Esther Steultjens

Occupational Therapy for Stroke Patients A Systematic Review

Background and Purpose— Occupational therapy (OT) is an important aspect of stroke rehabilitation. The objective of this study was to determine from the available literature whether OT interventions improve outcome for stroke patients. Methods— An extensive search in MEDLINE, CINAHL, EMBASE, AMED, and SCISEARCH was performed. Studies with controlled and uncontrolled designs were included. Seven intervention categories were distinguished and separately analyzed. If a quantitative approach (meta-analysis) of data analysis was not appropriate, a qualitative approach (best-evidence synthesis), based on the type of design, methodological quality, and significant findings of outcome and/or process measures, was performed. Results— Thirty-two studies were included in this review, of which 18 were randomized controlled trials. Ten randomized controlled trials had a high methodological quality. For the comprehensive OT intervention, the pooled standardized mean difference for primary activities of daily living (ADL) (0.46; CI, 0.04 to 0.88), extended ADL (0.32; CI, 0.00 to 0.64), and social participation (0.33; CI, 0.03 to 0.62) favored treatment. For the training of skills intervention, some evidence for improvement in primary ADL was found. Insufficient evidence was found to indicate that the provision of splints is effective in decreasing muscle tone. Conclusions— This review identified small but significant effect sizes for the efficacy of comprehensive OT on primary ADL, extended ADL, and social participation. These results correspond to the outcome of a systematic review of intensified rehabilitation for stroke patients. The amount of evidence with respect to specific interventions, however, is limited. More research is needed to enable evidence-based OT for stroke patients.

Evidence of the efficacy of occupational therapy in different conditions: an overview of systematic reviews

Objective: To summarize the research evidence available from systematic reviews of the efficacy of occupational therapy (OT) for practitioners, researchers, purchasing organizations and policy-makers. Data source: The search for systematic reviews was conducted in PubMed and the Cochrane Library (October 2004). Methods: The reviews included were those that utilized a systematic search for evidence with regard to OT for specific patient groups. Data were summarized for patient group, interventions, outcome domains, type of study designs included, method of data synthesis and conclusions. Results: Fourteen systematic reviews were included. Three reviews related to rheumatoid arthritis, four reviewed stroke and four focused on elderly people. Reviews of Parkinsons disease, multiple sclerosis, Huntingtons disease, cerebral palsy and mental illnesses were also identified. The reviews of rheumatoid arthritis, stroke and elderly people showed evidence of the efficacy of OT in increasing functional abilities. Positive results were presented for quality of life and social participation in elderly people and stroke respectively. The efficacy of OT in all other patient groups is unknown due to insufficient evidence. Conclusion: This summary shows that elderly people and people with stroke or rheumatoid arthritis can expect to benefit from comprehensive OT. Evidence of the efficacy of specific interventions is sparse and should be addressed in future research. The evidence that does exist should be incorporated into OT practice.

Occupational therapy for children with cerebral palsy: a systematic review

Objective: Occupational therapy (OT) for cerebral palsy focuses on the development of skills necessary for the performance of activities of daily living. The aim of this systematic review was to determine whether OT interventions improve outcome for children with cerebral palsy (CP). Methods: An extensive search in MEDLINE, CINAHL, EMBASE, AMED and SCISEARCH was performed. Studies with controlled and uncontrolled designs were included. Six intervention categories were distinguished and individually analysed using a best-evidence synthesis. This synthesis is based on the type of design, the methodological quality, the type of outcome measures and the statistical significance of the findings. Results: Seventeen studies were included in this review, seven of which were randomized controlled trials (RCTs). One RCT had a high methodological quality. The analyses resulted in insufficient evidence of the efficacy of occupational therapy in all intervention categories, due to the low methodological quality of studies presenting statistically nonsignificant results. Conclusion: Despite the reasonable number of studies identified, the inconclusive findings regarding the efficacy of occupational therapy for children with cerebral palsy may be a reflection of the difficulties in efficacy research in OT for children with CP. Future research should critically reflect on methodological issues.

A cluster randomised controlled trial on the efficacy of client-centred occupational therapy in multiple sclerosis: good process, poor outcome.

Abstract Purpose: To assess the efficacy of client-centred occupational therapy (OT) according to a client-centred process framework, as compared to usual care OT, in patients with multiple sclerosis (MS). Method: A multicentre cluster randomised controlled trial with the institution (i.e. hospital or rehabilitation centre) as the unit of randomisation was performed. A total of 269 outpatients with MS, 13 hospitals and rehabilitation centres and 29 occupational therapists participated. Primary outcomes included measures of disability, participation and autonomy. Secondary outcomes included fatigue, generic health-related quality of life, quality and evaluation of therapy, therapy compliance and therapy frequency. Measurements were taken at baseline, four months and at eight months follow-up. Results: Primary outcome measures did not show significant differences between the two interventions. Secondary outcomes revealed significant differences in favour of the usual care OT on fatigue (physical scale and total scale) and health-related quality of life (bodily pain and vitality) at four months. After eight months only significant differences on mental health were found. Process outcomes (i.e. the information scale of therapy quality and the client-centredness of the organisation) were in favour of the client-centred intervention. Conclusion: Because the client-centred intervention resulted in no effects on the primary outcomes and small but negative effects on the secondary functional outcomes, we should seriously reconsider the application of client-centred practice. Implications for Rehabilitation An increasing number of interventions claim to incorporate client-centred practice. Client-centred practice is associated with improved satisfaction but the effects on functional health-related outcomes have not been fully evaluated. The findings of this study show that the process outcomes of therapy were in favour of the client-centred intervention, but no effects were found on the primary outcomes and negative effects on the secondary functional health outcomes. It is suggested that the implementation of client-centred practice should be adjusted in order to achieve optimal health outcomes.

Occupational Therapy for Stroke Patients

Background and Purpose— Occupational therapy (OT) is an important aspect of stroke rehabilitation. The objective of this study was to determine from the available literature whether OT interventions improve outcome for stroke patients. Methods— An extensive search in MEDLINE, CINAHL, EMBASE, AMED, and SCISEARCH was performed. Studies with controlled and uncontrolled designs were included. Seven intervention categories were distinguished and separately analyzed. If a quantitative approach (meta-analysis) of data analysis was not appropriate, a qualitative approach (best-evidence synthesis), based on the type of design, methodological quality, and significant findings of outcome and/or process measures, was performed. Results— Thirty-two studies were included in this review, of which 18 were randomized controlled trials. Ten randomized controlled trials had a high methodological quality. For the comprehensive OT intervention, the pooled standardized mean difference for primary activities of daily living (ADL) (0.46; CI, 0.04 to 0.88), extended ADL (0.32; CI, 0.00 to 0.64), and social participation (0.33; CI, 0.03 to 0.62) favored treatment. For the training of skills intervention, some evidence for improvement in primary ADL was found. Insufficient evidence was found to indicate that the provision of splints is effective in decreasing muscle tone. Conclusions— This review identified small but significant effect sizes for the efficacy of comprehensive OT on primary ADL, extended ADL, and social participation. These results correspond to the outcome of a systematic review of intensified rehabilitation for stroke patients. The amount of evidence with respect to specific interventions, however, is limited. More research is needed to enable evidence-based OT for stroke patients.

Occupational Therapy for Stroke Patients: A Systematic Review * Occupational Therapy for Stroke Patients: When, Where, and How?

Background and Purpose— Occupational therapy (OT) is an important aspect of stroke rehabilitation. The objective of this study was to determine from the available literature whether OT interventions improve outcome for stroke patients. Methods— An extensive search in MEDLINE, CINAHL, EMBASE, AMED, and SCISEARCH was performed. Studies with controlled and uncontrolled designs were included. Seven intervention categories were distinguished and separately analyzed. If a quantitative approach (meta-analysis) of data analysis was not appropriate, a qualitative approach (best-evidence synthesis), based on the type of design, methodological quality, and significant findings of outcome and/or process measures, was performed. Results— Thirty-two studies were included in this review, of which 18 were randomized controlled trials. Ten randomized controlled trials had a high methodological quality. For the comprehensive OT intervention, the pooled standardized mean difference for primary activities of daily living (ADL) (0.46; CI, 0.04 to 0.88), extended ADL (0.32; CI, 0.00 to 0.64), and social participation (0.33; CI, 0.03 to 0.62) favored treatment. For the training of skills intervention, some evidence for improvement in primary ADL was found. Insufficient evidence was found to indicate that the provision of splints is effective in decreasing muscle tone. Conclusions— This review identified small but significant effect sizes for the efficacy of comprehensive OT on primary ADL, extended ADL, and social participation. These results correspond to the outcome of a systematic review of intensified rehabilitation for stroke patients. The amount of evidence with respect to specific interventions, however, is limited. More research is needed to enable evidence-based OT for stroke patients.

Organizational leadership, health risk screening, individually tailored programs, and supportive workplace culture might reduce presenteeism

To determine if Workplace Health Promotion programs (WHPs) are effective in improving presenteeism. The secondary objective was to identify characteristics of successful programmes and potential risk factors for presenteeism. The Cochrane Library, Medline and other electronic databases were searched from 1990 to January 2010 for all studies that examined WHP. A highly sensitive search strategy was used including reference list checking, hand searching, and contacting researchers. Fourteen studies (four strong and ten moderate methodological quality) were eligible for inclusion. A further 33 were considered ineligible for inclusion due to methodological weakness. The 14 eligible studies contained preliminary evidence for a positive effect of some WHP programs. Successful programs offered organizational leadership, health risk screening, individually tailored programs, and a supportive workplace culture. Potential risk factors contributing to presenteeism included being overweight, poor diet, lack of exercise, high stress, and poor relations with co-workers and management. There is preliminary evidence that some WHP programs can positively affect presenteeism and that certain risk factors are of importance. The presenteeism literature is young and heterogeneous.

What environmental factors influence resumption of valued activities post stroke: a systematic review of qualitative and quantitative findings

Objective: Identify the environmental factors that influence stroke-survivors’ reengagement in personally valued activities and determine what specific environmental factors are related to specific valued activity types. Data sources: PubMed, CINAHL and PsycINFO were searched until June 2016 using multiple search-terms for stroke, activities, disability, and home and community environments. Review methods: An integrated mixed-method systematic review of qualitative, quantitative and mixed-design studies was conducted. Two researchers independently identified relevant studies, assessed their methodological quality and extracted relevant findings. To validly compare and combine the various findings, all findings were classified and grouped by environmental category and level of evidence. Results: The search yielded 4024 records; 69 studies were included. Most findings came from low-evidence-level studies such as single qualitative studies. All findings were consistent in that the following factors facilitated reengagement post-stroke: personal adapted equipment; accessible environments; transport; services; education and information. Barriers were: others’ negative attitudes and behaviour; long distances and inconvenient environmental conditions (such as bad weather). Each type of valued activity, such as mobility or work, had its own pattern of environmental influences, social support was a facilitator to all types of activities. Although in many qualitative studies others’ attitudes, behaviour and stroke-related knowledge were seen as important for reengagement, these factors were hardly studied quantitatively. Conclusion: A diversity of environmental factors was related to stroke-survivors’ reengagement. Most findings came from low-evidence-level studies so that evidence on causal relationships was scarce. In future, more higher-level-evidence studies, for example on the attitudes of significant others, should be conducted.

Validation of a Danish translation of an occupational therapy guideline for interventions in apraxia: A pilot study

The objective of this study was to produce a valid Danish translation of the Dutch “Occupational therapy guideline for assessment and treatment of apraxia in CVA clients”; to investigate the inter-rater reliability of the assessment instrument in terms of ADL observations; and to determine the content validity of the translation. The inter-rater reliability was investigated using video observations and multiple raters, who also judged the content validity quantitatively. For the scores of the patients occupational performance the study found moderate to good inter-rater reliability for three of four variables and poor to fair inter-rater reliability for one variable, indicated by intra-class correlation coefficient and Kappa statistic. For the conclusion variables the results demonstrated fair inter-rater reliability for five of six variables and poor inter-rater reliability for one variable, also indicated by Kappa statistic. The content validity was judged valid for 100 and invalid for 28 of the guidelines defined elements. The conclusion, taking the complexity of the ADL observations and the study design into consideration, is that the Danish version can serve as a guideline within Danish occupational therapy practice. However, a translational recheck, further psychometric testing, and a minimum two-day training course is recommended before implementation in practice.

The Suitability of the Montreal Cognitive Assessment as a Screening Tool to Identify People with Dysfunction in Occupational Performance after Mild Stroke

Introduction: Cognitive deficits are an important determinant for experiencing limitations in occupational performance after stroke. It is important to recognize these deficits, and their impact on daily activities, at an early stage so people can get the support they need. The non-challenging environment of a hospital hampers this recognition, making it difficult for occupational therapists to select which patients should be assessed extensively, and which not. This study aims to explore the Montreal Cognitive Assessment as a screening tool by investigating its relationship with occupational performance in patients with mild stroke. Method: Twenty-nine people with mild stroke were recruited for this cross-sectional study. Scores on the Montreal Cognitive Assessment and Assessment of Motor and Process Skills were compared and correlations were calculated. Findings: The Montreal Cognitive Assessment cut-off did not identify those who might experience problems in daily functioning after mild stroke. A moderate correlation was found between scores on the Montreal Cognitive Assessment and the Assessment of Motor and Process Skills process scores. Conclusion: The Montreal Cognitive Assessment cannot be used as a screening tool to identify problems in occupational performance after mild stroke.