School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

CRITICALLY APPRAISED TOPIC (CAT) WORKSHEET
Focused Question:
Do home modifications improve function in adults with physical disabilities?
Prepared By:
Jared Hansen, OTS and Gifty Frimpong, OTS
School of Occupational Therapy
Touro University Nevada
874 American Pacific Drive
Henderson, NV 89014
Date Review Completed:
September 30, 2015
Clinical Scenario:
Many adults wants to remain independent as long as possible and have access to the care they
need to allow them to age in place. According to recent studies, older Americans prefer
receiving services that allow them to stay in their current home (American Association of
Retired Persons [AARP], 2003, para. 2). Adults today are living longer and the need for
affordable healthcare continues to increase (Mann, Ottenbacher, Fraas, Tomita, & Granger,
1999). Additionally limitations to successfully perform activities of daily living (ADLs) and
instrumental activities of daily living (IADLs) independently may develop in this population.
Home modifications is an emerging practice in occupational therapy, however few adults
receive beneficial adaptations to their homes. Home modifications are adaptations and
additions to the home environment that increase independent function for the individual.
Home modification is important to address for individuals with physical disabilities to promote
autonomy and independence in their home. In the adult population, some individuals may
experience difficulties in completing their daily routines and activities at home due to loss of
functioning and disability. People in the aging population tend not to have just one severe
disability but can present with many other minor factors (Christenson, 2011). The progress of
aging has an impact on health status, and it limits an individual to participation in his or her
desired activities.

Functional deficits may result in an individual depending on caregiver assistance or moving to

a community facility or family members home. Difficulty performing ADLs and IADLs
could cause an individual to experience poor self-efficacy, and high healthcare costs and
service utilization (Gitlin, 2006, p. 809). Also, Gitlin (2006) stated that functional difficulties
can result in social isolation, anxiety, and depression. Due to these impacts on an individuals
living conditions, home modifications could be great implications to increase safety and
effectiveness to complete many desired occupations in daily life.
If people are experiencing difficulties such as decreased visual function, limited mobility, or
decreased balance or strength, than they could have difficulty functioning independently in
their home. A desire of most adults is to remain living at home despite having impairments
that limit functional abilities. Home modification serves as a treatment technique to assist
clients with functional limitations or physical disabilities to overcome environmental barriers
within the home. Home modifications can promote safety, enhance functional performance,
and increase quality of life in adults.
Summary of Key Findings:
Summary of Levels I, II and III:
Level I:
Basic lighting adaptations improve quality of life and well-being in adults with
visual impairments and assist in improving ADL performance (Brunnstrm,
Srensen, Alsterstad, & Sjstrand, 2004).
While adults with disabilities declined in levels of independent living over time,
those receiving home modifications had slower decline in function and less decline
in independent living (Mann, Ottenbacher, Fraas, Tomita, & Granger, 1999;
Tomita, Mann, Stanton, Tomita, & Sundar, 2007; Wilson, Mitchell, Kemp,
Adkins, & Mann, 2009).
Home modifications decreased the amount spent on healthcare for older adults
compared to those who did not receive any modifications (Mann, Ottenbacher,
Fraas, Tomita, & Granger, 1999).
Smart home technology enabled older adults to remain living independently longer
than those without such modifications (Tomita, Mann, Stanton, Tomita, & Sundar,
2007).
Level II:
Adults experienced less difficulty in everyday life tasks, including self-care in the
bathroom, transfers, instrumental activities of daily living, and leisure, after home
modifications were installed in their homes (Petersson, Kottorp, Bergstrm, &
Lilja, 2009; Petersson, Lilja, Hammel, & Kottorp, 2008).
Home modifications are an effective method for decreasing difficulty in activity
performance for up to six months after installation (Petersson, Kottorp, Bergstrm,
& Lilja, 2009).

Level III:
Bathroom modifications are an effective method for improving independence in
ADL performance, and transferring for older adults (Gitlin, Miller, & Boyce
1999).
Adults increased in satisfaction, performance, and functional independence after
home modifications (Stark, Landsbaum, Palmer, Somerville, & Morris, 2009).
Approaching home modifications with a focus on the client is beneficial in
enhancing performance for adults with disabilities (Stark, 2004; Stark,
Landsbaum, Palmer, Somerville, & Morris, 2009).
Summary of Level IV and V:
Not included in review
Contributions of Qualitative Studies:
Not included in review
Bottom Line for Occupational Therapy Practice:
The clinical and community-based practice of occupational therapy:
Implementing home modifications can increase functional independence, performance, and
satisfaction in adults with physical impairments. Beneficial types of home modifications
include lighting adaptations, smart home technology, low cost adaptive technology, handrails,
grab bars, ramps, kitchen modifications, and bathroom modifications. Installing home
modifications soon after the need is identified may be affective in decreasing the performance
demands of everyday life tasks up to six months after installation.
Program development:
Deliberate choices of assessments in relation to housing adaptations can be beneficial in
enhancing the quality of life for aging adults. Implementing programs within the community
that decrease the time for identifying and installing home modifications can assist adults in
maintaining functional independence. Home modification programs that include education on
the use of computers and smart home technology can assist adults in living independently.
Societal needs:
Home modifications can provide adults with the opportunity to remain living at home longer
while decreasing the need for social support or caregiver assistance. Results suggest the need
for educating the community on the benefits of home modifications in reducing the rate of
decline in independence and the amount of healthcare costs of older adults.
Healthcare delivery and policy:
Results promote the necessity for early identification of needs and referral for home
modifications. Results suggest correlating the usability of housing adaptations with

installation and reimbursement of the modifications while utilizing a client-centered approach.

Results demonstrate the importance of a system of quality control in service delivery and
consistency of practices in home modification. Providing home modifications can be a
beneficial means of reducing healthcare costs and improving quality of life for adults.
Education and training of occupational therapy students:
Students should be introduced to smart home technology and strategies for assessing lighting
and task performance in entry level occupational therapy education. Students should be
educated on the early identification of home modification needs and making appropriate
suggestions for adaptations that individuals will utilize.
Refinement, revision, and advancement of factual knowledge or theory:
Additional studies representing the general population using objective measures are
recommended to increase the understanding of the benefits of home modifications. Results
suggest the need for research that includes specific modifications and focuses on specific
populations. Additional studies determining the long-term benefits of home modifications for
adults with disabilities are recommended.
Review Process:

Focus question was identified by review authors and approved by instructor of record
Inclusion and exclusion criteria was selected and approved by instructor of record
Search terms were developed by review authors for appropriate population, intervention,
and outcome
Multiple databases were searched by review authors
Inclusion and exclusion criteria were modified by review authors and approved by
instructor of record
Additional search was performed by review authors
Review of titles and abstracts was completed by review authors
Full text of articles were obtained and reviewed
Articles were eliminated based on exclusion criteria
Remaining articles were included according to inclusion criteria
Articles selected were critically appraised by review authors using the McMaster
University critical review forms and summarized information on an evidence table
Instructor of record reviewed critical appraisal forms, evidence table, and selected articles
Review authors developed the CAT, which was reviewed by instructor of record

Procedures for the Selection and appraisal of articles:

Inclusion Criteria:

Articles published since 1999

Articles published in English
Involving physical disabilities

Peer reviewed
Intervention involved home modification
Intervention was within the scope of occupational therapy practice
Outcome focusing on function or performance
Level I, II, and III evidence (IV and V if no other evidence is found)

Exclusion Criteria:

Article not involving physical disabilities

Not peer reviewed
Articles not in English
Focus on fall prevention as main outcome
Qualitative studies
Articles without a clearly defined home modification intervention
Presentations, conference proceedings, dissertations, and theses

Search Strategies:
Categories
Patient/Client Population
Intervention

Outcomes

Key Search Terms

Adults, older adults, physical disability, disability,
impairment
Home modification, environmental modification,
environmental barriers, universal design, home evaluations,
home safety, equipment, home hazards, environmental
supports, accessible design, house modification, built
environment, occupational therapy
Function, independence, performance, participation,
accessibility, quality of life, physical functioning,
occupational performance, activity of daily living

Databases and Sites Searched

CINAHL, PsychINFO, ERIC, Medline, Academic Search Complete, Cochrane Database of
Systematic Reviews, PubMed, SAGE Journals, ProQuest, Scopus, OTseeker, Google Scholar,
and hand searching of bibliographies
Quality Control/Peer Review Process:

Focus question was formulated by review authors and approved by instructor of record
Review authors concentrated on focus question, reviewing 10 articles, creating an evidence
table, and completing the CAT
The CAT was finalized and completed by review authors and reviewed by the instructor of
record for accuracy

Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of
Evidence
I
II
III
IV
V
Other

Study Design/Methodology of Selected Articles

Systematic reviews, meta-analysis, randomized
controlled trials
Two groups, nonrandomized studies (e.g., cohort, casecontrol)
One group, nonrandomized (e.g., before and after, pretest
and posttest)
Descriptive studies that include analysis of outcomes
(single-subject design, case series)
Case reports and expert opinion, which include narrative
literature reviews and consensus statements
Qualitative Studies
TOTAL:

Number of
Articles Selected
4
2
4
0
0
0
10

Limitations of the Studies Appraised:

Levels I, II, and III
Bias
Numerous studies were limited by potential bias. Examples of bias included attention
bias, a measurement bias due to a single rater who also provided treatment, a
volunteer bias in sampling, and possible co-intervention bias and contamination due
to inability to control for access to home modifications by participants (Brunnstrm,
Srensen, Alsterstad, & Sjstrand, 2004, Level I; Gitlin, Miller, & Boyce 1999, Level
III; Mann, Ottenbacher, Fraas, Tomita, & Granger, 1999, Level I; Petersson, Lilja,
Hammel, & Kottorp, 2008, Level II; Stark, Landsbaum, Palmer, Somerville, &
Morris, 2009, Level III; Tomita, Mann, Stanton, Tomita, & Sundar, 2007, Level I;
Wilson, Mitchell, Kemp, Adkins, & Mann, 2009, Level I).
Attrition
A few studies had a high attrition rate which limited the ability to establish validity
(Fnge, & Iwarsson, 2005, Level III; Petersson, Kottorp, Bergstrm, & Lilja, 2009,
Level II; Tomita, Mann, Stanton, Tomita, & Sundar, 2007, Level I).
Outcome Measurement
Some studies lacked reliable outcome measures (Petersson, Lilja, Hammel, &
Kottorp, 2008, Level II; Tomita, Mann, Stanton, Tomita, & Sundar, 2007, Level I),
and other studies did not use objective outcome measures (Gitlin, Miller, & Boyce
1999, Level III; Stark, 2004, Level III).

Sample Size and Group Variables

Most studies were limited by a small sample size (Brunnstrm, Srensen, Alsterstad,
& Sjstrand, 2004, Level I; Fnge, & Iwarsson, 2005, Level III; Gitlin, Miller, &
Boyce 1999, Level III; Mann, Ottenbacher, Fraas, Tomita, & Granger, 1999, Level I;
Petersson, Kottorp, Bergstrm, & Lilja, 2009, Level II; Petersson, Lilja, Hammel, &
Kottorp, 2008, Level II; Stark, 2004, Level III; Stark, Landsbaum, Palmer,
Somerville, & Morris, 2009, Level III; Tomita, Mann, Stanton, Tomita, & Sundar,
2007, Level I; Wilson, Mitchell, Kemp, Adkins, & Mann, 2009, Level I).
Masking
In one study the intervention group was not blinded (Mann, Ottenbacher, Fraas,
Tomita, & Granger, 1999, Level I), while in another study the researchers were not
blind to group assignments (Petersson, Kottorp, Bergstrm, & Lilja, 2009, Level II).
Levels IV and V
Not included in review
Other
Not included in review
Articles Selected for Appraisal:
Brunnstrm, G., Srensen, S., Alsterstad, K., & Sjstrand, J. (2004). Quality of light and
quality of lifethe effect of lighting adaptation among people with low vision. Ophthalmic and
Physiological Optics, 24(4), 274-280. doi: 10.1111/j.1475-1313.2004.00192.x
Fnge, A., & Iwarsson, S. (2005). Changes in ADL dependence and aspects of usability
following housing adaptationA longitudinal perspective. American Journal of Occupational
Therapy, 59(3), 296-304. doi: 10.5014/ajot.59.3.296
Gitlin, L. N., Miller, K. S., & Boyce, A. (1999). Bathroom modifications for frail elderly
renters: Outcomes of a community-based program. Technology and Disability, 10(3), 141-149.
Retrieved from http://search.ebscohost.com
Mann, W. C., Ottenbacher, K. J., Fraas, L., Tomita, M., & Granger, C. V. (1999).
Effectiveness of assistive technology and environmental interventions in maintaining
independence and reducing home care costs for the frail elderly: A randomized controlled
trial. Archives of Family Medicine, 8(3), 210-217. http://dx.doi.org/10.1001/archfami.8.3.210
Petersson, I., Kottorp, A., Bergstrm, J., & Lilja, M. (2009). Longitudinal changes in everyday
life after home modifications for people aging with disabilities. Scandinavian Journal of
Occupational Therapy, 16(2), 78-87. doi: 10.1080/11038120802409747

Petersson, I., Lilja, M., Hammel, J., & Kottorp, A. (2008). Impact of home modification
services on ability in everyday life for people ageing with disabilities. Journal of
Rehabilitation Medicine, 40(4), 253260. http://dx.doi.org/10.2340/16501977-0160
Stark, S. (2004). Removing environmental barriers in the homes of older adults with
disabilities improves occupational performance. OTJR: Occupation, Participation and Health,
24(1), 32-39. doi: 10.1177/153944920402400105
Stark, S., Landsbaum, A., Palmer, J. L., Somerville, E. K., & Morris, J. C. (2009). Clientcentred home modifications improve daily activity performance of older adults. The Canadian
Journal of Occupational Therapy, 76, 235-245. Retrieved from
http://search.proquest.com/docview/212956399?accountid=28843
Tomita, M. R., Mann, W. C., Stanton, K., Tomita, A. D., & Sundar, V. (2007). Use of
currently available smart home technology by frail elders: process and outcomes. Topics in
geriatric rehabilitation, 23(1), 24-34. http://dx.doi.org/10.1097/00013614-200701000-00005
Wilson, D., Mitchell, J., Kemp, B., Adkins, R., & Mann, W. (2009). Effects of assistive
technology on functional decline in people aging with a disability. Assistive
Technology, 21(4), 208-217. doi:10.1080/10400430903246068
Other References:
American Association of Retired Persons. (2003). These four walls. Americans 45+ talk about
home and community. Retrieved from http://assets.aarp.org/rgcenter/il/four_walls.pdf
Christenson, M. A. (2011). Environmental adaptations: Foundation for daily living. In C. H.
Christiansen & K.M. Matuska (Eds.), Ways of living: Adaptive strategies for special
needs. (4th ed., pp. 493-513). Baltimore, MD: AOTA Press.
Gitlin, L., Winter, L., Dennis, M., Corcoran, M., Schinfeld, S., & Hauck, W. (2006). A
randomized trial of a multicomponent home intervention to reduce functional difficulties
in older adults. Journal of the American Geriatrics Society, 54(5), 809-816.
doi:10.1111/j.1532-5415.2006.00703.x

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05