Deirdre Connolly

OPTIMAL, an occupational therapy led self-management support programme for people with multimorbidity in primary care: a randomized controlled trial

BackgroundWe investigated the effectiveness of an occupational therapy led self-management support programme, OPTIMAL, designed to address the challenges of living with multiple chronic conditions or multimorbidity in a primary care setting.MethodsPragmatic feasibility randomised controlled trial including fifty participants with multimorbidity recruited from family practice and primary care settings. OPTIMAL is a six-week community-based programme, led by occupational therapy facilitators and focuses on problems associated with managing multimorbidity. The primary outcome was frequency of activity participation. Secondary outcomes included self-perception of, satisfaction with and ability to perform daily activities, independence in activities of daily living, anxiety and depression, self-efficacy, health-related quality of life, self-management support, healthcare utilisation and individualised goal attainment. Outcomes were collected within two weeks of intervention completion.ResultsThere was a significant improvement in frequency of activity participation, measured using the Frenchay Activities Index, for the intervention group compared to the control group (Adjusted Mean Difference at follow up 4.22. 95% Confidence Interval 1.59-6.85). There were also significant improvements in perceptions of activity performance and satisfaction, self-efficacy, independence in daily activities and quality of life. Additionally, the intervention group demonstrated significantly higher levels of goal achievement, following the intervention. No significant differences were found between the two groups in anxiety, depression, self-management scores or healthcare utilisation.ConclusionsOPTIMAL significantly improved frequency of activity participation, self-efficacy and quality of life for patients with multimorbidity. Further work is required to test the sustainability of these effects over time but this study indicates that it is a promising intervention that can be delivered in primary care and community settings.Trial registrationTrial Number: ISRCTN67235963

Exploring the relationship between self-awareness of driving efficacy and that of a proxy when determining fitness to drive after stroke

BACKGROUND/AIM The inclusion of a driving specific self-awareness measure may assist the clinical screening process to determine fitness to drive after stroke. This article reports on the use of the Adelaide Driving Self-Efficacy Scale (ADSES) and a proxy ADSES for completion by a significant other in assessment of fitness to drive post-stroke. METHOD A prospective study among a clinical sample of stroke patients was conducted incorporating an off-road occupational therapy assessment, an on-road assessment and a six-month follow-up. Self and proxy driver efficacy ratings were compared with each other at off-road assessment and at six-month follow-up, both ratings were compared with structured on-road ratings of driving performance. RESULTS Forty-six stroke patients (37 men), mean age 63.5 years, were recruited to the study. Thirty-five participants successfully completed the on-road test. ADSES and proxy ratings were high and a ceiling effect was noted. Self and proxy ratings were significantly correlated with each other and both correlated with the on-road assessment ratings. The ADSES ratings were sensitive to the final driving outcome with scores of the restricted driving group significantly lower than the unrestricted group. Proxy ratings showed a decrease at six-month follow-up. CONCLUSIONS The ADSES is an easy to administer tool that warrants further use in stroke rehabilitation. Scores on the ADSES differentiated between restricted and unrestricted driving recommendations post-stroke. These preliminary findings indicate its potential use as a proxy measure to assist in identifying patient who are not ready for formal driving assessment.

Factors associated with ADL/IADL disability in community dwelling older adults in the Irish longitudinal study on ageing (TILDA)

Abstract Purpose: To identify the factors associated with disability across many domains using a large powered sample in the activities of daily living (ADL) and instrumental activities of daily living (IADL). Methods: Those aged ≥65 years from the Irish longitudinal study on ageing (TILDA) were included in this cross sectional analysis. Three logistic regression models were used to examine the relationships between 25 health, psychological and sociodemographic variables and difficulties in ADL, IADL and ADL/IADL combined. Results: The proportion of those reporting combined ADL/IADL difficulties was 18%. More individuals reported difficulty with ADLs (13%) than IADLS (11%). The main model showed that after age, the top three factors associated with difficulty in ADL/IADL combined were pain, taking five or more medications and depression. After age, the factors with the highest impact on ADL disability were pain, taking five or more medications and body mass index (BMI); the factors with the highest impact on IADL were being separated or divorced, living with others (non-spouse) and self-rated memory. Conclusions: Awareness of sociodemographics and early interventions for pain and cognitive deficits could reduce ADL/IADL disability and promote successful ageing. Identification of variables that influence ADL/IADLs can be used to inform policy and practice. Implications for rehabilitation After age, pain and taking five or more medications were the strongest factors associated with difficulty in ADL/IADL combined and ADL alone. Practice therefore needs to be cognizant that it is not the disease label but the symptoms of a disease that affect ADL and IADL activities. Given the strong influence of pain on difficulties with ADL and IADL, there is a need for early interventions from a multidisciplinary perspective for pain reduction, control, and self-management. These interventions should include development of pain-coping strategies and exercises to maintain mobility. After age, being separated/divorced or living with non-spouse others are the strongest factors associated with IADL difficulties. Awareness of these social factors can be used to inform support mechanisms, such as development of community services and suitable housing for those with these changing sociodemographics. Unsurprisingly, cognitive impairments were strongly associated with IADL difficulties. Simple cognitive screening assessments could be used for early detection of cognitive changes. In order to maintain optimal cognitive functioning, rehabilitation professionals should facilitate older adults’ engagement in activities that are cognitively demanding and socially interactive.

Impact of Fatigue in Rheumatic Diseases in the Work Environment: A Qualitative Study

Fatigue is a symptom of arthritis that causes difficulty at work. An improved understanding of this symptom could assist its management in the work environment. The aim of this study was to explore people with rheumatic diseases’ experiences of fatigue in work. A qualitative descriptive design was used with semi-structured interviews and a constant comparative method of data analysis. There were 18 participants, the majority of them female with Rheumatoid Arthritis (RA) and working full-time. Three themes were identified: “Impact of fatigue on work performance” with cognition, mood and physical abilities being the main difficulties reported. In the second theme “Disclosure at Work” participants discussed disclosing their disease to employers but reported a lack of understanding of fatigue from colleagues. The final theme “work-based fatigue management strategies” included cognitive strategies and energy management techniques, which were mainly self-taught. In this study, fatigue was reported to impact on many areas of work performance with limited understanding from colleagues and employers. Interventions from health professionals to assist with development of work-related self-management skills are required to assist with symptom management in the work place. Such interventions should include education to employers and colleagues on the nature of fatigue in Rheumatic diseases.

Exploring Occupational Adaptation through the Lives of Women with Multiple Sclerosis

Multiple sclerosis (MS) affects peoples physical capabilities and the lives of people with MS are constantly changing (Finlayson et al 2005), yet how people adapt to the disease from an occupational perspective has received little attention. This study explored the occupational adaptation of women with MS. Seven women with MS were recruited from the Multiple Sclerosis Society of Ireland. Each participant completed the Modified Interest Checklist (Kielhofner and Neville 1983), the Role Checklist (Oakley et al 1985) and the Occupational Questionnaire (Smith et al 1986). Qualitative data were also collected, using the Occupational Performance History Interview – II (Kielhofner et al 2004). The findings from all four tools were amalgamated and analysed. Three main themes emerged: the impact of MS on (i) performance capacity, (ii) roles and (iii) interests. The participants adapted by performing interests and roles differently and developing new meaningful interests and roles that were congruent with their performance capacity. The findings highlight the importance of having an understanding of the impact of different types of MS on the occupational adaptation process. A greater understanding will facilitate occupational therapists in enabling people with MS to adapt to their condition by engaging in meaningful occupations throughout the lifespan.

Managing fatigue in patients with chronic conditions in primary care

Fatigue is one of the common presenting complaints in primary care, being the primary complaint in 5–10% of presentations and an associated complaint in a further 10% of family practice consultations.1 Surveys suggest that the symptom is even more common in the community, with 5–20% of the general population complaining of persistent and troublesome fatigue. Almost half of those presenting with symptoms of severe fatigue remain fatigued 12 months later.2 Although family physicians may associate fatigue with conditions such as depression, it is a common underlying symptom across a range of chronic conditions and has particular relevance in the management of patients with multiple chronic conditions or multi-morbidity. In some chronic conditions, fatigue is reported by individuals to be one of their worst symptoms, having a key impact on their quality of life and ability to function. Despite being rated as an important symptom by up to 80% of patients, it is often a neglected component in the management of chronic conditions.3,4 It may also be a presenting symptom of co-morbid depression because patients with chronic illnesses are known to have a higher prevalence of major depressive illness, along with added functional impairment and increased medical costs.5 Many features of chronic conditions contribute to fatigue, including muscle weakness, pain, anxiety and disturbed sleep. Considering its multifaceted nature, management of fatigue should be comprehensive in targeting these diverse contributing factors. Potential management options include physiotherapy with a focus on endurance and fitness training, psychological interventions and structured fatigue management education programmes that usually include elements of all these approaches. Due to the impact of persistent fatigue on daily functioning, occupational therapists, whose focus is on facilitating maximum participation in self-care, work and leisure activities, are often the professionals who design and deliver fatigue management programmes. In a systematic review, occupational therapy-led fatigue management interventions have been identified as a promising approach to fatigue management.6 The overall aim of these interventions is to (i) increase patients’ understanding of fatigue, (ii) assist them in identifying factors that exacerbate their fatigue, and (iii) facilitate development of fatigue management strategies. This is achieved through analysis of their own daily activities and routines by patients in order to assess the effort and energy required for different activities. They are then informed of different methods for planning, pacing and prioritizing activities in order to enable participation in valued activities. Additionally, occupational therapists advise on work simplification skills, body mechanics, environmental adaptations, appropriate assistive devices and rest periods. Other factors that affect fatigue, such as anxiety management strategies (e.g. relaxation techniques and participation in leisure activities), sleep hygiene, nutrition and development of problem-solving skills, are also addressed to increase self-efficacy in managing fatigue.4 These inter ventions can be delivered either individually or in a group format, but there is limited evidence to support one approach over the other. Results of 6-week group-based energy management programmes for patients with multiple sclerosis have indicated decreased impact of fatigue, increased self-efficacy, improved quality of life and continued implementation of fatigue management strategies during a 1-year follow-up period.7 However, the major portion of this research has been conducted in patients with multiple sclerosis and cancer.4 Generic selfmanagement support programmes, which aim to address the management of chronic conditions, usually include fatigue management interventions.6 The multifaceted nature of these programmes may be appropriate in addressing the complex nature of fatigue, although most of their evaluations have not specifically focused on fatigue-related outcomes. The characteristics of patients who would benefit from a focus on fatigue management or a referral to a specific treatment programme remain unclear. Some limited research suggests that predictors of response to self-management interventions include ‘readiness to change’, willingness to adopt new behaviours and higher baseline of self-efficacy, as well as higher Family Practice 2013; 30:123–124 doi:10.1093/fampra/cmt005

Fatigue in Systemic Lupus Erythematosus: Impact on Occupational Participation and Reported Management Strategies

Purpose: Fatigue is reported by approximately 81 per cent of people with systemic lupus erythematosus, with subsequent lower quality of life. Although standardized measures have been used to examine the prevalence of fatigue, qualitative research is needed to explore how people describe and cope with fatigue in their daily lives. Method: Twelve people completed the Fatigue Impact Scale and were then interviewed using semi-structured interviews. Data were analysed using descriptive statistics and qualitative descriptive guidelines. Findings: Participants were aged 22–62 years with a mean of 14.3 years (SD 10) since diagnosis. Individual interviews identified an unpredictable pattern of fatigue for the study participants and an impact on participation in occupations of productivity and leisure, which resulted in loss of important life roles. Fatigue management strategies were self-developed, with participants reporting no input from health professionals. Conclusion: The unpredictable nature of fatigue makes it difficult to manage. It appears that development of both cognitive and practical strategies is required to reduce the impact of fatigue on valued occupations. Early fatigue management interventions could be beneficial for people with systemic lupus erythematosus in order to manage this symptom. However, a larger study is required to confirm the transferability of these findings.

Factors Influencing the Clinical Stratification of Suitability to Drive after Stroke: A Qualitative Study

ABSTRACT While a clinical pre-selection screening process for a stroke patients suitability for driving has been acknowledged, little is known about the factors or processes influencing this screening typically conducted by clinicians practicing at a generalist level. This study explored this clinical stratification process through the use of semi-structured interviews with senior occupational therapists (n = 17) and stroke physicians (n = 7) using qualitative description methodology. The findings revealed a trichotomy stratification of stroke patients for driving in the clinical setting; those who are fit to drive, unfit to drive, and a “maybe” group who need more detailed assessment and observation. Factors that had a major influence on this clinical-based stratification of driving suitability were clients levels of awareness, insight, and impulsivity. A period of prolonged contact with the client was preferential to guide the stratification decision in order for clinicians to build a comprehensive picture of the person. A mix of assessment approaches including standardized assessment but with increased emphasis on naturalistic observation of functional performance underpinned the clinical stratification process. This study uncovers some of the factors and processes influencing the early clinical-based stratification of driving suitability after stroke, and highlights the contribution of the generalist practitioner in the assessment of fitness to drive continuum.

Fatigue and Activity Management Education for Individuals with Systemic Lupus Erythematosus

Background Fatigue and Activity Management Education (FAME) is a six-week occupational therapy-led programme focusing on fatigue and stress management, exercise, nutrition, and joint protection. Each session consists of education and goal setting. Objectives of Study To assess the impact of FAME on occupational participation and fatigue management. Methods Three programmes were facilitated with twenty-one women with SLE. A mixed methods design was used. Quantitative data were collected using self-reported questionnaires administered before, immediately after, and eight weeks after intervention. Data were analysed using descriptive and nonparametric inferential statistics. Qualitative data were collected through focus groups and interviews. Thematic analysis was carried out on the qualitative data. Findings There was a statistically significant improvement in depression as measured by the Hospital Anxiety and Depression Scale and categories of “burden to others” and “fatigue” in the LupusQoL. There were nonsignificant improvements in fatigue, occupational participation, self-efficacy, and anxiety. Participants reported an improved understanding of fatigue and the impact of stress on fatigue. They also identified self-management strategies they were using on a daily basis.

Impact of a Dance Programme on Health and Well-Being for Community Dwelling Adults Aged 50 Years and Over

ABSTRACT Aims: The study examined the impact of a 6-week dance programme on frequency of activity participation, falls efficacy, and quality of life for community dwelling adults aged 50 years and over. It also explored participants’ perceptions of the programme impact and delivery. Methods: The programme was delivered by two dance instructors and targeted community dwelling adults aged 50 years and over, who were independently mobile. Sixty-two participants were recruited and provided baseline data. Thirty-five participants provided immediate follow-up data. Outcome measures were conducted at baseline and immediately post-intervention. Measures included frequency of participation in activities (The Frenchay Activities Index); falls efficacy (Falls Efficacy Scale- International); and quality of life (EQ-5D-3L). Focus groups explored participants’ perceptions of the programme. Results: Significant differences were found post-programme in frequency of activity participation (p = 0.036), including domestic activity (p = 0.048). No significant differences were found in falls efficacy or quality of life. Focus group data indicated participants enjoyed the programme and perceived enhanced physical abilities, emotional and psychological well-being and increased activity participation as a result of programme participation. Conclusion: Findings suggest that a dance programme may increase activity participation in social and community-based activities, however given the study limitations, further research is required to corroborate this.