School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

Critically Appraised Topic Project

EVIDENCE TABLE
Name: Jared Hansen, OTS and Gifty Frimpong, OTS
Date: September 30, 2015
Focus Question: Do home modifications improve function in adults with physical disabilities?

Rationale for inclusion/exclusion criteria applied to determine which articles should be included in the evidence table:
Inclusion:
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:
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Not peer reviewed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

Author/
Year

Study
Objectives

Level/Design/
Subjects

Intervention and
Outcome Measures

Results

Brunnstrm,
Srensen,
Alsterstad,
& Sjstrand
(2004)

To study the effect

of lighting
adaptations on
activities of daily
living (ADLs) for
individuals with
visual impairments.

Level I

Intervention
Compared control group
receiving lighting
adjustment in kitchen,
hall, and bathroom to
intervention group
receiving additional
lighting adjustments in
the living room.

The effect of

lighting in the living

room on quality of

life for the

intervention group
was significant (p <
.05). Basic lighting
adaptations had

significant effect on
ADL tasks
performed on the
working surface in
the kitchen (p = .03
& p = .04) for both
groups.

Randomized Control
Trial (RCT)
Participants
N = 56 participants in
five diagnostic groups:
macular degeneration,
retinitis pigmentosa,
glaucoma, and other

Outcome Measures
ADL and perceived
quality of life based
on three interview
questions.

Study
Limitations
Small sample
size
Limited
generalizability
due to
representation of
group studied
Limited validity
and reliability of
studied variables

Implications for OT
The Clinical and
Community-Based
Practice of OT:
Implementing lighting
adaptations can increase
quality of life and ADL
performance in clients
aging with visual
impairments.
Program Development:
Knowledge of these results
can assist in the choice of
assessments that include
visual acuity and quality of
life.
Societal Needs:
Results demonstrate an
increase in quality of life
and improvement in ADL
performance for
individuals obtaining
lighting adaptations.
Healthcare Delivery and
Policy:
Results can promote early
identification of needs and
referral for home
modifications.
Education and Training of
OT Students:
Strategies for assessing
lighting and task
performance should be
included in entry level

occupational therapy (OT)

education.

Fnge, &
Iwarsson
(2005)

To investigate
longitudinal
changes in ADL
dependence and
aspects of usability
in housing among
clients receiving
housing adaptation
grants in Sweden.

Level III
Before and after design
Participants
N = 131 adults that
requested home
modifications

Intervention
Housing adaptations to
hygiene facilities,
entrances, floors, balcony
and patios, stairways, and
doors were made and
followed up on at two to
three months and at six to
seven months.
Outcome Measures
ADL Staircase
Usability in My
Home (UIMH)

Overall ADL
dependence did not
change significantly
whereas dependence
in Bathing
decreased over time
(p = .002). Activity
aspects (p = .045)
and Personal and
social aspects (p =
.008) of usability
improved at
different phases in
the process.

Small sample
size
Gender
differences
between followup times due to
drop-outs
Mobility devices
prescribed
during study
Lack of
comprehensive
home
modification
intervention

Refinement, Revision, and

Advancement of Factual
Knowledge or Theory:
Additional studies are
needed to increase the
knowledge of the benefits
of lighting adaptations, the
quality of lighting, and the
populations benefitted
from such modifications.
The Clinical and
Community-Based
Practice of OT:
Housing adaptations may
be useful for only a limited
time due to clients
functional decline.
Program Development:
Deliberate choices in
assessments and
evaluations in relation to
housing adaptations should
be made.
Societal Needs:
Recognizing that the areas
of the home that most
often need adaptations
include the bathroom,
entrances, stairways, and
doorways.
Healthcare Delivery and
Policy:
Results suggest correlating
the usability of housing

adaptations with
installation and
reimbursement of the
modifications.
Education and Training of
OT Students:
Students should
understand the importance
of making appropriate
suggestions for home
modifications that
individuals will utilize.

Gitlin,
Miller, &
Boyce
(1999)

To evaluate if
clients improved in
self-care,
encountered
difficulties using
adaptive
equipment, or
continued to use the
equipment
provided.

Level III
Before and after design
Participants
N = 34 adults, primarily
African American
females

Intervention
Two home visits were
conducted. The first
consisted of an initial OT
visit followed by
equipment
recommendations. These
recommendations were
followed by installation
of specific equipment.
The second visit was
performed three months
after the initial visit and
included a re-evaluation
of participants and
instruction in self-care
techniques.

Participants

demonstrated
significant
improvement in
bathing (t = 2.65, p
< .01), ADL

performance (t =
3.01, p < .01), and
transferring (t =

5.08, p < .001). No

significant difficulty
with single self-care
items was noted.

Possible bias due

to single rater
who also
provided
treatment
No objective
measure for
outcome
Small sample
size

Refinement, Revision, and

Advancement of Factual
Knowledge or Theory:
Additional studies are
recommended that include
specific modifications and
focus on specific
populations.
The Clinical and
Community-Based
Practice of OT:
Home modifications for
areas of self-care can
increase independence in
ADL performance.
Program Development:
Incorporating home
modification into
established housing service
programs offered to older
people is an important
aspect of meeting their
needs for independence.
Societal Needs:

Outcome Measure
Katz ADL Index

Assessments of home
modifications may need
the skill of an OT with
specialized knowledge of
compensatory strategies
that are beneficial to
clients.
Healthcare Delivery and
Policy:
Results demonstrate the
importance of funding for
community programs, and
a system of quality control
in service delivery and
consistency of practices in
home modification.
Education and Training of
OT Students:
Home modifications
should be a part of entry
level OT education with an
understanding of the desire
of older adults to age in
place.

Mann,
Ottenbacher,
Fraas,
Tomita, &

To evaluate the
impact of assistive
technology and
home modification

Level I
RCT

Intervention
A comprehensive
functional assessment by
an occupational therapist,

Both groups

demonstrated a
decline in functional
status. The control

Potential
volunteer bias

Refinement, Revision, and

Advancement of Factual
Knowledge or Theory:
Additional studies with
objective measures should
be performed to consider
the benefits of home
modifications in areas
other than self-care.
The Clinical and
Community-Based
Practice of OT:

Granger
(1999)

services on the
independence and
healthcare costs of
frail older adults.

Participants
N = 104 older adults
Mean age: 73 years

recommendations for
assistive technology and
environmental
interventions, and a
follow-up assessment.
Outcome Measures
Functional
Independence
Measure (FIM)
Older Americans
Research and
Services Center
Instrument
Craig Handicap
Assessment and
Reporting Technique
(CHART)
Functional Status
Index

group had a
significantly greater
decline in
independence (p =
.01) and increase in
pain (p = .01) than
the intervention
group. The control
group also had a
significantly greater
amount (d = .56) of
expenditure for
healthcare.

Intervention
group not
blinded
Possible cointervention bias

Low cost adaptive

technology and home
modification may prevent
and postpone morbidity in
frail elderly persons.
Program Development:
Home modification should
be included as part of an
all-inclusive healthcare
plan.
Societal Needs:
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:
As healthcare costs
increase, providing this
equipment may assist in
deferring and decreasing
costs associated with rising
healthcare needs.
Education and Training of
OT Students:
Results suggest the need
for students to understand
the influence of home
modifications on the health
of aging adults.

Petersson,
Kottorp,
Bergstrm,
& Lilja
(2009)

To investigate the
effects of home
modifications on
the performance of
everyday life tasks
for individuals with
disabilities.

Level II
Quasi-Experimental
pretest posttest design
Participants
N = 103 adults with
disabilities

Intervention
Home modifications
were completed as
needed.
Outcome Measures
The Swedish version
of the ClientClinician Assessment
Protocol (C-CAP)

Participants
receiving home
modifications
experienced
significantly less
difficulties (p =
.023) in everyday
life up to six months
after installation
compared to the
control group.

Lack of
randomization
Uneven group
sizes
Large attrition
rate
Small control
group

Refinement, Revision, and

Advancement of Factual
Knowledge or Theory:
Additional studies
examining the costs of
home modifications and
the utility of the
adaptations in the homes
of older adults is needed to
understand the benefits
within the healthcare
system.
The Clinical and
Community-Based
Practice of OT:
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:
Implementing programs
that decrease the time for
identifying and installing
home modifications is
important in meeting the
needs of adults requiring
these services.
Societal Needs:
Results suggest that
individuals apply for home
modifications as soon as
the need arises to obtain
maximal benefits.

Healthcare Delivery and

Policy:
Results from this study
suggest the importance of
implementing policies that
support the reimbursement
of home modifications and
adaptive equipment for
adults with disabilities.
Education and Training of
OT Students:
Teaching students the
importance of early
identification of home
modification needs is an
important aspect of OT
education.

Petersson,
Lilja,
Hammel, &
Kottorp
(2008)

To examine the
impact of home
modifications on
self-rated ability in
daily life for people
aging with
disabilities.

Level II
Cohort
Participants
N = 114 adults over age
40 that requested home
modifications

Intervention
The intervention group
comprised individuals
recruited from a pool of
applicants to the Agency
for Home Modification
(AHM) who had been
approved and were
scheduled to receive
home modifications
within four weeks. The

Significant
differences were
found between
baseline and followup in self-rated
difficulty (d = .32, p
= .001) and safety (d
= .40, p = .001) for
the intervention
group, indicating
that they felt safer

Small sample
size
Researchers not
blind to group
assignment
Potential
volunteer bias
Limited validity
and reliability of
outcome
measures

Refinement, Revision, and

Advancement of Factual
Knowledge or Theory:
Results suggest the need
for additional research to
demonstrate the benefit of
home modifications in
facilitating a less
demanding performance of
everyday life tasks.
The Clinical and
Community-Based
Practice of OT:
Home modifications may
improve persons feelings
of safety and ease in daily
life.
Program Development:
Developing programs that
provide home

data was collected in the

participants home and
the home modifications
were provided once by
AHM.
Outcome Measures
The Swedish version
of the ClientClinician Assessment
Protocol (C-CAP)

and had less

difficulty in
everyday life after
home modifications.
Between baseline
and follow-up, for
self-rated difficulty,
there were
statistically
significant (p < .05)
differences for six
tasks: get in and out
of home, bath or
shower, grooming,
transfer to toilet,
walk one block, and
move in and out of
bed. Between
baseline and followup for self-rated
safety, there were
statistically
significant (p < .05)
differences for 10
tasks related to selfcare in the
bathroom, transfers,
instrumental
activities of daily
living, and leisure.

modifications can greatly

enhance the quality of life
for those aging with
disabilities.
Societal Needs:
Home modifications may
provide adults with the
opportunity to remain
living at home longer
while decreasing the need
for social support.
Healthcare Delivery and
Policy:
Providing home
modifications may be a
beneficial means of
reducing healthcare costs
and improving quality of
life.
Education and Training of
OT Students:
Results suggest that
students should be
educated on appropriate
home modifications and
adaptive equipment for
adults aging with
disabilities.
Refinement, Revision, and
Advancement of Factual
Knowledge or Theory:
Additional studies should
be performed to determine
if functional independence
is affected or improved by
home modifications.

Stark (2004)

This study
examined the
efficacy of a home
modification
intervention
program on selfreported
occupational
performance in
older adults with
disabilities.

Level III
Before and after design
Participants
N = 29 private home
owners identified by a
not-for-profit agency

Intervention
Home modifications
were provided, including
adaptive equipment,
architectural
modifications, and major
home renovations. No
remedial interventions
were provided. All
intervention
modifications addressed
occupational
performance issues. The
modifications were
provided by the agency
and the occupational
therapist provided
training in the use of the
modifications and made
follow-up visits as
needed. Photographs
were taken to verify the
changes that were made.
Outcome Measures
FIM
Canadian
Occupational
Performance
Measure (COPM)
Enviro-FIM

Only 45 of 75
identified barriers
were completed by
the agency. The
COPM was used to
identify differences
between pretest and
posttest scores of
performance and
satisfaction. Paired
t tests were used to
examine the scores.
A mean satisfaction
score of 2.25 at
pretest increased
significantly to 7.69
at posttest (t = -9.54;
p = .0001), while
the mean
performance score
increased
significantly from
3.19 at pretest to
7.81 at posttest (t =
-8.23; p = .0001).

Participants may
not represent
general
population
Limited number
of needed
modifications
identified were
completed
Half of
participants
received
additional
services limiting
ability to
conclude that
results were
from
modifications
Objective
measures only
used at baseline

The Clinical and

Community-Based
Practice of OT:
Providing home
modifications can increase
performance and
satisfaction of older adults
living at home with
disabilities.
Program Development:
Implementing programs
for reducing environmental
barriers by incorporating
home modifications is an
important aspect in the
care of older adults.
Societal Needs:
Environmental barriers can
have a significant impact
on the ability of a person
to perform desired
occupations and their
feelings of satisfaction
with performance.
Healthcare Delivery and
Policy:
A client-centered approach
to home modifications
may be beneficial in
enhancing the occupational
performance of adults
living with disabilities.
Education and Training of
OT Students:
Students should be
educated on the use of the

COPM and how it can be

utilized in home
modification settings.

Stark,
Landsbaum,
Palmer,
Somerville,
& Morris
(2009)

To describe a
client-centered
occupational
therapy, home
modification
intervention
program and
examine the impact
of the intervention
on daily activity
performance over
time.

Level III
Quasi-Experimental,
single group
prospective study
Participants
N = 80 adults over the
age of 60

Intervention
The intervention included
home modifications,
adaptive equipment,
architectural
modifications, and major
home renovations.
Training in the use of the
adaptations was provided
by the occupational
therapist. Clientcenteredness was
preserved by focusing on
the barriers the client
identified with the chosen
solution.
Outcome Measures
FIM
COPM

Participants had a

significant increase
from baseline to

posttest in
satisfaction (p <
.0001), performance
(p < .0001), and
functional
independence (p <

.0001), and a
significant decrease
in the influence of
environmental
barriers (p < .0001)
on the person.

Small sample
size
A single rater
who was also the
treating therapist
may have led to
measurement
bias
No control group

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.
The Clinical and
Community-Based
Practice of OT:
Understanding that
compensating for
functional loss by
providing environmental
supports is a possibility in
meeting the needs of an
aging population.
Program Development:
Implementing home
modification programs in
the community can impact
the functional
independence of older
adults.
Societal Needs:
Educating adults on the
benefits of home
modifications for
addressing their barriers to

engaging in meaningful
occupations and activities.
Healthcare Delivery and
Policy:
With the increase in older
adults aging in place and
the growing burden on the
healthcare services, a
possible solution may be to
compensate for functional
loss by providing
environmental supports
through home
modifications.
Education and Training of
OT Students:
Educating students on
concepts of personenvironment fit is key in
understanding the potential
of the benefits of home
modifications.

Tomita,
Mann,
Stanton,
Tomita, &
Sundar
(2007)

Evaluate the
effectiveness of
smart home
technology in
improving
functional

Level I
RCT
Participants

Intervention
Both groups received a
2.5-hr in home
assessment by an
occupational therapist or
nurse. The intervention

The treatment group

had a significantly
higher (F = 7.895, p
= .006) cognitive

level as measured
by the FIM at the

High attrition
rate
Attention bias
Lack of
standardization

Refinement, Revision, and

Advancement of Factual
Knowledge or Theory:
Additional studies
determining the long-term
benefits of home
modifications for adults
with disabilities are
recommended.
The Clinical and
Community-Based
Practice of OT:
Smart home technology
may increase the

performance and
maintaining current
living situation.

N = 113 adults 60 years

of age and older

group received
installation of and
training on a computer
and smart home
technology.
Outcome Measures
FIM
Duke Older
Americans Resources
and Services
Procedures (OARS)
IADL
Sickness Impact
Profile (SIP)
Craig Handicap
Assessment and
Reporting Technique
(CHART)
Mini-Mental State
Examination
(MMSE)

third interview. For

instrumental
activities of daily
living (IADL) total
score, the treatment
group scored 11.9
initially and stayed
the same (11.8) for
two years, whereas
the control group
scored 12.3 initially
and dropped to 11.9,
which was a
significant decline
that resulted in
significant
difference (F =
3.177, p < .05). The
treatment group was
significantly higher
(p = .043) than the
control group in rate
of independent
living.

Lack of
reliability in
outcome tools
Statistical
difference in age
between groups

independence of adults
aging with a disability.
Program Development:
Knowledge of these results
could assist programs to
educate older adults in the
use of computers and
smart home technology to
maintain independent
living.
Societal Needs:
Results suggest the
benefits of educating
adults on the availability,
use, and benefits of smart
home technology for
independent living.
Healthcare Delivery and
Policy:
Smart home technology
should be offered as an
additional form of home
modification to enhance
independent living.
Education and Training of
OT Students:
Students should be
introduced to smart home
technology as a possible
home modification
technique.
Refinement, Revision, and
Advancement of Factual
Knowledge or Theory:

Wilson,
Mitchell,
Kemp,
Adkins, &
Mann
(2009)

To determine
whether the
appropriate use of
an assistive
technology (AT)
intervention
program including
AT devices, home
modifications, and
environmental and
behavioral changes
for people aging
with an early-onset
disability improves
function and
reduces the rate of
functional decline.

Level I
RCT
Participants
N = 107 adults with
impairments that
included polio, spinal
cord injury, rheumatoid
arthritis, cerebral palsy,
stroke, and peripheral
neuropathy

Intervention
The treatment group
received a functional
evaluation and needs
assessment in the
participants homes.
Recommendations for
AT devices or home
modifications were made
and provided, and
training provided for
using the modifications.
The control group also
received a functional
evaluation in homes of
the participants but
received no AT devices
or home modifications.
Outcome Measures
OARS
FIM

At both the 12

month (t = 5.8, p <

.001) and 24 month
(t = 2.04, p < .05)
period, the treatment
group had
significantly more
pieces of equipment
than the control
group.
There was a
significant increase
in monthly
caregiver hours for
both groups over
time (p < .05). At
baseline, no
significant
difference was
found between
groups for the FIM
and IADLs. The
control group scored
significantly lower
on the FIM for
ADLs (t = 2.05, p <
.05). Repeated
analysis of
covariance
(ANCOVA) were
done and
examination of FIM
scores suggested a
slower decline (2 =

Small sample
size
Inability to
control for
access to home
modifications by
control group

Additional research is
needed in determining
specific implications of
utilizing smart home
technology for improving
functional performance.
The Clinical and
Community-Based
Practice of OT:
Home modifications can
assists in maintaining
functional independence in
adults with physical
impairments.
Program Development:
Specific areas of the home,
such as bathrooms, should
be the focus of home
modification programs
because of their assistance
in improving function in
adults with disabilities.
Societal Needs:
Home modifications can
offset the demand for
caregiver assistance in
adults with disabilities.
Healthcare Delivery and
Policy:
Results suggest that AT
devices and home
modifications should be
provided for individuals
with disabilities earlier in
the aging process.

4.32, p < .05) in

function for the
treatment group
than for the control
group in IADLs.

Education and Training of

OT Students:
Students need to be aware
that individuals aging with
a disability will have
functional decline that
occurs earlier than those
aging without a disability.
Refinement, Revision, and
Advancement of Factual
Knowledge or Theory:
Additional research is
needed to determine what
home modifications are
most beneficial in
improving function in
adults with physical
impairments.