Occupational Therapy for patients with problems in personal activities of daily living after stroke. Avril Drummond April, 2008

Or Why bother giving Occupational Therapy to people who have had a stroke?

Activities of daily living Basic/Personal ADL ‘those tasks which all of us undertake every day of our lives in order to maintain our level of care’ (Hopson, 1981). -includes such tasks as feeding, dressing, toileting and bathing.

Instrumental/Extended ADL -includes activities such as shopping, preparing a meal, housework, laundry.

Nottingham SUE study Drummond et al, 1996 Patients with a stroke were randomly allocated to treatment on the stroke unit or to other wards (General Medical or Health Care of the Elderly wards). Found that SU patients did better on personal ADL than other patients- why? In comparison, mobility same in all settings.

Occupational Therapy Trials Corr and Bayer, 1995 Drummond and Walker, 1995 Logan et al, 1997 Walker et al, 1999 Gilbertson et al, 2000 Sackley et al, 2006

Corr and Bayer, 1995 follow up/review Drummond and Walker, 1995 leisure or ADL Gilbertson et al, 2000 6 week follow up Logan et al, 1997 enhanced social services

Walker et al (1999) recruited people who were not admitted to hospital after their stroke. Those who had an occupational therapy intervention performed better than a control group at six month follow up on a range of self care measures. Unpublished- expertise of therapist important.

Sackley et al (2006) recruited people in nursing homes who had had a stroke. Those who had an occupational therapy intervention had higher scores indicating maintenance and slight improvement in the functional status compared to the control group. More participants survived in the intervention group.

Treatment by an Occupational Therapist, who is an expert in stroke care, can reduce activity limitation in people who have had a stroke.

However, with the exception of the Sackley trial, all these trials were small and single-centred.

TOTAL Trial of Occupational Therapy and Leisure. Patients who had a stroke were randomly allocated in five UK centres to receive either; additional occupational therapy focused on leisure additional occupational therapy focused on activities of daily living normal care. Parker, Gladman, Drummond et al (2001)

Centres

1750 patients registered July 1996 - June 1998

In contrast to the findings of the previous smaller trials, neither of the additional occupational therapy treatments showed a clear beneficial effect on mood, leisure activity or independence in ADL measured at either six or twelve months follow up.

Problems? Publication bias – negative trials difficult to get published. Overall impact of results in stroke.

Explanation for results? artificial situation for therapists who found day to day implementation difficult, resulting in contamination between the groups. people were withdrawn -or indeed not even entered into the study- by therapists, who believed they needed normal, routine care (that is, both ADL and leisure interventions). i.e. practical difficulties with protocol adherence could explain the negative results obtained.

Literature now confusing We decided to conduct a systematic review. Information already there- therefore no use repeating.

Objective To determine whether Occupational Therapy focused specifically on personal activities of daily living (ADL) improves recovery for patients following a stroke.

Systematic reviews are important but the details can be dull!

Criteria for studies All RCTs of stroke pts receiving intervention by an Occupational Therapist (or under OT supervision) with aim of facilitating personal ADL compared to usual/no care. Definition of stroke. Excluded mixed aetiology (less than 50% stroke).

Search strategy Databases (e.g. Cochrane, MEDLINE, EMBASE, CINAHL, PsycLIT, AMED, ……..) Hand searches Unpublished and ongoing trials Reference lists checked Authors/researchers contacted

Titles (and abstracts) screened for inclusion. Most rejected as- Not stroke, Not RCT, Not OT, Not ADL If any doubt, included.

Two review authors (LL, AD) scrutinised Methodological quality assessed Data extracted independently by two authors (LL, AD) Contact with trialists Disagreements resolved by consensus.

RESULTS Legg, L. et al. BMJ 2007;0:bmj.39343.466863.55v1-bmj.39343.466863.55 Copyright ©2007 BMJ Publishing Group Ltd.

Excluded Studies 54 excluded Not RCT Not OT Comparing 2 OT treatments, no control, therefore no unconfounded estimate of effect of OT. Not ADL focussed 2 trials awaiting assessment (China, Sweden)

Results for ADL Results for 1258 participants from 9 RCTs

Effects of occupational therapy on personal activities of daily living Legg, L. et al. BMJ 2007;0:bmj.39343.466863.55v1-bmj.39343.466863.55 Copyright ©2007 BMJ Publishing Group Ltd.

Effects of occupational therapy on outcome Legg, L. et al. BMJ 2007;0:bmj.39343.466863.55v1-bmj.39343.466863.55 Copyright ©2007 BMJ Publishing Group Ltd.

Occupational Therapy- Increased performance scores (St Mean diff 0.18, 95% CI 0.04 to 0.32, p=0.01) Reduced risk of poor outcome (death, deterioration or dependency in PADL) (OR 0.67, 95% CI 0.51 to 0.87, p=0.003) i.e. life in years not years in life.

Thus For every 100 people who received Occupational Therapy focused on PADL, 11 would be spared a poor outcome. (95% CI 7 to 30)

Difficulties Information from trialists- some not forthcoming or slow to obtain Cluster randomization- statistical nightmare Time and money Authorship

Occupational Therapy Trialists Susan Corr Mireille Donkervoort Avril Drummond Judi Edmans Louise Gilbertson Lyn Jongbloed Lynn Legg Pip Logan Catherine Sackley Marion Walker

Why bother giving Occupational Therapy to people who have had a stroke?

Occupational Therapy focused on improving personal ADL in patients with a stroke can improve performance and reduce the risk of deterioration in these abilities.

The debate now needs to move away from whether focussed Occupational Therapy is beneficial to whether it is a right and not a privilege for everyone who has had a stroke.

The questions we should now seek to answer are; what specific interventions are most effective?, with whom? (i.e. the selection of appropriate patients), how much? (i.e. the intensity of treatment sessions) and for how long? (the duration of the treatment).

Patient with stroke- medical note entry Patient with stroke- medical note entry. ‘Nothing more could be done for the patient so he was referred for rehabilitation’