Kate Radford

A multicentre randomized controlled trial of leisure therapy and conventional occupational therapy after stroke

Objective: To evaluate the effects of leisure therapy and conventional occupational therapy (OT) on the mood, leisure participation and independence in activities of daily living (ADL) of stroke patients 6 and 12 months after hospital discharge. Design: Multicentre randomized controlled trial. Setting and participants: Four hundred and sixty-six stroke patients from five UK centres. Main outcome measures: The General Health Questionnaire (12 item), the Nottingham Extended ADL Scale and the Nottingham Leisure Questionnaire, assessed by post, with telephone clarification. Results: Four hundred and forty (94%) and 426 (91%) subjects were alive at 6 and 12 months, respectively. Three hundred and seventy-four (85% of survivors) and 311 (78% of survivors) responded at 6 and 12 month follow-up respectively. At six months and compared to the control group, those allocated to leisure therapy had nonsignificantly better GHQ scores (–1.2: 95% CI –2.9, +0.5), leisure scores (+0.7, 95% CI –1.1, +2.5) and Extended ADL scores (+0.4: 95% CI –3.8, +4.5): the ADL group had nonsignificantly better GHQ scores (–0.1: 95% CI –1.8, +1.7) and Extended ADL scores (+1.4: 95% CI –2.9, +5.6) and nonsignificantly worse leisure scores (–0.3: 95% CI –2.1, +1.6). The results at 12 months were similar. Conclusion: In contrast to the findings of previous smaller trials, neither of the additional OT treatments showed a clear beneficial effect on mood, leisure activity or independence in ADL measured at 6 or 12 months.

The Effects of Cognitive Abilities on Driving in People with Parkinson's Disease

Objective: The aim was to develop a cognitive screening procedure, which could be used to identify cognitive problems in patients with Parkinsons disease, which might affect their safety to drive. Design: Two group comparison of those found safe to drive and those found unsafe. Setting: People living in the community who were attending an outpatient Movement Disorders clinic or who had been referred to a Regional Mobility Centre. Participants: Fifty-one people with Parkinsons disease who were driving or who wished to resume driving. The 41 men and 10 women were aged 44 – 85 years (mean 64.4 SD 9.1). Main measures: Websters Rating Scale, Unified Parkinsons Disease Rating Scale motor examination, Stroke Drivers Screening Assessment, Adult Memory and Information Processing Battery, Stroop, Paced Auditory Serial Addition Task and a Tapping task. Results: The unsafe drivers were significantly more disabled, as assessed on Websters Scale, than those who were found safe to drive. There were no significant differences in the cognitive abilities of safe and unsafe drivers. The most common faults, which caused drivers to be judged unsafe, were lack of observations to the side at junctions, poor positioning on the road and poor driving on roundabouts. There were significant correlations (p < 0.05) between driving ability and performance on the SDSA Dot Cancellation task and the AMIPB Story Recall and Information Processing A. Conclusions: Cognitive abilities were not found to be associated with fitness to drive in people with Parkinsons disease. Websters Rating Scale differentiated between safe and unsafe drivers. This could be used to determine who to refer to a mobility centre for advice on fitness to drive.

Validation of the stroke drivers screening assessment for people with traumatic brain injury

Cognitive impairments resulting from brain injury affect driving performance. The question of fitness to drive often arises during rehabilitation. Healthcare professionals need reliable criteria against which decisions about driving fitness can be made. Nouri et al. developed the Stroke Drivers Screening Assessment (SDSA), which was found predictive of on-road driving performance in stroke patients. The purpose of this study was to determine whether the SDSA, either alone or combined with other tests, predicted fitness to drive in brain injured people. Fifty-two participants were assessed on the SDSA plus additional cognitive tests. Their fitness to drive was examined on the public road. The SDSA predictions based on equations developed for stroke patients were not an accurate predictor of road test performance. Discriminant analysis was used to identify tests predictive of fitness to drive. Results indicated that a combination of the SDSA, the Stroop and the AMIPB Information Processing tasks correctly classified 87% of cases and may be useful predictors of driving fitness following brain injury. However, cross-validation on an independent sample of people with brain injury is required.

Return to work after traumatic brain injury: Cohort comparison and economic evaluation

Background: Returning to work (RTW) in the UK is problematic following TBI. Vocational rehabilitation (VR) is limited and efficacy or costs seldom reported. This study aimed to determine whether a TBI specialist VR intervention (TBI VR) was more effective at work return and retention 12 months after injury than usual care (UC). Secondary aims were to explore the feasibility of collecting economic data to inform a definitive trial. Method: Work outcomes of TBI-VR were compared to UC. Ninety-four participants (40 TBI-VR) with TBI resulting in hospitalization ≥48 hours, who were working at injury were followed up by postal questionnaire at 3, 6 and 12 months post-hospital discharge. Primary outcome was RTW. Secondary outcomes were functional ability, mood and quality-of-life. Health resource use was measured by self-report. Results: At 12 months, 15% more TBI-VR participants (27% more with moderate/severe TBI) were working than UC (27/36, 75% vs. 27/45, 60%). Mean TBI-VR health costs per person (consultant, GP, therapy, medication) were only £75 greater at 1 year. Secondary outcomes showed no significant baseline differences between groups. Discussion: More TBI-VR participants returned to work than UC. People with moderate/severe TBI benefitted most. This positive trend was achieved without greatly increased health costs, suggesting cost-effectiveness. This study justifies the need for and can inform a definitive Randomized Controlled Trial (RCT).

The Use of Transport by Stroke Patients

The objectives of this research were to survey the use of transport by stroke patients in the community and study its relationship to their activities of daily living and mood. The records of 90 consecutive stroke patients receiving community occupational therapy in a rehabilitation trial were surveyed for entries of therapy related to transport. A further 50 stroke patients in the same study were surveyed about their use of transport one year after discharge from hospital. In the survey of occupational therapy notes, a transport assessment had been recorded for all 90 patients. Of these, 22 patients had been given leaflets describing the range of transport options locally but had been unable to use these options. In the survey of transport use, 42/50 (84%) patients surveyed at one year responded. Twenty-one (50%) had used transport on their own, six of whom scored <26/66 on the Extended Activities of Daily Living scale (indicating that they needed help in most activities of daily living). Twenty-one (50%) patients had not travelled alone, four of whom scored >48/66 on the Extended Activities of Daily Living scale (very able in activities of daily living). Only 1 (2%) patient had used specialist transport and 22 (52%) reported that they did not get out as much as they wished. Despite receiving advice, these patients did not use specialist transport options, yet many still wanted to get out more. The reason for this is unclear but it is not due simply to physical disability.

Occupational Therapy can Flourish in the 21st Century — A Case for Professional Engagement with Health Economics

The view that the profession of occupational therapy will flourish in the 21st century was expressed before the banking system and financial market collapse in 2008. The profession now competes for scarce resources as austerity measures take effect. A summit meeting at the College of Occupational Therapists, in May 2013, discussed how to improve the professions understanding and use of health economics. At this meeting, short-, medium-, and longer-term approaches were discussed, with the aim of improving the quality and quantity of publications on economic evaluations in occupational therapy. Despite an increasing number of publications on health economics across professions, occupational therapy lags behind. This focus is now vital for the profession.

An Investigation of the Number and Cost of Assistive Devices Used by Older People Who Had Fallen and Called a 999 Ambulance

Some assistive devices, such as walking frames and bath boards, are provided by health and social services, but some are bought by people through shops, the internet and magazines or second hand. Using a face-to-face interview, the number and cost of assistive devices bought by people who had fallen and called a 999 ambulance were investigated. Two hundred and four older people (mean age 83 years, 72/35% men) who had fallen and called an emergency ambulance were interviewed at home by a research occupational therapist. A structured questionnaire about the cost and use of assistive devices was completed. Functional ability was measured using the Barthel Index and the Nottingham Extended Activities of Daily Living Scale. One hundred and ten people (54%) had bought their own devices, spending a median of £700 each. People with multiple sclerosis, cancer, heart conditions and Parkinsons disease had spent over twice as much as those with osteoarthritis, stroke, diabetes and dementia. Many older people buy their own assistive devices at a considerable cost to themselves. As social services direct payments allow people to manage their own care packages, more people will be buying direct and may be looking for advice.

Development and evaluation of an early specialised traumatic brain injury vocational rehabilitation training package

Background In a feasibility randomised controlled trial, training was developed to equip occupational therapists to deliver early specialised traumatic brain injury vocational rehabilitation in the English National Health Service (NHS). Method The package was developed by experts in vocational rehabilitation and traumatic brain injury, and included a manual, direct instruction by six trainers and opportunity for mentorship by four therapists. Following training, therapists were interviewed regarding the effectiveness and ease of use of the package. Interviews were analysed using the framework approach. Results Five trained therapists were interviewed regarding the package. Results were organised into six categories: (1) motivation to participate in research; (2) impact of the learning environment; (3) changing confidence levels over time; (4) growing appreciation of complexities about the intervention; (5) acceptability of the training package; and (6) lessons for future implementation. Conclusion The therapists reported acquiring the knowledge necessary to implement the intervention. The data indicate that the training packages require detailed descriptions of the interventions being taught for local implementation in the NHS and for future research. The training materials are valued by therapists but require time for familiarisation, and reminders from mentors help put training into practice. The therapists have concerns about implementing the interventions within a research context, which researchers should address.

NICE on rehabilitation. New guidelines on rehabilitation likely to restrict practices and stifle innovation.

We are pleased that the National Institute for Health and Care Excellence thought it important to develop guidelines for the management of patients with stroke.1 We are also reassured by the position taken by the Guideline Development Group (GDG)—that the evidence pointed to intervention improving function and mobility, but that there was little evidence to support one type of intervention over another.2 However, despite the GDG’s intentions to facilitate innovations in practice,3 there is a serious risk that …

NICE on rehabilitation

We are pleased that the National Institute for Health and Care Excellence thought it important to develop guidelines for the management of patients with stroke.1 We are also reassured by the position taken by the Guideline Development Group (GDG)—that the evidence pointed to intervention improving function and mobility, but that there was little evidence to support one type of intervention over another.2 However, despite the GDG’s intentions to facilitate innovations in practice,3 there is a serious risk that …