Lyn Jongbloed

Rehabilitation therapy services for stroke patients living at home: systematic review of randomised trials.

BACKGROUND Stroke-unit care can be valuable for stroke patients in hospital, but effectiveness of outpatient care is less certain. We aimed to assess the effects of therapy-based rehabilitation services targeted at stroke patients resident in the community within 1 year of stroke onset or discharge from hospital. METHODS We did a systematic review of randomised trials of outpatient services, including physiotherapy, occupational therapy, and multidisciplinary teams. We used Cochrane collaboration methodology. FINDINGS We identified a heterogeneous group of 14 trials (1617 patients). Therapy-based rehabilitation services for stroke patients living at home reduced the odds of deteriorating in personal activities of daily living (odds ratio 0.72 [95% CI 0.57-0.92], p=0.009) and increased ability of patients to do personal activities of daily living (standardised mean difference 0.14 [95% CI 0.02-0.25], p=0.02). For every 100 stroke patients resident in the community receiving therapy-based rehabilitation services, seven (95% CI 2-11) would not deteriorate. INTERPRETATION Therapy-based rehabilitation services targeted at selected patients resident in the community after stroke improve ability to undertake personal activities of daily living and reduce risk of deterioration in ability. These findings should be considered in future service planning.

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.

Individual Patient Data Meta-Analysis of Randomized Controlled Trials of Community Occupational Therapy for Stroke Patients

Background and Purpose— Trials of occupational therapy for stroke patients living in the community have varied in their findings. It is unclear why these discrepancies have occurred. Methods— Trials were identified from searches of the Cochrane Library and other sources. The primary outcome measure was the Nottingham Extended Activities of Daily Living (NEADL) score at the end of intervention. Secondary outcome measures included the Barthel Index or the Rivermead ADL (Personal ADL), General Health Questionnaire (GHQ), Nottingham Leisure Questionnaire (NLQ), and death. Data were analyzed using linear or logistic regression with a random effect for trial and adjustment for age, gender, baseline dependency, and method of follow-up. Subgroup analyses compared any occupational therapy intervention with control. Results— We included 8 single-blind randomized controlled trials incorporating 1143 patients. Occupational therapy was associated with higher NEADL scores at the end of intervention (weighted mean difference [WMD], 1.30 points, 95% confidence intervals [CI], 0.47 to 2.13) and higher leisure scores at the end of intervention (WMD, 1.51 points; 95% CI, 0.24 to 2.79). Occupational therapy emphasizing activities of daily living (ADL) was associated with improved end of intervention NEADL (WMD, 1.61 points; 95% CI, 0.72 to 2.49) and personal activities of daily living (odds ratio [OR], 0.65; 95% CI, 0.46 to 0.91), but not NLQ. Leisure-based occupational therapy improved end of intervention NLQ (WMD, 1.96 points; 95% CI, 0.27 to 3.66) but not NEADL or PADL. Conclusions— Community occupational therapy significantly improved personal and extended activities of daily living and leisure activity in patients with stroke. Better outcomes were found with targeted interventions.

Disability Policy in Canada An Overview

Over the last century there has been a shift from conceptualizing disability as a challenge to law and order, to viewing disability as a medical and/or economic deficit and then as a sociopolitical issue. In Canada, these changing conceptualizations of disability have been reflected in the development of disability policies, which form part of general Canadian social policies. Each model of disability captures a particular aspect of disability and focuses on particular goals, and each depicts a different account of what society owes people with disabilities. However, the lack of linkages between the models and their conceptual bases means that no one model can be used to guide disability policy development. Decision making about the goals of disability policy and the rights of people with disabilities requires the development of a normative foundation.

A New Definition of Disability: Implications for Rehabilitation Practice and Social Policy

Until the 1970s, individual physical, be-haviourial and vocational limitations were seen as the main difficulties preventing people with disabilities from participating fully in society. Rehabilitation professionals concentrated on improving functional abilities of disabled clients and the main policy approaches were income maintenance and vocational rehabilitation. In the 1970s, the individualistic conception of disability was challenged by a socio-political definition. The socio-political model implies that improvement in the status of persons with disabilities requires alterations in the social environment as well as changes in individual functional abilities. This paper examines the extent to which disability policies and rehabilitation practice have changed to embrace this new definition. There has been some progress in policies related to shelter and transportation but little progress in the areas of employment and income maintenance. Rehabilitation professionals still have a largely clinical or individualistic ideology and focus very little on improving the circumstances of disabled people through changes in laws or social policies. They should be less willing to accept individual explanations for problems which are, essentially, economic, social or political and become more involved in advocacy with persons with disabilities.

Disability income: The experiences of women with multiple sclerosis

This paper examines the experiences of unemployed women with multiple sclerosis with three income support programmes, the Canada/Quebec Pension Plan, long term disability insurance and social assistance. Findings are based on ethnographic interviews with 23 women. Difficulties experienced with these programmes include the low level of benefits of two of the programmes, the earnings-based component of two of the programmes, and requirements in eligibility criteria that applicants be defined as permanently unemployable. The occupational consequences of disability income policies are mediated by marital and socio-economic status. For some, policies mean lives of poverty and marginalization, for others they mean lack of freedom to change jobs, to work part-time or hesitance to return to the work force. The ways in which social policies shape the individual experience of disability should inform occupational therapy intervention at the individual level. Therapists are also challenged to help create policy environments that will enhance client function.

Difficulties in Shifting from Individualistic to Socio-political Policy Regarding Disability in Canada

ABSTRACT An individualistic conception of disability has been replaced by a socio-political definition. The socio-political model implies that disability stems from the failure of the social environment to adjust to the needs of people with disabilities rather than from the inability of disabled individuals to adapt to societal demands. This paper will examine the extent to which Canadian policies have changed to embrace this new definition. There has been some progress in policies related to shelter, transportation and recreation. However, policies related to income and employment are still individualistic in nature because policy change in these areas requires a major shift in governmental approach to unemployment and fundamental reform of the Social Assistance system. In a period of high unemployment, people with disabilities are viewed as surplus labour, and the Canadian government has found that high unemployment is politically tolerable. Obstacles to an increase in income support include a strong wo...

Associations between social participation and subjective quality of life for adults with moderate to severe traumatic brain injury

Abstract Purpose: To examine the association between social participation and subjective quality of life (SQOL) for non-employed, community-dwelling adults with moderate to severe traumatic brain injury (TBI) at 1 year or greater post-injury. Method: A correlational study was conducted involving 46 participants. Social participation was measured using the Community Integration Questionnaire, Social Provisions Scale and the Adult Subjective Assessment of Participation. SQOL was measured using the Quality of Life and Health Questionnaire, Abdel-Khalek Happiness Scale and UCLA Loneliness Scale. Results: Higher levels of happiness and global quality of life were each associated with higher levels of enjoyment, satisfaction with performance and higher proportion of activities performed with others. Lower levels of loneliness were associated with higher levels of general social integration and higher levels of perceived social supports. There were no associations found between SQOL and the objective social participation measures of diversity, frequency (intensity) or proportion of activities performed outside of home. Conclusions: Findings contribute to the TBI literature in showing that it is: (a) the more subjective and not objectively measured nature of participation that is associated with SQOL and (b) positive and negative aspects of quality of life show different relationships with social participation variables. Implications for Rehabilitation A high proportion of individuals with traumatic brain injury (TBI) experiences reduced involvement in social participation (involvement in social and leisure activities and within a social network) and low subjective quality of life (SQOL). This study suggests that, by simply increasing the variety and frequency of social and leisure activities, there may be no positive influences on SQOL. Instead, this study suggests that, to increase SQOL, it is important to increase opportunities for individuals to participate with others and also to enhance their subjective experience of social and leisure activities. The large variance obtained of scores for social participation and SQOL provide a reminder to clinicians to maintain an individualized approach when working with individuals with TBI.

Family Adaptation to Altered Roles following a Stroke

This paper analyzes the impact of a stroke on the roles of people who experienced a stroke and their partners, focusing on the relationship between the environment and role performance. Ethnographic research methods were used to discover the ways in which the meaning and content of roles are shaped within the context of social relationships. Suggestions are offered regarding questions occupational therapists can ask to assess family role structure, the effect of disability on family roles and the influence of the social and physical environment on family roles.

The Impact of Reimbursement Systems on Occupational Therapy Practice in Canada and the United States of America

Different funding and cost-control mechanisms in Canada and the United States of America (USA) have a powerful influence on occupational therapy practice in each country. Canadas public health insurance system emphasizes access to health care services based on medical need. Costs are controlled at the provincial government level by limiting the capacity of facilities and personnel. Occupational therapists in publicly-funded settings have considerable professional autonomy to use occupational therapy theoretical models and to be client-centred. The measurement of outcomes is not always required and the interventions of individual occupational therapists are infrequently scrutinized. The USA has no universal, publicly-funded, comprehensive health insurance. Health care policies are driven by financial priorities and cost control occurs at the service delivery level. Insurance companies define the scope of occupational therapy practice by identifying what services they will pay for and they scrutinize occupational therapy interventions. The emphasis on effectiveness and efficiency leads to critical examination of interventions by therapists. Canadian occupational therapists can learn much from their colleagues in the USA in this area.