Mireille Donkervoort

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.

Determinants of functioning of adolescents and young adults with cerebral palsy

Purpose. To describe the level of functioning of adolescents and young adults with cerebral palsy (CP) and study determinants of their level of functioning. Method. In the CP Transition study, adolescents and young adults aged 16 – 20 years, diagnosed with CP without severe learning disabilities (n = 103) participated. In this group we assessed subject characteristics, i.e., age, type of CP, gross motor function (GMFCS), level of education as well as outcome measures on functioning in daily activities and social participation (Life Habits questionnaire, Vineland Adaptive Behavior Scale, Functional Independence Measure). Multivariate regression analyses were performed. Results. About 20 – 30% of the participants encountered restrictions in daily activities (mobility, self-care, nutrition) and social participation (taking responsibility, community living, leisure activities and employment). The GMFCS level, level of education, and age proved to be important determinants of functioning in daily activities and social participation, explaining 70% and 66% of the variance in outcome respectively. Conclusion. A significant number of adolescents and young adults with CP without severe learning disabilities are restricted in daily activities and social participation. These problems are mainly attributable to restricted gross motor functioning, a low level of education and younger age.

Efficacy of strategy training in left hemisphere stroke patients with apraxia: A randomised clinical trial

The objective of the present study was to determine in a controlled study the efficacy of strategy training in left hemisphere stroke patients with apraxia. A total of 113 left hemisphere stroke patients with apraxia were randomly assigned to two treatment groups; (1) strategy training integrated into usual occupational therapy and (2) usual occupational therapy only. Assessments took place at baseline, after an 8 week treatment period and 5 months after baseline (follow-up). Patients were assessed on apraxia, motor functioning and activities of daily living (ADL). The primary outcome measure was a standardised ADL observation by a blinded research assistant. Additional ADL measures were used as secondary outcome measures (Barthel ADL index, ADL judgement by occupational therapist and by patient). After 8 weeks of treatment, patients who received strategy training (n = 43) improved significantly more than patients in the usual treatment group (n = 39) on the ADL observations (mean change .24; 90% CI, .15–.34 vs. .12, .03–.21). This reflects a small to medium effect (effect size .37) of strategy training on ADL functioning. With respect to the secondary outcome measures a medium effect (effect size .47) was found on the Barthel ADL index. No beneficial effects of strategy training were found after 5 months (at follow-up). In this trial evidence was found for the short-term effectiveness of strategy training in left hemisphere stroke patients with apraxia.

Prevalence of apraxia among patients with a first left hemisphere stroke in rehabilitation centres and nursing homes

Objective: To investigate the prevalence of apraxia in patients with a first left hemisphere stroke. Subjects: Left hemisphere stroke patients staying at an inpatient care unit of a rehabilitation centre or nursing home and receiving occupational therapy (n = 600). Measures: A short questionnaire on general patient characteristics and stroke-related aspects was completed by occupational therapists for every left hemisphere stroke patient they treated. A diagnosis of apraxia or nonapraxia was made in every patient, on the basis of a set of clinical criteria. Results: The prevalence of apraxia among 492 first left hemisphere stroke patients in rehabilitation centres was 28% (96/338) and in nursing homes 37% (57/154). No relationship was found between the prevalence of apraxia and age, gender or type of stroke (haemorrhage or infarct). Conclusions: This study shows that approximately one-third of left hemisphere stroke patients has apraxia.

Transition to adulthood: validation of the Rotterdam Transition Profile for young adults with cerebral palsy and normal intelligence

The aim of this study was to investigate the validity of the Rotterdam Transition Profile (RTP) to describe the transition process from childhood to adulthood in young adults with cerebral palsy (CP). Participants were recruited from rehabilitation centres and hospital departments of rehabilitation. In total, 81 young adults (47 males, 34 females) with CP and normal intelligence participated (mean age 20y 5mo [SD 1y 4mo] range 18−22y; 95% spastic CP, 48% hemiplegia, 38% diplegia, 14% quadriplegia; 78% Gross Motor Function Classification System Level I, 83% Manual Ability Classification System Level I). The RTP and the Assessment of Life Habits questionnaire are used to measure transition and functioning in daily activities and participation. Almost all participants were in the transition process or had reached an independent adult lifestyle (ranging from 60−100%, housing 42%). Compared with able‐bodied peers, young adults with CP lagged behind in their development in housing (25 vs 36%; p<0.05), employment (33 vs 49%; p<0.05), and intimate relationships (37 vs 76%; p<0.01). Associations were found between the phase of transition and age, parents’ level of education, gross motor functioning, manual ability, level of education, and level of functioning in daily activities and participation. The RTP is a valid tool to gain more insight into the transition process, at the individual as well as at group level.

Experienced Problems of Young Adults With Cerebral Palsy: Targets for Rehabilitation Care

OBJECTIVE To determine the problems experienced by young adults with cerebral palsy (CP) and the relationship between those problems and personal and CP-related characteristics. DESIGN Cross-sectional study. SETTING Rehabilitation centers in the southwest Netherlands. PARTICIPANTS Young adults (N=87; aged 18-22y) with CP and normal intelligence (roughly corresponding to an intelligence quotient >70, excluding participants who attended schools for those with learning disabilities). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES We used the Canadian Occupational Performance Measure in a semistructured interview to assess participants for experienced problems. We further categorized experienced problems according to the domains of the International Classification of Functioning, Disability and Health and assessed the relationship between those problems and personal and CP-related characteristics (eg, age, sex, level of gross motor functioning, manual ability, level of education) using appropriate correlation coefficients. RESULTS Approximately 70% of participants experienced problems in daily life, addressing the areas of self-care (59%), productivity (52%), and leisure activities (37%). More specifically, problems were most prevalent in recreation and leisure (30%), preparing meals (29%), housework (14%), and dressing (14%). Problems in functional mobility, paid or unpaid work, and socialization were considered as most important (represented by the highest mean importance score). Mobility problems were associated with lower levels of gross motor functioning (Spearman rho=.39), and problems with self-care were associated with lower levels of manual ability (Spearman rho=.40). CONCLUSIONS Although frequently addressed during pediatric rehabilitation care, problems with mobility and self-care still prevail in young adults with CP. In addition, during the transition into adulthood, young adults with CP may experience problems regarding domestic life and work, which they consider important.

Transfer of training effects in stroke patients with apraxia: an exploratory study

The goal of the present study was to examine the transfer of the effects of cognitive strategy training for stroke patients with apraxia from trained to non-trained tasks. In strategy training, the occurrence of transfer is expected as the training programme is aimed, not at relearning specific tasks, but at teaching patients new ways to handle the problems resulting from the impairment. Exploratory analyses were conducted on data previously collected in a randomised controlled trial on the efficacy of the strategy training. A total of 113 left hemisphere stroke patients were randomly assigned to a strategy training group and a group receiving occupational therapy as usual. Assessment of apraxia, motor functioning and activities of daily living (ADL) took place at baseline, after an eight-week treatment period, and five months after baseline. The primary outcome measure consisted of standardised ADL observations of trained and non-trained tasks. The analyses showed that in both treatment groups, the scores on the ADL observations for non-trained tasks improved significantly after eight weeks of training as compared with the baseline score. Change scores of non-trained activities were larger in the strategy training group as compared with the usual treatment group. By using previously collected data we are able to illustrate the potential transfer of treatment effects in a large sample of stroke patients. We found indications for the occurrence of transfer, although the study was not originally designed for the purpose of evaluating transfer. Therefore these results are worth exploring more profoundly. We will further investigate our preliminary conclusions in a new prospective study which is specifically designed to examine the transfer of training effects.

Unmet needs and health care utilization in young adults with cerebral palsy

Purpose. To gain insight into the unmet needs and utilization of health care of young adults with cerebral palsy (CP) and to explore relations between unmet needs, health care utilization and subject characteristics. Method. A cross-sectional study was performed in 29 young adults with CP without severe learning disabilities (IQ > 70). Subject characteristics such as age, gender, limb distribution, level of gross motor functioning, level of education and perceived participation and autonomy were measured. Outcome measures were the Southampton Needs Assessment Questionnaire, Impact on Participation and Autonomy and a questionnaire on health care utilization. Results. Young adults with CP reported unmet needs mostly on information (79%), mobility (66%) and health care (66%). About half of the participants visited a rehabilitation physician (52%) or a physical therapist (55%) in the past year. Participants with lower levels of gross motor functioning were found to have more unmet needs and visited various health care professionals more often than young adults with higher levels of gross motor functioning. However, participants with higher levels of gross motor functioning still reported several unmet needs. Conclusions. Although young adults with CP frequently receive treatment from health care professionals, they indicate unmet needs with respect to several areas such as information on diagnosis, functional mobility and formal health care. In the treatment of young adults with CP, attention should be paid to these aspects.

Social, intimate and sexual relationships of adolescents with cerebral palsy compared with able-bodied age-mates

OBJECTIVE To describe the social, intimate and sexual relationships of Dutch adolescents with cerebral palsy compared with their able-bodied age mates. DESIGN Cross-sectional study. SUBJECTS A total of 103 adolescents with cerebral palsy without severe learning problems aged 16-20 years. METHODS We used a structured interview and questionnaires to assess subject characteristics such as age, type of cerebral palsy, gross motor function and level of education. Main outcome measures on social, intimate and sexual relationships are the Life-Habits questionnaire, the Vineland Adaptive Behaviour Scale, and a structured interview developed for Dutch studies in able-bodied persons and persons with spina bifida. Experienced competence was assessed with the Dutch version of the Self-Perception Profile of Adolescents and the Physical Disability Sexual and Body Esteem Scale. These data were compared with matching reference data, mainly from able-bodied (Dutch) adolescents. RESULTS Approximately 30% of the subjects functioned socially below their age level. Adolescents with cerebral palsy find it difficult to develop intimate relationships and they have less sexual experience than their able-bodied age mates. CONCLUSION Although adolescents with cerebral palsy do have social relationships, it is difficult for them to develop intimate relationships. They perceive various barriers, but seem to have a positive self-perception.

The course of apraxia and ADL functioning in left hemisphere stroke patients treated in rehabilitation centres and nursing homes

Objective: To study the course of apraxia and daily life functioning (ADL) in left hemisphere stroke patients with apraxia. Design: Prospective cohort study. Setting: Rehabilitation centres and nursing homes. Subjects: One hundred and eight left hemisphere stroke patients with apraxia, hospitalized in rehabilitation centres and nursing homes. Measures: ADL-observations, Barthel ADL Index, Apraxia Test, Motricity Index. Results: During the study period of 20 weeks, patients showed small improvements in apraxia (standardized mean differences of 0.19 and 0.33) and medium-sized improvements in ADL functioning (standardized mean differences from 0.37 to 0.61). About 88% of the patients were still apraxic at week 20. Less improvement in apraxia was observed in initially less severe apraxic patients. Less improvement in ADL functioning was found to be associated with more severe apraxia, a more independent initial ADL score, higher age, impaired motor functioning and longer time between stroke and first assessment. Conclusions: Apraxia in stroke patients is a persistent disorder, which has an adverse influence on ADL recovery.