Susan Corr

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.

Classification Systems for Hallux Rigidus: A Review of the Literature

Background Hallux rigidus (HR) is one of the most common causes of forefoot pain. A number of classification systems have been developed to evaluate HR. These systems are based on either radiological parameters alone or a combination of radiological and clinical features. The purpose of this paper is to critically evaluate HR classification systems by undertaking a detailed review using English language medical and paramedical databases. Materials and Methods The authors identified 18 formal HR classification systems described in the literature, some of which are variations on a theme. Results No clear consensus on the construction of HR classification systems appears to exist. Different criteria and methods are used which make comparison difficult. Furthermore, it appears that, no serious consideration has been given to their reliability and validity. Criteria used to justify inclusion of these parameters have been based mainly on clinical experience rather than formal research. Conclusion For such a common condition, there is a need for a properly constructed, prospective study to develop a suitable classification system. It should include scientifically validated parameters to help stratify different stages of the disease and aid clinical and scientific communication.

Investigation into the occupational lives of healthy older people through their use of time

BACKGROUND/AIM Older people are one of the largest groups using health-care services; therefore, it is important for occupational therapists to have an understanding of their occupational lives. Temporality is a key element of occupation, yet little research exists regarding older people and time use, despite the considerable temporal adjustments taking place at this lifestage. The aim of this study was to identify the occupational lives of healthy older people through the activities they undertake in a 24-hour period. METHOD Data analysis of time-use diaries from 90 older UK residents (aged 60-85 years) who considered themselves to be healthy was undertaken, using 15 activity codes and three pre-coded terms: necessary, enjoyable and personal. RESULTS The participants spent most of their time sleeping and resting (34%), followed by performing domestic activities (13%), watching television, listening to the radio or music, or using computers (11%), eating and drinking (9%) and socialising (6%). Enjoyable activities occupied most of their time (42% of the day), followed by necessary (34%) and personal activities (16%). CONCLUSION These data contribute to the growing evidence base regarding older people as occupational beings, indicating that they are a diverse group of individuals who are meeting their needs with dynamic, positive activities. This highlights the importance of a client-centred approach to occupational therapy, as it enables the clients to have choice, control and diversity in their activities when meeting their needs.

Returning to Work after a Stroke: An Important but Neglected Area

Work is key to participating in society. This paper reports two independent studies, which addressed different aspects of returning to work after a stroke. Study I, using the Canadian Occupational Performance Measure and the Role Checklist, established the perception of returning to work of 26 participants aged 34–55 years post-stroke. Study II, using interviews, established the support required and obtained for six participants who returned to work post-stroke. Both studies found that the participants considered work to be important, that they wished to return to work and that help was needed to do so. Study II found that occupational therapists had a limited role in providing support and recommends their greater involvement in work rehabilitation service provision for those who have had a stroke. The findings of these studies suggest that there is a gap in providing appropriate support to enable people to carry out an occupation that both they and society value.

Evaluation of a pilot service designed to provide support following stroke: a randomized cross-over design study

Objective: To evaluate a day service for people aged 18–55 years who had a stroke. Design: A randomized cross-over study design was used, randomly allocating individuals to attend the service for six months followed by a period of no attendance for six months. Setting: A day service pilot project was launched in Cardiff in July 1995 for people who were aged between 18 and 55 years and had a stroke. It met one day a week. Subjects: Twenty-six participants were recruited to the study between June 1998 and February 2000. Their mean age was 48 years (SD = 7). Interventions: The service aimed to offer participants the opportunity to identify and pursue meaningful and realistic opportunities within the community. A range of activities occurred at the service including creative activities and social outings. Main outcome measures: The Barthel ADL Index, Extended ADL Scale, Nottingham Leisure Questionnaire, Short Form 36, the Hospital Anxiety and Depression Scale, the Canadian Occupational Performance Measure, the Role Checklist and the Semantic Differential Self Concept Scale were used to assess the outcomes from the service. Results: Attending the service increased occupational performance and satisfaction with performance but there was no evidence that depression and anxiety were reduced or that quality of life and self-concept were improved. Conclusion: Although there were some gains from attending the service there were also many unmet needs. Further research is required to continue to identify how best to meet the needs of individuals post stroke under retirement age.

An Investigation into the Leisure Occupations of Older Adults

Participating in leisure is known to enhance physical wellbeing, mental health and social functioning. There is, however, little knowledge of the current level of engagement in leisure occupations by older adults in the United Kingdom. Therefore, the aim of this study was to explore the current leisure occupations of adults over 60 years who considered themselves to be healthy and to identify the motivations that underpinned participation in those occupations. Structured interviews were conducted with 70 adults with a mean age of 72 years. The majority of the participants (51, 73%) reported engaging in leisure occupations. The range of leisure occupations was wide and included walking, sailing, listening to music, emailing and volunteering. Of these, 23% were active leisure, 18% passive leisure, 24% social leisure, 20% hobbies and 15% other leisure occupations. Content analysis was adopted to explain the motivators for taking part in these leisure occupations. It was found that enjoyment, pleasure and relaxation were the key motivators. This study shows that the majority of well older people are participating in leisure occupations and feeling positive about doing so. Further research is required to establish the role that occupational therapists can have in encouraging older adults to continue with or develop new leisure occupations to enhance health and quality of life.

An Introduction to Q Methodology, a Research Technique

In an attempt to develop the range of research methodologies within the occupational therapy profession, it is necessary to consider methods that may be appropriate to use in studies. Q methodology has been used in the United States, and to a lesser extent in the United Kingdom, by a broad range of researchers, including psychologists, social scientists, educationalists, political scientists and other health care professionals. It is basically a quantitative method for analysing qualitative data, based on viewpoints. The process involves developing a Q sort pack (a number of items representing the range of ideas on a topic), administering the sort (asking participants to rank the ideas with reference to their own views), analysing the data (looking for patterns in the way that individuals respond) and interpreting the results. This approach has a number of potential uses in occupational therapy. It is recommended that this method is given consideration as a research tool when attempting to identify the perceptions of clients, colleagues, students or others on any service or educational issue.

Hallux rigidus: A cross-sectional study to evaluate clinical parameters

BACKGROUND Hallux rigidus (HR) is a common condition with history and physical examination used to help evaluate pathology, grade clinical changes and to inform treatment. METHOD A cross-sectional study was undertaken to evaluate the demographics of and clinical parameters encountered in HR. In 110 subjects (180 feet) aged 18-70 years (mean 52 years) a standardized history and physical examination was undertaken. Clinical parameters associated with HR were evaluated. The Foot Health Status Questionnaire (FHSQ) was used to measure health-related quality-of-life dimensions. RESULTS Seventy (64%) subjects had bilateral HR and 73 (66%) were female. Mean HR onset was 44 (14-68 years) years and median HR duration 6 years (1-33 years). A history of 1st MTPJ trauma presented in 22% of subjects; 74% of whom had unilateral HR. Eighty-four (47%) feet had pes planus based on a positive Foot Posture Index. A correlation between pes planus and 1st MTPJ pain was found (r=0.84, p=0.05). In 74% of feet, hallux abductus interphalangeus angle (HAI degrees ) was greater than normal (< or =10 degrees ). A correlation between HAI and reduced 1st MTPJ ROM was found (r=0.92, p=0.05). Second toe length was the same as the hallux in 111 feet (62%). A correlation between valgus hallucal rotation and 1st MTP joint pain in HR was found (r=.78, p=.05). A positive relationship was found between 2nd toe length and 1st MTPJ pain (p=0.001<0.05). A correlation between hallucal interphalangeal joint (IPJ) hyperextension and 1st MTPJ pain was found (r=0.78, p=0.01). A positive relationship was found between lesser MTPJ pain and supination at propulsion (p<0.001). There was no evidence of Achilles tendon contracture. The FHSQ results concur with clinical findings. CONCLUSIONS HR was associated with female gender, bilateral involvement, older age groups, increased HAI degrees, 2nd toe length similar to hallux, hallucal IPJ hyperextension, lesser MTP joint pain, flat foot and certain gait alterations. HR was not associated with Achilles tendon tightness or footwear. The content validity of clinical parameters of HR needs to be established by formal research prior to their inclusion in a classification of HR.