. Based on the Short
Form-36 General health and Role-emotional
results, a sample of 118 subacute stroke patients per
group would be required for a lager study.
One of the main reasons for exclusion of patients
in the study was cognitive deficit. Our previous
study demonstrated that Mini-Mental State
Examination score of 8 was a suitable cut-off point
for choosing meaningful activities using the Aid
for Decision-making in Occupation Choice tool,
which suggests that the occupation-based approach
could apply to patients with cognitive deficits.
Additional investigation is required to examine
inclusion criteria that do not lead to the rejection of
potential participants with cognitive deficits.
In addition, the requirement for an attending
research occupational therapist is a potentially

Clinical Rehabilitation 29(8)

modifiable aspect of the research protocol.
Moreover, of the 1,411 potential participants
excluded from this study, 266 did not have an
attending research occupational therapist. We
could not control allocation of all participants who
met the criteria to a research occupational therapist
because this was undertaken by the hospital.
Although the allocation of research occupational
therapists was not a concern in this study, the
recruitment protocol requires modification.
According to retention rates for the interventions, it appears that the withdrawal rate was higher
in the experimental group than in the control group;
however, 8 of the 11 participants in the experimental group withdrew because they were discharged
from the ward within the first two months. None of
the participants refused the occupation-based
approach, and 1 was not suited occupation-based
approach due to cognitive dysfunction. Therefore,
we speculated that occupation-based occupational
therapy was applicable and may have a high retention rate for subacute stroke patients.
Although this study contributes to the literature,
it has limitations. First, there is wide inter-individual variability in outcomes. In this study, the experimental group engaged in impairment-based
occupational therapy (e.g., functional or ADL
training) within one-third of the intervention time
and involved a multidisciplinary team approach, as
there is strong evidence in favor of both among
subacute stroke patients. Although, this mix of
interventions may have caused the variability in the
experimental group, we could prove feasibility in
subacute stroke rehabilitation setting.
Second, we did not conduct a follow-up assessment after discharge because we could not secure a
masked assessor. Hopman etal.37 reported marked
and statistically significant declines in Short Form36 Role-emotional and General health scores in
stroke patients six months after discharge. A difference in intervention effects may therefore be detected
after discharge, which necessitates modification of
the study protocol. Further study is needed to followup with patients after discharge to their homes.
Third, we did not use individualized outcome
measurements, such as the Canadian Occupational
Performance Measure and Goal Attainment Scale.
Since it is ethically difficult, we did not work on

Tomori et al.
the individual goal identified by the patient and
therapist in the control group in the Japanese subacute stroke care system.
Finally, the absence of a non-intervention group
is an undeniable possibility of the natural recovery
in pre-post group intervention.

Clinical messages

The occupation-based and impairment-based occupational therapies
have comparable efficacy for patients
with subacute stroke.

Occupation-based therapy has more
potential to improve General health
(d = 0.42) and Role-emotional (d =
0.43) scores on the Short Form-36
than impairment-based therapy.

A sample of 118 subacute stroke
patients per group would be required
for a larger study.

Acknowledgements
The authors thank all the occupational therapists
(Uruma M, Hosokawa H, Taniguchi T, Yamada S, Kato
T, Hirata A, Nakahara K, Miyamoto Y, Nakatsuka S,
Kawakami A, Yoshimura A, Uezu S) that participated
in this study.

Conflict of interest
The authors declare no conflict of interests.

Funding
This work was supported in part by a Grant-in-Aid for
Scientific Research (C) (project no. 24531257 to K
Tomori and project no. 23590610 to R Nagatani) from
the Japan Society for the Promotion of Science.

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