Factors affecting outcome in participation after stroke
achieve a positive outcome in participation than those
receiving in-patient rehabilitation. However, interes-
tingly, the difference in outcome with regard to context
of rehabilitation was found only in the control group.
This result might reflect that the home environment
itself induces a more client-centred approach, i.e. the
needs are more easily identified by the client and sup-
ported by the therapist in the client’s real-life world, as
has been suggested in previous studies (29, 30). Thus,
it is plausible that, in the context of the home environ-
ment, the difference in client-centred behaviour between
the occupational therapists who used an enhanced
client-centred approach and those who delivered usual
rehabilitation was too small or non-existent, whereas
there was a difference in client-centeredness within the
in-patient rehabilitation in the hospital between occupa-
tional therapists who used the client-centred approach
and those who delivered usual rehabilitation.
This leads us to propose that, in contrast to the in-
patient hospital environment, the home environment
empowers the client and, as a consequence, facilitates
the team members in adopting a more client-centred
approach. Receiving rehabilitation in one’s home en-
vironment has previously been shown to contribute to
individualization of the rehabilitation, and increased
patient participation in goal-setting and participation in
everyday life (31, 32). Furthermore, multi-professional
teams providing rehabilitation in the clients’ homes
described that the context enabled them to propose
strategies to assist the clients to manage daily life (32).
In addition, the home environment has been reported
to make the clients aware of their limitations and to
facilitate identification of difficulties in ADL that they
wanted to address. It also allowed the clients to become
partners in the rehabilitation process, in goal-setting
and in planning their rehabilitation (33). Rehabilitation
at home after stroke is recommended in the Swedish
national guidelines for stroke care for those with mild
to moderate stroke (1). Based on this study, providing
an enhanced client-centred approach could be benefi-
cial for those receiving rehabilitation at home, although
it might be even more important for those receiving
rehabilitation at an in-patient unit.
Methodological considerations
Since this study was a secondary analysis of a previous
RCT, the result should be interpreted with caution. Ho-
wever, although the results from the RCT showed no
differences in participation between participants who
had received the enhanced client-centred rehabilitation
and those who had received usual rehabilitation, the
results from the secondary subgroup analyses of the
present study complement our previous results.
165
When interpreting the results, the plausible dif-
ference in number of contacts with an occupational
therapist should be taken into consideration, since
the intervention group seemed to have had a higher
mean number of contacts, whereas the total number
of contacts seemed to be higher in the control group.
However, these plausible differences have not been
statistically confirmed.
Participation in everyday life is a complex concept
that includes both the performance of, the meaning of,
and engagement in activities (6, 7, 11). It is a challenge
to find measures that capture the multifaceted concept
of participation and that are sufficiently sensitive to
detect change (34). One strength of this study was the
inclusion of 3 different measures enabling capture of
different aspects of participation. The measurements
used; SIS (22), FAI (21) and OGQ (26) overlap in
some areas and, combined, they cover the areas of
instrumental ADL , leisure, social activities and work.
The SIS 3.0 and FAI are 2 of the 5 most frequently
used measurements in rehabilitation research on pe-
ople after stroke (35). We also used OGQ to highlight
participation in desired occupations, although it has
been proven that the questionnaire is not sufficiently
sensitive to be used to evaluate outcome of interven-
tions, but is more suitable as a tool for goal-setting (36).
Our results, showing that the 3 instruments identified
different subgroups of participants as having a positive
outcome, imply that in order to operationalize partici-
pation several measurements need to be used.
In order to increase participation, it is recommen-
ded that rehabilitation after stroke is carried out with
a client-centred approach by multidisciplinary teams
(1, 38). The client-centred ADL intervention has been
used solely by occupational therapists, and it is not
known to what extent other team members have used
a client-centred approach.
Conclusion
Using an enhanced client-centred rehabilitation after
stroke may reduce the perceived impact of stroke on
participation in everyday life for those with moderate
or severe stroke. In addition, it seems particularly
important within in-patient rehabilitation to use an
enhanced client-centred approach in order to increase
participation in everyday life for people after stroke.
ACKNOWLEDGEMENT
Financial support was provided by the Doctoral School in Health
Care Sciences at Karolinska Institutet; The Swedish Research
Council (VR); Swedish Research Council for Health, Working
Life and Welfare (FORTE) and the Swedish Stroke Association.
J Rehabil Med 51, 2019