Abstract

Importance: Occupational therapy practitioners evaluate students’ ability to participate in school and may provide services to improve learning, academic performance, and participation.

Objective: To examine the effectiveness of interventions within the scope of occupational therapy practice to improve academic participation of children and youth ages 5–21 yr.

Data Sources: We searched MEDLINE, PsycINFO, CINAHL, OTseeker, and Cochrane databases for articles published from 2000 to 2017 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Study Selection and Data Collection: Within the scope of occupational therapy practice and focused on children ages 5–21 yr.

Findings: Forty-six studies were included, based on three themes: (1) interventions to support participation and learning in the classroom; (2) interventions to support motivation and participation in literacy, including combined reading, written expression, and comprehension; and (3) interventions to support handwriting. Low strength of evidence supports the use of weighted vests and stability balls, and moderate strength of evidence supports the use of yoga to enhance educational participation. Moderate strength of evidence supports the use of creative activities, parent-mediated interventions, and peer-supported interventions to enhance literacy participation. Strong evidence supports therapeutic practice for handwriting intervention, and low strength of evidence supports various handwriting programs as replacement or additional instructional strategies to enhance handwriting abilities.

Conclusions and Relevance: More rigorous studies are needed that are conducted by occupational therapy practitioners in school-based settings and that use measures of participation and academic outcomes.

What This Article Adds: This systematic review provides occupational therapy practitioners with evidence on the use of activity-based and occupation-centered interventions to increase children’s participation and learning in school.

Learning and academic achievement are primary childhood endeavors. Occupational proficiency in the role of student is essential for children’s successful participation in school. Educational participation is evidenced by engagement in classroom activities that are required for learning and participating in school (American Occupational Therapy Association [AOTA], 2014). Indicators of successful participation in the classroom include on-task behaviors, following classroom rules, engagement, response time, attention, time spent seated, duration of independent work and work with peers, academic performance, communication, and classroom contribution (Burgoyne & Ketcham, 2015; Butzer et al., 2015; Fedewa et al., 2015; Hodgetts et al., 2011). Students with disabilities participate less than students without disabilities in school-related activities (Coster et al., 2013). Occupational therapy practitioners evaluate students’ ability to participate in school and may provide a continuum of services to improve learning, academic performance, and participation.

Literacy, as related to educational participation, is the ability to read and write and to express oneself in written form (Frolek Clark, 2016). Handwriting is a component of literacy frequently addressed by occupational therapy practitioners (Hoy et al., 2011). Impairment in handwriting has been linked to barriers in fluent composition and productive engagement in academic tasks (Santangelo & Graham, 2016). The reading component of literacy can also be understood from the perspective of occupational engagement and participation. When a child reads, he or she engages with a task object within a context, and many variables within this context influence participation (Grajo et al., 2016).

According to Law (2002), participation in occupations has several dimensions, which include one’s preferences and interests in activities, what one does, where and with whom one does it, and how much enjoyment and satisfaction one finds in participating in these activities. Although rarely addressed directly, literacy does appear in the occupational therapy literature. The third edition of the Occupational Therapy Practice Framework: Domain and Process (OTPF–3;AOTA, 2014) includes literacy (reading and writing) as part of formal education participation. Literacy thus is included within the domain of occupational therapy, yet the provision of occupational therapy specifically to children having reading problems is not well addressed (Grajo et al., 2016). Likewise, few studies have analyzed the effectiveness of occupation-based interventions to address handwriting and educational participation. There is a significant gap in the literature regarding interventions for school-age children aimed at the participation level.

The purpose of this systematic review was to provide occupational therapy practitioners with evidence on the use of activity-based or occupation-centered interventions to increase children’s participation and learning in school. This study aimed to answer the question, What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve learning, academic achievement, and successful participation in school for children and youth ages 5–21?

Method

This systematic review was supported and funded by AOTA as part of its Evidence-Based Practice Project. The search terms and search strategy were developed by an AOTA staff member and research methodologist, a medical librarian, and an advisory group (Table 1). Searches were conducted of the MEDLINE, PsycINFO, CINAHL, OTseeker, and Cochrane databases. The initial search returned 89,461 results with dates ranging from 2000 to 2017. After initial review and screening by the AOTA research methodologist, the authors screened 5,310 results for inclusion in the systematic reviews. Hand searching located an additional 12 articles for further screening. Articles were critically appraised using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009).

Inclusion Criteria

To be included in the systematic review, articles were required to be published in a peer-reviewed journal; written in English; published between January 2000 and March 2017; Level I, II, or III studies; within the scope of occupational therapy practice (i.e., activity or occupation based and within the domain of practice and process of occupational therapy as guided by the OTPF–3); and focused on children ages 5 to 21 yr and must describe intervention studies conducted by school practitioners and researchers or other health professionals (i.e., not necessarily occupational therapy practitioners), as long as the outcomes were within the scope of occupational therapy.

In addition, included studies needed to use specific outcome measures relating to academic participation. We operationalized three themes for study outcomes on the basis of the literature review and collaborative consultation with the AOTA Evidence-Based Project team and staff methodologist:

  1. Educational participation—for example, classroom on-task behaviors, engagement, and attention; ability to follow classroom rules; amount of time spent seated to attend to classroom tasks; amount of time spent on independent work and work with peers; academic performance; and amount of time and frequency of communication and classroom contribution

  2. Literacy participation—for example, frequency of reading and writing; motivation for and interest in reading and writing; positive self-concept, perception of mastery and competence, and attitudes regarding reading and writing; time spent engaging in print; and perception of performance and satisfaction in reading and writing engagement

  3. Handwriting—for example, component skills for handwriting (e.g., visual, motor, sensory); writing rate or speed, legibility, and accuracy; and frequency and amount of handwriting participation.

Exclusion Criteria

Studies were excluded from the systematic review if they were dissertations, theses, presentations, or proceedings; published before or after the review range; Level IV or V studies, regardless of outcomes measured; or studies of interventions for parents and service providers with no child-focused outcomes. Studies with outcomes that did not fall within the three outcome themes were not included; for example, we excluded studies examining outcomes of social participation in schools, engagement in physical activity, life skills and employment, driver education, after-school programs, and active commuting to school.

Screening

Of the 5,322 articles selected during title and abstract screening, we screened 456 more closely to determine whether a full review was warranted and further eliminated 371 articles (Figure 1). At least two researchers reviewed the full text of the 85 remaining articles to determine whether they met the inclusion and exclusion criteria. If reviewers could not reach a consensus on whether to include an article, they consulted with AOTA staff and the research methodologist. AOTA staff and the research methodologist also reviewed all studies to ensure they met the criteria. A total of 46 articles met the inclusion criteria and are included in this systematic review.

We analyzed the studies on the basis of level of evidence (design), quality (scientific rigor), and significance of findings and entered our findings in an evidence table (Table A.1 in the Appendix). In addition, we assessed the intervention studies for risk of bias using the Cochrane Collaboration tool (Higgins et al., 2011; Table A.2) and the systematic reviews using the AMSTAR tool (Shea et al., 2007; Table A.3). No overall assessments of risk of bias were identified that might affect the cumulative analysis. For quality control, the AOTA research methodologist and project staff reviewed all tables and provided feedback.

We evaluated the strength of evidence for each outcome theme according to the guidelines from the U.S. Preventive Services Task Force (2018):

  • Strong evidence includes consistent results from at least two randomized controlled trials (RCTs) that are well designed and well conducted.

  • Moderate evidence indicates at least one RCT or two or more moderate-quality studies. Confidence is constrained by inconsistency of findings or by the number, size, or quality of the individual studies.

  • Low evidence indicates that the evidence is insufficient because of a small number of studies, flaws in study design or method, inconsistency in results, or lack of information on important outcomes.

Results

Educational Participation

Eight articles (4 Level I, 1 Level II, 3 Level III) met the criteria for the review and provide evidence related to activity-based interventions addressing educational participation in school. Risk of bias of these studies ranged from low to high, and findings regarding effectiveness were mixed. Of the 8 studies, only 1 was conducted by occupational therapy clinicians and researchers (Hodgetts et al., 2011); the rest were conducted by exercise physiologists, educational psychologists, physical and recreational therapists, neuropsychologists, and special education researchers.

Weighted Vests

Low evidence from 2 studies addresses the use of weighted vests in the classroom to increase participation and academic achievement. A Level II single-case withdrawal study measured classroom behaviors in children with autism spectrum disorder (ASD) during three phases: without wearing a vest, wearing a vest with weight, and wearing a vest without weight (Hodgetts et al., 2011). Sitting time, attention to task, and seated behavior did not significantly improve when wearing weighted vests. A systematic review found 13 group or single-case studies of the use of weighted vests by students with ASD (Taylor et al., 2017). Eight of the studies did not support the use of weighed vests to increase in-seat behaviors and engagement. Five studies showed strong support for the use of weighted vests during classroom activities to decrease off-task behavior time; however, the results of these studies do not meet What Works Clearinghouse (WWC) criteria for evidence-based practice because of the limited number of participants (n = 5 total) and limited geographic regions represented. Therefore, the evidence is insufficient to support weighted vest intervention for children with ASD in the classroom.

Stability Balls

Low evidence from three studies addresses the use of stability balls in the classroom to increase educational participation. An RCT examined the use of stability balls versus classroom chairs in second-grade general education classrooms throughout the day (Fedewa et al., 2015). Students using stability balls significantly increased their interaction with teachers, whereas students using standard classroom chairs spent more time on task when working independently and with peers. Use of stability balls did not significantly improve on-task behavior or achievement levels in math and literacy.

A Level III comparison of second-grade students’ classroom behaviors while using classroom chairs versus stability balls found significant increases in observed on-task behaviors, as measured by focused activity and following classroom rules, while using stability balls (Burgoyne & Ketcham, 2015). A Level III study examined classroom behaviors while using a stability ball in third- through fifth-grade students diagnosed with attention deficit hyperactivity disorder; descriptive results indicated an increase in average time spent seated and on-task time when seated on a stability ball (Fedewa & Erwin, 2011).

Yoga

Moderate evidence based on 3 studies supports the effectiveness of yoga interventions to enhance school participation. A Level III study of the Yoga4 Classroom program for second-grade students resulted in significant improvements in social interaction, attention, and on-task academic performance as reported by teachers (Butzer et al., 2015).

An RCT examined use of a manualized yoga-based social–emotional wellness promotion program, Transformative Life Skills, with sixth- and ninth-grade students to address stress, physical and emotional awareness, self-regulation, and healthy relationships (Frank et al., 2017). The intervention group had significantly fewer unexcused absences and significantly higher levels of school engagement. Finally, a systematic review of 12 studies examined the effectiveness of yoga programs for children with and without disabilities delivered in school. Results were inconclusive because of high risk of bias (Serwacki & Cook-Cottone, 2012); however, significant improvements in communication and classroom contribution were exhibited by children with learning disabilities and emotional and behavioral problems compared with control groups.

Literacy Participation

Thirteen studies (6 Level I, 6 Level II, 1 Level III) examined interventions to promote literacy participation. The studies were rated as having an overall moderate risk for bias, and all but one (Sylva et al., 2008) had a low risk of reporting bias. Only one study was conducted by occupational therapy clinicians and researchers (Grajo & Candler, 2016); the rest were conducted by reading specialists, special education researchers, and educational psychologists. Interventions varied in format (groups vs. dyads vs. individuals) and duration (one time vs. multiple weeks). Level of evidence is reported separately for three types of intervention: embedded and supplemental creative literacy activities, parent-mediated interventions, and peer-supported reading participation.

All studies used skill-level outcome measures (e.g., phonological processing, receptive and expressive language tests, reading and writing tests). Five studies used standardized published assessments of behavior and attitudes toward reading (Chong et al., 2014; Chow et al., 2018; Grajo & Candler, 2016; Higgins et al., 2015; Lee, 2014). Four studies used author-developed questionnaires on reading attitudes (Kim & Guryan, 2010; Saint-Laurent & Giasson, 2005; Steiner, 2014; Sylva et al., 2008). Two studies used standardized literacy environment assessments (Jordan et al., 2000; Ullery et al., 2014).

Embedded and Supplemental Creative Literacy Activities

Strong evidence based on four studies (2 Level I, 1 Level II, 1 Level III) supports the use of embedded creative and engaging literacy activities in classroom and supplemental intervention sessions. Two RCTs found that embedding creative discussions and rotating literacy activities in small groups led to significant increases in positive attitudes toward reading and improved self-concept as a reader (Chow et al., 2018; Higgins et al., 2015). Creative activities included having students create their own stories through drawings and interactive discussions.

A Level II study found that a pullout session in preschool integrating creative reading and writing activities to develop early literacy skills led to significant improvements in social behaviors that promote literacy engagement, such as attention and positive interaction with peers during literacy tasks (Chong et al., 2014). The creative activities included helping the children with beginning reading through word recognition, one-to-one word correspondence, visual discrimination, and phonemic awareness and with developing writing skills.

A Level III study integrated choice and creative participation during occupational therapy sessions in an 8-wk program and led to significant increases in perceived reading performance and satisfaction (Grajo & Candler, 2016). As part of the intervention, participants were allowed to identify their occupation-based reading goals (e.g., reading from an iPad for fun, reading at church in front of people) and to structure the format of the sessions.

Parent-Mediated Interventions

Moderate evidence based on 7 studies (3 Level I, 4 Level II) supports parent-mediated literacy interventions. An RCT found that enhancing parent–child interactions through a family literacy event led to significant increases in frequency of reading and number of books read (Kim & Guryan, 2010). It included a control group and two intervention groups: (1) a treatment group in which children received 10 self-selected books during summer vacation and (2) a treatment group with a family literacy group in which children received 10 self-selected books and were invited with their parents to attend three 2-hr summer literacy events.

An RCT evaluating nine family literacy workshops with an emphasis on successful reading engagement found significant changes in reading and writing scores but not in reading attitudes (Saint-Laurent & Giasson, 2005). The workshops facilitated reading with parents through adapting parental intervention to the child’s gradually increasing skills in reading during the school year, support for writing activities, and enjoyable home activities complementing the in-class teaching.

A Level II study using a parent-mediated literacy coaching approach led to significant increases in dyadic reading frequency and in mother-initiated dialogues with their children (Levin & Aram, 2012). Another Level II study of an 8-wk parent training program resulted in descriptively increased storybook reading frequency by parents and significant increases in children’s concepts about print (Steiner, 2014). A Level II study found that organized parent training sessions over 5 mo led to significant increases in home literacy activities and home literacy environments, but these increases were not significantly different from those of a control group that received the traditional curriculum (Jordan et al., 2000). An RCT examining a 70-hr parent training program found significant increases in children’s single-word reading scores but no changes in print concepts or phonological awareness compared with a control group that had access to a phone helpline (Sylva et al., 2008).

Peer-Supported Reading Participation

Moderate evidence based on 2 studies (1 Level I, 1 Level II) supports the effectiveness of peer-supported reading programs. A meta-analysis of 12 studies found that cross-age tutoring, direct reading tutoring, and tutoring with longer duration (16 hr or more) by student peers led to the highest effect sizes (Jun et al., 2010). A Level II study found that an 8-wk peer tutoring program led to significant improvements in reading attitude for recreational reading (Lee, 2014).

Handwriting

Twenty-five studies (10 Level I, 10 Level II, 5 Level III) related to handwriting legibility outcomes were included in this review. Nineteen studies were conducted by occupational therapy clinicians and researchers and the rest by special education teachers and researchers, educational psychologists, and developmental optometrists. Fifteen studies examined the handwriting performance of typically developing children and 10 studies of children with identified handwriting difficulties. Children with a confirmed diagnosis (e.g., autism, cerebral palsy, intellectual disabilities) were excluded from the studies. Participants’ average age was 7 yr (range = 4.6–12.0 yr).

The studies presented an array of interventions with an average of approximately 11 hr of training (range = 3–18 hr) over an average of 8 wk (range = 1–12 wk), with some of the interventions spaced over an academic year. Three studies used computer-based, technology-driven, or robotics-assisted interventions (Leung et al., 2016; Palsbo & Hood-Szivek, 2012; Poon at al., 2010). Results are presented separately for four intervention approaches: component skills, sensorimotor versus therapeutic practice, interventions in addition to usual classroom activities, and interventions in place of usual classroom activities.

Approaches to Address Component Skills

Handwriting is a complex task that involves an array of component skills, including visual perception, kinesthesia, in-hand manipulation, and visual–motor integration (Denton et al., 2006). Four RCTs with low risk of bias examined interventions that isolated and specifically addressed component skills hypothesized to underlie handwriting proficiency. None provided evidence for an effect on handwriting legibility of isolated activities addressing the components of visual perception, kinesthesis, or motor skill. One study showed no effect for kinesthetic training (Sudsawad et al., 2002). The other 3 studies provided moderate evidence for an effect of visual perception or motor skill training on handwriting speed but no effect on handwriting legibility (Leung et al., 2016; Li et al., 2014; Poon et al., 2010).

Sensorimotor Versus Therapeutic Practice Approaches

Seven studies (4 Level I, 2 Level II, 1 Level III) with low risk of bias compared the relative effectiveness of sensorimotor versus therapeutic practice approaches to promote handwriting legibility outcomes. Sensorimotor approaches described in the studies consisted of combined activities that addressed visual perception, kinesthesia, in-hand manipulation, visual–motor integration, and biomechanical features of handwriting. Therapeutic practice approaches used paper-and-pencil activities with an emphasis on cognitive strategies such as self-evaluation techniques and the provision of performance feedback (Denton et al., 2006). Participants included children with and without identified handwriting difficulties.

Strong evidence from 3 Level I studies (Chang & Yu, 2014; Denton et al., 2006; Weintraub et al., 2009) and 1 Level II study (Jongmans et al., 2003, who also reported a Level III study; see Table A.1) supports therapeutic practice over sensorimotor approaches or usual classroom activities to improve handwriting legibility for children with handwriting difficulties. Moderate evidence from 3 studies supports the effectiveness of interventions to improve handwriting legibility for typically developing children (Howe et al., 2013, Level II; Kaiser et al., 2011, Level III; Zwicker & Hadwin, 2009, Level I).

Interventions in Addition to Usual Classroom Activities

Low evidence from 5 studies (2 Level I, 2 Level II, 1 Level III) with mixed results was found for combined programs provided in addition to usual classroom activities. An average of 9.8 hr of added instruction provided over 10 wk was provided; added instruction in one study occurred over an academic year and consisted of one to three additional lessons per week and 20 occupational therapy visits (Hape et al., 2014). An RCT with low risk of bias (Peterson & Nelson, 2003) and a Level II study (Lust & Donica, 2011) found significant positive results for the added intervention for typically developing participants. An RCT with unclear bias risk (Shimel et al., 2009) and a Level II study (Hape et al., 2014) found no differences between groups. A Level III study found significant improvements for a combined program for children with handwriting difficulties but used no comparison group (Roberts et al., 2010).

Interventions in Place of Usual Classroom Activities

Eight studies (6 Level II, 2 Level III) examined combined programs provided in place of usual classroom activities. An average of 16.5 hr of instruction provided over 10.6 wk was reported in five studies. Programs in three studies were conducted as curriculum throughout the academic year. All participants were typically developing.

Low evidence from 4 Level II studies (Case-Smith et al., 2014; Donica, 2015; Pfeiffer et al., 2015; Roberts et al., 2014) and 2 Level III studies (Case-Smith et al., 2011, 2012) supports combined programs over usual classroom activities. A confounding factor in these comparisons is incomplete descriptions of the curriculums replaced by the combined programs.

A Level II study found no differences after implementation of a manualized combined program compared with a manualized therapeutic practice–oriented program (Salls et al., 2013). Another Level II study showed significant improvement from use of teacher-designed instruction over a manualized combined program (Schneck et al., 2012).

Discussion

Educational Participation

The studies in this review addressed a variety of interventions to enhance educational participation. Yoga was found to be an effective activity-based intervention to improve classroom communication and engagement in school. Sensory-based interventions and environmental supports that address identified sensory-related issues have been used to support participation in school settings (Dunn, 2013; Roley et al., 2015); weighted vests are used to improve attention, on-task behaviors, and staying seated (Hodgetts et al., 2011), and stability balls are provided as an alternative seating option to improve in-seat and on-task behavior (Fedewa & Erwin, 2011; Schilling et al., 2003). The evidence does not support the use of either intervention, however; standard chairs were found to be more effective than stability balls in the classroom, and weighted vests to increase educational participation for children with ASD were not found to be effective.

Literacy Participation

The strength of evidence is moderate supporting the effectiveness of activity-based interventions to support creative engagement in literacy and involve parents and peers in enhancing literacy participation. The activity-based interventions described in the 13 included articles were mainly carried out by teachers and reading specialists; only one was carried out by occupational therapists. The role of occupational therapy in literacy and the literature remains focused more on handwriting interventions and prerequisite skills for reading than on reading as an occupation and literacy participation (Grajo et al., 2016). Although the interventions in included studies were found to enhance literacy participation, not all interventions directly addressed reading as a skill (e.g., language-based skills needed for reading).

Our review revealed little evidence regarding explicit use of computer-based and assistive technologies to enhance literacy participation. The searches located 28 studies that used computer-based and assistive technologies (e.g., tablets, computer games, interactive books) as the primary method of intervention delivery, but these studies were excluded because they did not meet the outcomes and inclusion criteria for this systematic review. Twenty-three studies used computer- and technology-based programs to enhance prerequisite phonological processing, working memory, gross motor, visual–perceptual, and morphological skills for reading, which are critical for literacy participation, but these studies did not measure outcomes at the participation level (e.g., attitudes toward reading, reading and writing frequency, perception of mastery and competence toward literacy engagement).

When integrating activity-based interventions to promote literacy participation, occupational therapy practitioners should consider duration of intervention, level and quality of parent involvement, and support of peers of a variety of ages (i.e., cross-age rather than same-age peers). In addition, practitioners should use standardized measures of attitudes toward reading, reading preferences, and literacy-related behavior to measure self-concept related to literacy and outcomes of intervention (Grajo et al., 2016). Moreover, development of more occupation-centered assessments to measure literacy participation is needed.

Handwriting

This review found moderate evidence to support interventions to address handwriting legibility outcomes, including therapeutic practice, cognitive strategies such as self-evaluation techniques, and the provision of performance feedback. Therapeutic practice is an evidence-based approach to improve handwriting legibility. In contrast, the evidence indicates that sensorimotor handwriting interventions that address isolated component skills, such as visual perception, kinesthesia, in-hand manipulation, visual–motor integration, or biomechanical features of handwriting, have no effect on handwriting legibility.

Because of low strength of evidence, no definitive recommendation can be made concerning the effectiveness of handwriting programs with combined sensorimotor and therapeutic practice approaches for children either with or without identified handwriting difficulties. Whether these programs as a group have added benefit over usual classroom activities for typical writers cannot be determined without deeper examination of what constitutes usual classroom activities. Therefore, occupational therapy practitioners should be cautious when recommending additional instruction time using combined programs and should carefully evaluate the effectiveness of handwriting programs already in place before recommending combined programs as an alternative or for curriculum adoption.

Limitations

This systematic review presents a selected set of three themes—educational participation, literacy participation, and handwriting—to describe the effectiveness of interventions within the scope of occupational therapy to enhance literacy participation. Findings on themes related to social participation in schools, engagement in physical activity, life skills and employment, driver education, after-school programs, active commuting to school, and learning outcomes as they relate to school participation were not included.

Common limitations of the studies included in this review were small sample sizes, lack of random sampling, and lack of a control group. We included only research at Levels I through III; several Level IV studies were excluded that might have provided some preliminary evidence on the effectiveness of educational participation interventions. We also searched a limited number of databases and included only articles published in English.

Last, this review did not focus on interventions performed mainly by occupational therapy practitioners, but rather on activity-based interventions that are within the scope of occupational therapy. It may be hard to determine the generalizability of direct application of the interventions in these studies to school-based and pediatric occupational therapy practice.

Implications for Occupational Therapy Practice and Research

The findings of this review support the following recommendations for occupational therapy practice and research:

  • • Caution must be used in generalizing the use of stability balls and weighted vests to enhance educational participation in classrooms.

  • • Interventions that use choice, creative engagement, collaboration with parents, and support by cross-age peers show promise in enhancing children’s attitudes toward literacy and participation in literacy activities.

  • • Isolated skills training to address prerequisite skills for handwriting does not translate to improved handwriting performance. The use of prerequisite skills in interventions must be directly tied to handwriting tasks.

  • • More rigorous research is needed to support the effectiveness of interventions and to develop occupation-focused measures of educational participation.

Acknowledgments

This project was funded by the American Occupational Therapy Association (AOTA). Sincere gratitude to Deborah Lieberman, Elizabeth Hunter, and Marian Arbesman of the AOTA Evidence-Based Practice Project for their support, assistance, and leadership in this project.

Evidence and Risk-of-Bias Tables

*

Indicates studies included in the systematic review.

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