Pip Logan

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.

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.

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.

Randomised controlled trial of an occupational therapy intervention to increase outdoor mobility after stroke

Abstract Objective To evaluate an occupational therapy intervention to improve outdoor mobility after stroke. Design Randomised controlled trial. Setting General practice registers, social services departments, a primary care rehabilitation service, and a geriatric day hospital. Participants 168 community dwelling people with a clinical diagnosis of stroke in previous 36 months: 86 were allocated to the intervention group and 82 to the control group. Interventions Leaflets describing local transport services for disabled people (control group) and leaflets with assessment and up to seven intervention sessions by an occupational therapist (intervention group). Main outcome measures Responses to postal questionnaires at four and 10 months: primary outcome measure was response to whether participant got out of the house as much as he or she would like, and secondary outcome measures were response to how many journeys outdoors had been made in the past month and scores on the Nottingham extended activities of daily living scale, Nottingham leisure questionnaire, and general health questionnaire. Results Participants in the treatment group were more likely to get out of the house as often as they wanted at both four months (relative risk 1.72, 95% confidence interval 1.25 to 2.37) and 10 months (1.74, 1.24 to 2.44). The treatment group reported more journeys outdoors in the month before assessment at both four months (median 37 in intervention group, 14 in control group: P < 0.01) and 10 months (median 42 in intervention group, 14 in control group: P < 0.01). At four months the mobility scores on the Nottingham extended activities of daily living scale were significantly higher in the intervention group, but there were no significant differences in the other secondary outcomes. No significant differences were observed in these measures at 10 months. Conclusion A targeted occupational therapy intervention at home increases outdoor mobility in people after stroke.

A randomized controlled trial of enhanced Social Service occupational therapy for stroke patients

Objective: To determine whether stroke patients referred to the Social Service occupational therapy service would benefit from an enhanced service compared to the usual service. Design: Randomized controlled study allocating patients to the enhanced service or the usual service. Subjects: Stroke patients discharged home from hospital and referred to Social Service occupational therapy department. Outcome measures: The sections and total score from the Nottingham Extended Activities of Daily Living Scale (EADL), the Barthel Index, the General Health Questionnaire (GHQ) and the number of pieces of equipment provided were analysed. Results: One hundred and eleven stroke patients were recruited to this study. Fifty-three were randomly allocated to the enhanced service and 58 to the usual service. Patients receiving the enhanced service were seen more quickly after referral, for longer, and received significantly more visits (p <0.01 ) than those receiving the usual service. Three months after entry to the study the enhanced service group had better EADL (p <0.01 ) than the usual service group. This benefit remained significant in only the mobility section of the EADL at six months. Carers of the stroke patients in the enhanced group had lower GHQ scores (p <0.05) than those in the usual group at six months. Conclusions: This trial supports the use of domiciliary occupational therapy for stroke patients after discharge from hospital in terms of improvements in functional outcomes in the short term, but the long-term benefits remain unclear.

Health status of UK care home residents: a cohort study

Background: UK care home residents are often poorly served by existing healthcare arrangements. Published descriptions of residents’ health status have been limited by lack of detail and use of data derived from surveys drawn from social, rather than health, care records. Aim: to describe in detail the health status and healthcare resource use of UK care home residents Design and setting: a 180-day longitudinal cohort study of 227 residents across 11 UK care homes, 5 nursing and 6 residential, selected to be representative for nursing/residential status and dementia registration. Method: Barthel index (BI), Mini-mental state examination (MMSE), Neuropsychiatric index (NPI), Mini-nutritional index (MNA), EuroQoL-5D (EQ-5D), 12-item General Health Questionnaire (GHQ-12), diagnoses and medications were recorded at baseline and BI, NPI, GHQ-12 and EQ-5D at follow-up after 180 days. National Health Service (NHS) resource use data were collected from databases of local healthcare providers. Results: out of a total of 323, 227 residents were recruited. The median BI was 9 (IQR: 2.5–15.5), MMSE 13 (4–22) and number of medications 8 (5.5–10.5). The mean number of diagnoses per resident was 6.2 (SD: 4). Thirty per cent were malnourished, 66% had evidence of behavioural disturbance. Residents had contact with the NHS on average once per month. Conclusion: residents from both residential and nursing settings are dependent, cognitively impaired, have mild frequent behavioural symptoms, multimorbidity, polypharmacy and frequently use NHS resources. Effective care for such a cohort requires broad expertise from multiple disciplines delivered in a co-ordinated and managed way.

A study of interventions and related outcomes in a randomized controlled trial of occupational therapy and leisure therapy for community stroke patients

Objective: To undertake a detailed analysis of therapy provided in a multicentred randomized controlled trial of activities of daily living (ADL) and leisure (TOTAL), testing the hypothesis that specific interventions given in the trial affected specific aspects of outcome. Subjects: Three hundred and nine stroke patients who had been randomly allocated to receive either occupational therapy aimed at ADL activities (n = 156) or leisure (n = 153). Measures: Number, duration and type of activity undertaken per patient. Barthel Index, Extended Activities of Daily Living Scale (EADL) and Nottingham Leisure Questionnaire (NLQ) six months after entry to the study. Method: Activities that had been used in treatment were coded and categorized. Frequently used activities identified. These activities were matched to items from the six-month outcome measures. Patient independence in these outcome items was compared between the leisure and ADL groups. Results: Three hundred and nine therapy record forms were returned. Patients received a median of ten sessions with a median duration of 55 minutes. The ADL group received significantly more, mobility training, transfer training, cleaning, dressing, cooking and bathing training (chi-squared, p < 0.05). Sport, creative activities, games, hobbies, gardening, entertainment and shopping were used significantly more in the leisure group (chi-squared, p < 0.05) than the ADL group. Fifteen items from the outcome measures were identified as specific to these interventions. There were no statistically significant differences in outcome on these 15 items between the ADL and leisure groups (chi-squared, p > 0.05). Conclusions: We found no evidence that specific ADL or leisure interventions led to improvements in specific relevant outcomes. We believe that these findings should prompt a review of the relationship between process and outcome of occupational therapy.

Development and validation of the Nottingham Leisure Questionnaire (NLQ)

Objectives: To reduce the length of the Nottingham Leisure Questionnaire (NLQ) in order to make it more suitable for postal use, and to evaluate its test–retest reliability, sensitivity, stability and validity in relation to other measures of activities of daily living (ADL), mood and handicap. Method: The NLQ was shortened and the response categories collapsed. Results from a previous trial which had used the NLQ were reanalysed to establish if significant group differences were maintained. The new version of the NLQ was subsequently tested for test–retest reliability on a new group of patients from the Nottingham stroke register who were asked to complete it twice. The new NLQ and other measures were sent to patients in a multicentre rehabilitation trial (TOTAL) six and twelve months after recruitment for postal completion. Subjects: One hundred and thirty-seven consecutive patients from the Nottingham stroke register and 466 patients with a stroke in a multicentre rehabilitation trial. Results: The original NLQ was reduced from 37 to 30 items and from five to three response categories. Data from an earlier study were reanalysed and differences between treatment groups remained. The results of a test–retest analysis using kappa showed that six items had excellent agreement, 15 good and nine fair, suggesting acceptable test–retest reliability. Results from the rehabilitation trial showed that the subjects performed all items and few additional activities were suggested. Higher NLQ scores were associated with higher subscores on the Nottingham Extended Activities of Daily Living Scale (NEADL) and lower NLQ scores with living alone and worse emotional health. Conclusion: The NLQ has been successfully modified for postal self administration but there is potential for further development.

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.