Judi Edmans

Occupational therapy for patients with problems in personal activities of daily living after stroke: systematic review of randomised trials

Objective To determine whether occupational therapy focused specifically on personal activities of daily living improves recovery for patients after stroke. Design Systematic review and meta-analysis. Data sources The Cochrane stroke group trials register, the Cochrane central register of controlled trials, Medline, Embase, CINAHL, PsycLIT, AMED, Wilson Social Sciences Abstracts, Science Citation Index, Social Science Citation, Arts and Humanities Citation Index, Dissertations Abstracts register, Occupational Therapy Research Index, scanning reference lists, personal communication with authors, and hand searching. Review methods Trials were included if they evaluated the effect of occupational therapy focused on practice of personal activities of daily living or where performance in such activities was the target of the occupational therapy intervention in a stroke population. Original data were sought from trialists. Two reviewers independently reviewed each trial for methodological quality. Disagreements were resolved by consensus. Results Nine randomised controlled trials including 1258 participants met the inclusion criteria. Occupational therapy delivered to patients after stroke and targeted towards personal activities of daily living increased performance scores (standardised mean difference 0.18, 95% confidence interval 0.04 to 0.32, P=0.01) and reduced the risk of poor outcome (death, deterioration or dependency in personal activities of daily living) (odds ratio 0.67, 95% confidence interval 0.51 to 0.87, P=0.003). For every 100 people who received occupational therapy focused on personal activities of daily living, 11 (95% confidence interval 7 to 30) would be spared a poor outcome. Conclusions Occupational therapy focused on improving personal activities of daily living after stroke can improve performance and reduce the risk of deterioration in these abilities. Focused occupational therapy should be available to everyone who has had a stroke.

The frequency of perceptual deficits after stroke

The frequency of perceptual problems in stroke patients was assessed using a standardised assessment, The Rivermead Perceptual Assessment Battery.1 One hundred and fifty stroke patients (75 right hemiplegic and 75 left hemiplegic), admitted consecutively to two general hospitals, were assessed one month after stroke, to identify the proportion with perceptual difficulties. Perceptual difficulties were identified in 71 % of right hemiplegic stroke patients and 81 % of left hemiplegic patients. They were identified in 97% of dysphasic right hemiplegic patients, compared to 47% of nondysphasic right hemiplegic patients and 84% of female hemiplegic patients, compared to 67% of male hemiplegic patients. Unilateral neglect was identified in both right and left hemiplegic patients. The proportion of patients with neglect varied according to the measure chosen. The results indicate that perceptual problems are common following both right and left hemiplegic stroke, with unilateral neglect accounting for a relatively small proportion of the problems.

The Relation between Perceptual Deficits after Stroke and Independence in Activities of Daily Living

The impact of perceptual difficulties on daily life was evaluated using standardised procedures. One hundred and fifty stroke patients (75 right hemiplegic and 75 left hemiplegic) of all ages, admitted consecutively to two general hospitals, were assessed one month after stroke. They were assessed on the Rivermead Perceptual Assessment Battery to identify perceptual difficulties and on an activities of daily living (ADL) scale. Patients without perceptual deficits were more often independent than those with perceptual deficits. On simple ADL tasks, left hemiplegic patients were more often independent than right hemiplegic patients, but not on more complex ones. There was a significant correlation between perceptual abilities and independence in all ADL scales. There was no correlation between visual neglect and independence in ADL in left hemiplegic patients.

The Identification of Seniors at Risk (ISAR) score to predict clinical outcomes and health service costs in older people discharged from UK acute medical units

Background: tools are required to identify high-risk older people in acute emergency settings so that appropriate services can be directed towards them. Objective: to evaluate whether the Identification of Seniors At Risk (ISAR) predicts the clinical outcomes and health and social services costs of older people discharged from acute medical units. Design: an observational cohort study using receiver–operator curve analysis to compare baseline ISAR to an adverse clinical outcome at 90 days (where an adverse outcome was any of death, institutionalisation, hospital readmission, increased dependency in activities of daily living (decrease of 2 or more points on the Barthel ADL Index), reduced mental well-being (increase of 2 or more points on the 12-point General Health Questionnaire) or reduced quality of life (reduction in the EuroQol-5D) and high health and social services costs over 90 days estimated from routine electronic service records. Setting: two acute medical units in the East Midlands, UK. Participants: a total of 667 patients aged ≥70 discharged from acute medical units. Results: an adverse outcome at 90 days was observed in 76% of participants. The ISAR was poor at predicting adverse outcomes (AUC: 0.60, 95% CI: 0.54–0.65) and fair for health and social care costs (AUC: 0.70, 95% CI: 0.59–0.81). Conclusions: adverse outcomes are common in older people discharged from acute medical units in the UK; the poor predictive ability of the ISAR in older people discharged from acute medical units makes it unsuitable as a sole tool in clinical decision-making.

Validity of a Virtual Environment for Stroke Rehabilitation

Background and Purpose— Virtual environments for use in stroke rehabilitation are in development, but there has been little evaluation of their suitability for this purpose. We evaluated a virtual environment developed for the rehabilitation of the task of making a hot drink. Methods— Fifty stroke patients undergoing rehabilitation in a UK hospital stroke unit were involved. The performance of stroke rehabilitation patients when making a hot drink had the neurological impairments associated with performance of this task, and the errors observed were compared for standardized task performance in the real world and in a virtual environment. Neurological impairments were measured using standardized assessments. Errors in task performance were assessed rating video recordings and classified into error types. Results— Real-world and virtual environment performance scores were not strongly associated (&rgr;=0.30; P<0.05). Performance scores in both settings were associated with age, Barthel ADL score, Mini Mental State Examination score, and tests of visuospatial function. Real-world performance only was associated with arm function and sequencing ability. Virtual environment performance only was associated with language function and praxis. Participants made different errors during task performance in the real world and in the virtual environment. Conclusions— Although this virtual environment was usable by stroke rehabilitation patients, it posed a different rehabilitation challenge from the task it was intended to simulate, and so it might not be as effective as intended as a rehabilitation tool. Other virtual environments for stroke rehabilitation in development require similar evaluation.

The recovery of perceptual problems after stroke and the impact on daily life

The frequency of perceptual problems in stroke patients and the impact of daily life, were assessed at one month and two years after onset of the stroke. Ninety patients were assessed on the Rivermead Perceptual Assessment Battery (RPAB) and an Activities of Daily Living (ADL) scale. Perceptual problems were identified in 69% of patients on the one month assessment and in 74% of patients on the two-year assessment. There was no significant difference in the frequency or severity of perceptual problems, between the two assessments. Significant improvement occurred in activities such as mobility, preparing a hot drink and crossing a road. There remained a significantly high correlation between perceptual problems and independence in activities of daily living.

A multicentre randomised controlled trial of day hospital-based falls prevention programme for a screened population of community-dwelling older people at high risk of falls

Objective: to determine the clinical effectiveness of a day hospital-delivered multifactorial falls prevention programme, for community-dwelling older people at high risk of future falls identified through a screening process. Design: multicentre randomised controlled trial. Setting: eight general practices and three day hospitals based in the East Midlands, UK. Participants: three hundred and sixty-four participants, mean age 79 years, with a median of three falls risk factors per person at baseline. Interventions: a day hospital-delivered multifactorial falls prevention programme, consisting of strength and balance training, a medical review and a home hazards assessment. Main outcome measure: rate of falls over 12 months of follow-up, recorded using self-completed monthly diaries. Results: one hundred and seventy-two participants in each arm contributed to the primary outcome analysis. The overall falls rate during follow-up was 1.7 falls per person-year in the intervention arm compared with 2.0 falls per person-year in the control arm. The stratum-adjusted incidence rate ratio was 0.86 (95% CI 0.73–1.01), P = 0.08, and 0.73 (95% CI 0.51–1.03), P = 0.07 when adjusted for baseline characteristics. There were no significant differences between the intervention and control arms in any secondary outcomes. Conclusion: this trial did not conclusively demonstrate the benefit of a day hospital-delivered multifactorial falls prevention programme, in a population of older people identified as being at high risk of a future fall.

Clinical evaluation of a non-immersive virtual environment in stroke rehabilitation

Background and purpose: We describe our attempts to evaluate the effectiveness of a virtual environment developed to rehabilitate stroke patients in the task of making a hot drink. Methods: Single case studies were performed in 13/138 (9%) stroke patients undergoing rehabilitation in a UK stroke unit. Participants in AB/BA (n = 5) and ABA (n = 2) design studies received 5 one-hour sessions of attention control training (A phase) and 5 one-hour sessions of virtual environment training (B phase). An AB design with random duration of A and B phases (minimum duration of A and B phases 3 and 5 days respectively, with total duration of 3 weeks) was used in 6 participants. Results: Visual inspection of scores across all cases showed a trend towards improvement over time in both real and virtual hot drink making ability in both control and intervention phases. There was no significant difference (Wilcoxon, p > 0.05) in the improvements in real and virtual hot drink making ability during all control and intervention phases in the 13 cases. Ceiling effects limited the evaluation of effectiveness in 5 of the 8 cases in which daily performance measures were used. Conclusions: Few people in this setting were suitable for this intervention. The case studies showed no evidence of a strong effect of this intervention, but we had great difficulty in performing single case studies. We conclude that more testing and development of this system is required before it is subjected to rigorous testing of clinical effectiveness.

Treatment of Visual Perceptual Deficits after Stroke: Single Case Studies on Four Patients with Right Hemiplegia:

The transfer of training approach to the treatment of visual perceptual deficits was evaluated with four right hemiplegic stroke patients, using single-case experimental designs. The results showed little evidence of effective treatment for individual perceptual deficits. Perceptual stimulation alone may have produced some general improvements. The importance of perceptual assessment and the monitoring of progress is discussed.

The DRESS trial: a feasibility randomized controlled trial of a neuropsychological approach to dressing therapy for stroke inpatients

Objective: To investigate two approaches to treating patients with persistent dressing problems and cognitive difficulties following stroke. Design: Pilot randomized controlled trial. Setting: Inpatient stroke rehabilitation service. Subjects: Seventy consecutive stroke patients with persistent dressing problems and accompanying cognitive difficulties at two weeks after their stroke. Interventions: Patients were randomly allocated to six weeks of either a systematic neuropsychological approach, based on analysis of dressing problems and further cognitive testing, or to the control group who received conventional (functional) dressing practice. Both groups received treatment three times a week in accordance with two separately prepared manuals. Main measures: Nottingham Stroke Dressing Assessment (NSDA), Line Cancellation, 10-hole peg transfer test, Object Decision, Gesture Imitation. Patients were assessed at six weeks after randomization by an independent assessor masked to group allocation. Results: Both neuropsychological and functional groups improved performance on the NSDA over the treatment period (31% and 22%, respectively) but there was no significant difference between groups at six weeks. However, the neuropsychological group showed a significantly greater improvement on a line cancellation test of visual neglect (t(62) = 2.1, P < 0.05) and a planned subanalysis for those with right hemisphere damage showed a trend towards better dressing outcome (P = 0.07, one-tailed). Conclusions: Results demonstrate the potential benefits of a systematic neuropsychological approach to dressing therapy, particularly for patients with right hemisphere damage. This study suggests the need for a phase III study evaluating the efficacy of a systematic neuropsychological approach in treating dressing difficulties, targeting patients with right hemisphere stroke and visuospatial impairments.