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Black GB, Ramsay AIG, Simister R, Baim-Lance A, Eng J, Melnychuk M, Fulop NJ. Temporal structures that determine consistency and quality of care: a case study in hyperacute stroke services. BMJ Qual Saf 2024; 33:587-596. [PMID: 37336572 PMCID: PMC11347214 DOI: 10.1136/bmjqs-2022-015620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 05/20/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Temporal structuring is determined by practices and social norms and affects the quality and timing of care. In this case study of hyperacute stroke wards which provide initial stroke investigation, treatment and care, we explored temporal structuring patterns to explain how these may affect quality of care. METHODS This paper presents a thematic analysis of qualitative interviews with hyperacute stroke staff (n=76), non-participant observations (n=41, ~102 hours) and documentary analysis of the relevant service standards guidance. We used an inductive coding process to generate thematic findings around the concept of temporal structuring, with graphically illustrated examples. RESULTS Five temporal structures influence what-happens-when: (1) clinical priorities and quality assurance metrics motivate rapid activity for the initial life-prolonging assessments and interventions; (2) static features of ward organisation such as rotas and ward rounds impact consistency of care, determining timing and quality of care for patients; (3) some services experimented with staff rotas to try to meet peaks in demand, sometimes unsuccessfully; (4) implicit social norms or heuristics about perceived necessity affected staff motivation to make changes or improvements to consistency of care, particularly around weekend work; and (5) after-effects such as bottlenecks or backlogs affect quality of care, which are hard to measure effectively to drive service improvement. CONCLUSIONS Patients need temporally consistent high quality of care. Temporal consistency stems from the design of services, including staffing, targets and patient pathway design as well as cultural attitudes to working patterns. Improvements to consistency of care will be limited without changes to structures such as rotas and ward rounds, but also social norms around weekend work for certain professional groups.
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Affiliation(s)
- Georgia B Black
- Applied Health Research, University College London, London, UK
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | | | - Robert Simister
- Stroke Research Centre, Institute of Neurology, University College London, London, UK
| | - Abigail Baim-Lance
- Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, New York, USA
- James J Peters VA Medical Center, US Department of Veterans Affairs, New York, New York, USA
| | - Jeannie Eng
- Stroke Research Centre, Institute of Neurology, University College London, London, UK
| | | | - Naomi J Fulop
- Applied Health Research, University College London, London, UK
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Ouyang RG, Long Y, Zhang JQ, Cao Z. Interventions for improving self-efficacy in patients after stroke based on self-efficacy-related principles of Bandura's cognition theory: a systematic review and meta-analysis. Top Stroke Rehabil 2023; 30:820-832. [PMID: 36755444 DOI: 10.1080/10749357.2023.2172832] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/22/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Interventional approaches based on Bandura's cognition theory are effective in improving self-efficacy poststroke. However, a systematical investigation for identifying effectives therapeutic components of the intervention has not yet been conducted. OBJECTIVE This meta-analysis was conducted to systematically investigated the effects of interventions with different principles on improving self-efficacy after stroke. METHODS Searches were conducted in PubMed, EMBASE, CINAHL, PsycINFO, MEDLINE, Cochrane Library, and two randomized controlled trials registration websites for randomized controlled trials from inception to 18th January 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. The meta-analysis was performed using Review Manager and Stata software. RESULTS In total, 36 RCTs were included. Interventions using any one of the self-efficacy principles - principle 1 (Mastery), principle 2 (Modeling), principle 3 (Social persuasion), and principle 4 (Understanding), were more effective in improving self-efficacy in patients with stroke at post-training and follow-up, compared with the control group. Psycho-educational interventions might significantly improve self-efficacy in both post-intervention and follow-up stages, compared with control group. Meta-regression revealed time since stroke onset was significantly associated with effect sizes. CONCLUSION Interventions developed based on Bandura's cognition theory are beneficial to the improvement of self-efficacy. This review highlights principles of Bandura's cognition theory are worth considering to be integrated to interventions targeted at improving self-efficacy. The application of self-efficacy principles with Bandura's cognitive theory could be encouraged in clinical practice in the future. PROTOCOL REGISTRATION NUMBER PROSPERO CRD42020154984.
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Affiliation(s)
- Rang-Ge Ouyang
- Department of Rehabilitation, Xiangya Hospital Central South University, Changsha, Hunan, China
| | - Yi Long
- Department of Rehabilitation, Xiangya Hospital Central South University, Changsha, Hunan, China
| | - Jia-Qi Zhang
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Zeng Cao
- Department of Rehabilitation, Xiangya Hospital Central South University, Changsha, Hunan, China
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Clark B, Burridge J, Whitall J, Turk R, Hughes AM, Truman J. Why do some people with stroke not receive the recommended 45 min of occupational therapy and physiotherapy after stroke? A qualitative study using focus groups. BMJ Open 2023; 13:e072275. [PMID: 37993170 PMCID: PMC10668261 DOI: 10.1136/bmjopen-2023-072275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 09/01/2023] [Indexed: 11/24/2023] Open
Abstract
OBJECTIVES To generate qualitative data on the views of Occupational Therapists and Physiotherapists about why people do not receive the Royal College of Physicians' recommended minimum of 45 minutes (min) of daily therapy after stroke, in order to inform a Delphi study. DESIGN Focus group study. SETTING Stroke services in the South of England. PARTICIPANTS A total of nine participants, in two groups, including therapists covering inpatient and Early Supported Discharge (ESD) services with awareness of the 45 min guideline. RESULTS Thematic analysis of focus group data identified five factors that influence the amount of therapy a person receives: The Person (with stroke), Individual Therapist, Stroke Multidisciplinary Team, the Organisation and the Guideline. Study findings suggest that the reasons why a person does not receive the therapy recommendation in inpatient and ESD services relate to either the suitability of the guideline for the person with stroke, or the ability of the service to deliver the guideline. CONCLUSION This study provides evidence for possible reasons why some people do not receive a minimum of 45 minutes of therapy, 5 days per week, related to (1) the suitability of the guideline for people with stroke and (2) services' ability to deliver this amount of intervention. These two factors are related; therapists decide who should receive therapy and how much in the context of (a) resource availability and (b) people's need and the benefit they will experience. The study findings, combined with the findings from other studies, will be used to initiate a Delphi study, which will establish consensus among therapists regarding the reasons why some people do not receive the guideline amount of therapy.
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Affiliation(s)
- Beth Clark
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Jane Burridge
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Jill Whitall
- Department of Physical Therapy and Rehabilitation Science, School of Medicine, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Ruth Turk
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Ann-Marie Hughes
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Juliette Truman
- Department of Rehabilitation and Sports Sciences, Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, Dorset, UK
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Qin H, Reid I, Gorelik A, Ng L. Environmental enrichment for stroke and other non-progressive brain injury. Cochrane Database Syst Rev 2021; 11:CD011879. [PMID: 34811724 PMCID: PMC8609277 DOI: 10.1002/14651858.cd011879.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Rehabilitation is effective for recovery after stroke and other non-progressive brain injuries but it is unclear if the rehabilitation environment itself, outside of limited therapy hours, is maximally conducive to recovery. Environmental enrichment is a relatively new concept within rehabilitation for humans. In this review, this is defined as an intervention designed to facilitate physical (motor and sensory), cognitive and social activity by the provision of equipment and organisation of a structured, stimulating environment. The environment should be designed to encourage (but not force) activities without additional specialised rehabilitation input. OBJECTIVES To assess the effects of environmental enrichment on well-being, functional recovery, activity levels and quality of life in people who have stroke or non-progressive brain injury. SEARCH METHODS We conducted the search on 26 October 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE (from 1950); Embase (from 1980); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; from 1982); the Allied and Complementary Medicine Database (AMED; from 1985); PsycINFO (from 1806); the Physiotherapy Evidence Database (PEDro; from 1999); and 10 additional bibliographic databases and ongoing trial registers. SELECTION CRITERIA We planned to include randomised controlled trials (RCTs) that compared environmental enrichment with standard services. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligible studies, extracted data, and assessed study quality. Any disagreements were resolved through discussion with a third review author. We determined the risk of bias for the included study and performed a 'best evidence' synthesis using the GRADE approach. MAIN RESULTS We identified one RCT, involving 53 participants with stroke, comparing environmental enrichment (which included physical, cognitive and social activities such as reading material, board and card games, gaming technology, music, artwork, and computer with Internet) with standard services in an inpatient rehabilitation setting. We excluded five studies, found two studies awaiting classification and one ongoing study which described environmental enrichment in their interventions. Of the excluded studies, three were non-RCTs and two described co-interventions with a significant component of rehabilitation. Based on the single small included RCT at high risk of bias, data are insufficient to provide any reliable indication of benefit or risk to guide clinical practice in terms of the provision of environmental enrichment. AUTHORS' CONCLUSIONS The gap in current research should not, however, be interpreted as proof that environmental enrichment is ineffective. Further research is needed with robust study designs, such as cluster RCTs, and consistent outcome measurement evaluating the effectiveness of environmental enrichment in different settings (inpatient versus outpatient), the relative effectiveness of various components of environmental enrichment, cost-effectiveness, and safety of the intervention in people following stroke or other non-progressive brain injuries. It should be noted, however, that it is challenging to randomise or double-blind trials of environmental enrichment given the nature of the intervention.
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Affiliation(s)
- Helen Qin
- Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Isabella Reid
- Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Alexandra Gorelik
- Melbourne EpiCentre Melbourne Health, Royal Melbourne Hospital, Melbourne, Australia
| | - Louisa Ng
- Melbourne Medical School, The University of Melbourne, Melbourne, Australia
- Department of Rehabilitation Medicine, The Royal Melbourne Hospital, Melbourne, Australia
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Forster A, Ozer S, Crocker TF, House A, Hewison J, Roberts E, Dickerson J, Carter G, Hulme C, Fay M, Richardson G, Wright A, McKevitt C, McEachan R, Foy R, Barnard L, Moreau L, Prashar A, Clarke D, Hardicre N, Holloway I, Brindle R, Hall J, Burton LJ, Atkinson R, Hawkins RJ, Brown L, Cornwall N, Dawkins B, Meads D, Schmitt L, Fletcher M, Speed M, Grenfell K, Hartley S, Young J, Farrin A. Longer-term health and social care strategies for stroke survivors and their carers: the LoTS2Care research programme including cluster feasibility RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
It is reported that the longer-term outcomes for stroke survivors are poor, with a range of unmet needs identified.
Objectives
The aims were to develop and test a longer-term stroke care strategy focused on improving the quality of life of stroke survivors and their carers by addressing unmet needs, and maintenance and enhancement of participation (i.e. involvement in life situations).
Design
Five overlapping workstreams were undertaken – (1) refinement of content by semistructured interviews with stroke survivors and their carers and by a review of the literature to inform content and delivery of the care strategy; (2) exploration of service models by national survey and focus groups with purposely selected services; (3) intervention development by interaction with a reference group of stroke survivors, carers, and health and social care professionals; (4) refinement and pilot implementation of the developed intervention in three stroke services (case studies); and (5) a cluster randomised controlled feasibility trial in 10 stroke services across England and Wales.
Setting
The intervention development work and feasibility trial were in stroke services (inclusive of primary, secondary, community and social care provision) across England and Wales.
Participants
Participants were stroke survivors resident in the community and their carers, and health and social care professionals in the included stroke services.
Data sources
Interviews with 28 stroke survivors and their carers at least 9 months post stroke ascertained their needs and the barriers to and facilitators of addressing those needs. Additional literature reviews identified 23 needs. No evidence-based interventions to address these needs were reported; self-management was highlighted as a possible delivery mechanism. In workstream 2, a national survey revealed that the most common model of stroke service provision was care up to 12 months post stroke, reported by 46 (40%) services. Thirty-five (30%) services provided care up to 6 months post stroke and 35 (30%) provided care beyond 12 months, thus identifying 6 months post stroke as an appropriate delivery point for a new intervention. Through focus groups in a range of services, stroke survivors’ perceived unmet needs and the barriers to and enablers of service provision were identified.
Intervention
Using information obtained in workstreams 1 and 2 and working closely with a stakeholder reference group, we developed an intervention based on the unmet needs prioritised by stroke survivors and their carers (workstream 3). In workstream 4, action groups (clinicians, stroke survivors and researchers) were established in three stroke services that led implementation in their service and contributed to the iterative refinement of the intervention, associated training programme and implementation materials. The intervention (called New Start) was delivered at 6 months post stroke. Key components were problem-solving self-management with survivors and carers, help with obtaining usable information, and helping survivors and their carers build sustainable, flexible support networks.
Results
A cluster randomised feasibility trial (workstream 5) was successfully implemented in 10 stroke services across England and Wales, with associated process and health economic evaluations. Five services were randomised to provide New Start, while five continued with usual care; 269 participants were recruited. Progression criteria – in terms of our pre-determined (red, amber, green) criteria for progress to a full trial: target stroke survivor recruitment rates were achieved, on average, across sites (24.1 per site over 6 months, green); 216 (80.3%) registered stroke survivors returned follow-up questionnaires at 9 months (84.1% in the intervention arm and 75.8% in the usual care arm, green); according to data reported by sites, overall, 95.2% of registered stroke survivors were offered at least one session of the intervention (green); all five intervention sites had at least two facilitators deemed competent, delivered the New Start intervention and provided it to stroke survivors (green). However, at some sites, there were concerns regarding the number of stroke survivors being offered, accepting and receiving the intervention. Only small differences in outcomes and costs were observed between the New Start and usual care groups, and considerable uncertainty around the cost-effectiveness remains.
Conclusions
We report a complex programme of work that has described the longer-term needs of stroke survivors and highlighted evidence and service gaps. Working closely with stroke survivors, an intervention was developed that has been refined in three services and feasibility tested in a cluster randomised controlled trial. Further refinement of the target population and optimisation of the intervention materials is required prior to a full randomised controlled trial evaluation.
Future work
Optimisation of the intervention, and clearer specification of recipients, are required prior to a full trial evaluation.
Trial registration
Current Controlled Trials ISRCTN38920246.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Anne Forster
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Seline Ozer
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Thomas F Crocker
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Allan House
- Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK
| | - Jenny Hewison
- Division of Health Services Research, School of Medicine, University of Leeds, Leeds, UK
| | | | - Josie Dickerson
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Gill Carter
- Patient and public involvement contributor, York, UK
| | - Claire Hulme
- College of Medicine and Health, University of Exeter, Exeter, UK
- Academic Unit of Health Economics, School of Medicine, University of Leeds, Leeds, UK
| | | | | | - Alan Wright
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Christopher McKevitt
- School of Population Health & Environmental Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | - Rosemary McEachan
- Born in Bradford, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Robbie Foy
- Division of Primary Care, Palliative Care and Public Health, School of Medicine, University of Leeds, Leeds, UK
| | - Lorna Barnard
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Lauren Moreau
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Arvin Prashar
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - David Clarke
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Natasha Hardicre
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Ivana Holloway
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Richard Brindle
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jessica Hall
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Louisa-Jane Burton
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Ross Atkinson
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Rebecca J Hawkins
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Lesley Brown
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Nicola Cornwall
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Bryony Dawkins
- Academic Unit of Health Economics, School of Medicine, University of Leeds, Leeds, UK
| | - David Meads
- Academic Unit of Health Economics, School of Medicine, University of Leeds, Leeds, UK
| | - Laetitia Schmitt
- Academic Unit of Health Economics, School of Medicine, University of Leeds, Leeds, UK
| | - Marie Fletcher
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Michael Speed
- Patient and public involvement contributor, York, UK
| | - Katie Grenfell
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Suzanne Hartley
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - John Young
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Amanda Farrin
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Rapolthy-Beck A, Fleming J, Turpin M, Sosnowski K, Dullaway S, White H. A comparison of standard occupational therapy versus early enhanced occupation-based therapy in a medical/surgical intensive care unit: study protocol for a single site feasibility trial (EFFORT-ICU). Pilot Feasibility Stud 2021; 7:51. [PMID: 33602337 PMCID: PMC7889705 DOI: 10.1186/s40814-021-00795-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 02/08/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Admissions to intensive care units (ICUs) are increasing due to an ageing population, and rising incidence of cardiac and respiratory disease. With advances in medical care, more patients are surviving an initial stay in critical care; however, they can experience ongoing health and cognitive limitations that may influence return to baseline function up to a year post-admission. Recent research has focused on the introduction of early rehabilitation within the ICU to reduce long-term physical and cognitive complications. The aim of this study is to explore the feasibility and impact of providing early enhanced occupation-based therapy, including cognitive stimulation and activities of daily living, to patients in intensive care. METHODS This study involves a single site randomised-controlled feasibility trial comparing standard occupational therapy care to an early enhanced occupation-based therapy. Thirty mechanically ventilated ICU patients will be recruited and randomly allocated to the intervention or control group. The primary outcome measure is the Functional Independence Measure (FIM), and secondary measures include the Modified Barthel Index (MBI), Montreal Cognitive Assessment (MoCA), grip strength, Hospital Anxiety and Depression Scale (HADS) and Short-Form 36 Health survey (SF-36). Measures will be collected by a blind assessor at discharge from intensive care, hospital discharge and a 90-day follow-up. Daily outcome measures including the Glasgow Coma Scale (GCS), Richmond Agitation and Sedation Scale (RASS) and Confusion Assessment Measure for intensive care units (CAM-ICU) will be taken prior to treatment. Participants in the intervention group will receive daily a maximum of up to 60-min sessions with an occupational therapist involving cognitive and functional activities such as self-care and grooming. At the follow-up, intervention group participants will be interviewed to gain user perspectives of the intervention. Feasibility data including recruitment and retention rates will be summarised descriptively. Parametric tests will compare outcomes between groups. Interview data will be thematically analysed. DISCUSSION This trial will provide information about the feasibility of investigating how occupational therapy interventions in ICU influence longer term outcomes. It seeks to inform the design of a phase III multicentre trial of occupational therapy in critical care general medical intensive care units. TRIAL REGISTRATION Australia New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618000374268 ; prospectively registered on 13 March 2018/ https://www.anzctr.org.au Trial funding: Metro South Health Research Support Scheme Postgraduate Scholarship.
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Affiliation(s)
- Andrea Rapolthy-Beck
- Logan Hospital, Brisbane, Queensland, Australia.
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Queensland, Australia.
| | - Jennifer Fleming
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Merrill Turpin
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Queensland, Australia
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Occupational therapy assessment and treatment approach in patients with subacute and chronic stroke: A single-blind, prospective, randomized clinical trial. Turk J Phys Med Rehabil 2020; 66:316-328. [PMID: 33089088 PMCID: PMC7557632 DOI: 10.5606/tftrd.2020.4321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 09/18/2020] [Indexed: 01/19/2023] Open
Abstract
Objectives
The aim of this study was to examine the effects of occupational therapy (OT) combined with standard rehabilitation (SR) on the activities of daily living, quality of life, and psychological symptoms of hemiplegic patients. Patients and methods
Between August 2014 and February 2016, a total of 35 hemiplegic patients with post-diagnostic periods (19 males, 16 females; mean age 58.3 years; range 37 to 77 years) were included. The patients were randomized into two groups as OT+SR group (n=17) and SR only group (n=18). The study was completed by 16 patients in each group. The patients in the OT group were given 45-min SR five days a week plus 45-min OT three days a week over an eight-week period, while the patients in the SR group received SR only (of the same duration and frequency as the OT group). The patients were assessed at enrolment (pre-treatment), and again after eight weeks of treatment using the Pinch and Grip Strength and the Purdue Pegboard tests, Global Daily Living Activities Scale, Performance Assessment of Self-care Skills (PASS), Nottingham Extended Activities of Daily Living (NEADL) Scale, Quality of Life Short Form (SF-36) Questionnaire, and Hospital Anxiety and Depression Scale (HAD) for their psychological state. Results
Significant improvements were observed in within-group scores for PASS, Pinch and Grip Strength Test, NEADL Scale, and Purdue Pegboard test (p<0.05). After treatment, a significant increase was found in the SF-36 physical function, general health and physical total in-group scores of the OT group, whereas a significant increase was observed only in the physical total scores of the SR group (p<0.05). There was no significant improvement in the HAD scores within both groups (p>0.05). Inter-group comparisons revealed a further significant improvement in PASS instrumental daily activity index-physical subscale and Purdue Pegboard Test scores of the OT group (p<0.05). However, there was no significant difference in PASS activity, self-care and instrumental daily activity cognitive subscale, SF-36, HAD and hand grip and pinch strength scores between the groups (p>0.05). Conclusion Occupational therapy combined with SR applications has a beneficial impact on certain daily living activities and hand functions. Occupational therapy does not have any additional benefits on the quality of life, pinch and grip strength, and the psychological state.
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Gonzalez-Santos J, Soto-Camara R, Rodriguez-Fernández P, Jimenez-Barrios M, Gonzalez-Bernal J, Collazo-Riobo C, Jahouh M, Bravo-Anguiano Y, Trejo-Gabriel-Galan JM. Effects of home-based mirror therapy and cognitive therapeutic exercise on the improvement of the upper extremity functions in patients with severe hemiparesis after a stroke: a protocol for a pilot randomised clinical trial. BMJ Open 2020; 10:e035768. [PMID: 32978182 PMCID: PMC7520843 DOI: 10.1136/bmjopen-2019-035768] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Neuroplasticity is defined as the capacity of the brain to reorganise new neuronal pathways. Mirror therapy (MT) and cognitive therapeutic exercise (CTE) are two neurorehabilitation techniques based on neuroplasticity and designed to improve the motor functions of the affected upper extremity in patients with severe hemiparesis after a stroke. Home-based interventions are an appropriate alternative to promote independence and autonomy. The objective of this study is to evaluate which of these techniques, MT and CTE, combined with task-oriented training, is more effective in functional recovery and movement patterns of the upper extremities in patients with severe hemiparesis after a stroke. METHODS AND ANALYSIS This is a home-based, single-blind, controlled, randomised clinical trial with three parallel arms, including 154 patients who had a stroke aged above 18 years. The primary outcome will be the functionality of the affected upper extremity measured using the Fugl-Meyer Assessment. Secondary variables will include cognitive performance, emotional state, quality of life and activities of daily living. During 6 weeks, one of the intervention groups will receive a treatment based on MT and the other one on CTE, both combined with task-oriented training. No additional interventions will be provided to the control group. To assess the progress of patients who had a stroke in the subacute phase, all variables will be evaluated at different visits: initial (just before starting treatment and 4 weeks post-stroke), post-intervention (6 weeks after initial) and follow-up (6 months). ETHICS AND DISSEMINATION This protocol has been approved by the Institutional Review Board (CEIm-2.134/2.019) and registered at ClinicalTrials.gov (NCT04163666). The results will be disseminated through open-access peer-reviewed journals, conference presentation, broadcast media and a presentation to stakeholders. These study results will provide relevant and novel information on effective neurorehabilitation strategies and improve the quality of intervention programmes aimed at patients after a stroke. TRIAL REGISTRATION NUMBER ClinicalTrials.gov (NCT04163666).
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Affiliation(s)
| | | | | | | | | | | | - Maha Jahouh
- Health Sciences, University of Burgos, Burgos, Spain
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Freburger JK, Chou A, Euloth T, Matcho B. Variation in Acute Care Rehabilitation and 30-Day Hospital Readmission or Mortality in Adult Patients With Pneumonia. JAMA Netw Open 2020; 3:e2012979. [PMID: 32886119 PMCID: PMC7489809 DOI: 10.1001/jamanetworkopen.2020.12979] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Pneumonia often leads to functional decline during and after hospitalization and is a leading cause of hospital readmissions. Physical and occupational therapists help improve functional mobility and may be of help in this population. OBJECTIVE To evaluate whether use of physical and occupational therapy in the acute care hospital is associated with 30-day hospital readmission risk or death. DESIGN, SETTING, AND PARTICIPANTS This cohort study included the electronic health records and administrative claims data of 30 746 adults discharged alive with a primary or secondary diagnosis of pneumonia or influenza-related conditions from January 1, 2016, to March 30, 2018. Patients were treated at 12 acute care hospitals in a large health care system in western Pennsylvania. Data for this study were analyzed from September 2019 through March 2020. EXPOSURES Number of physical and occupational therapy visits during the acute care stay categorized as none, low (1-3), medium (4-6), or high (>6). MAIN OUTCOMES AND MEASURES Outcomes were 30-day hospital readmission or death. Generalized linear mixed models were estimated to examine the association of therapy use and outcomes, controlling for patient demographic and clinical characteristics. Subgroup analyses were conducted for patients older than 65 years, for patients with low functional mobility scores, for patients discharged to the community, and for patients discharged to a post-acute care facility (ie, skilled nursing or inpatient rehabilitation facility). RESULTS Of 30 746 patients, 15 507 (50.4%) were men, 26 198 (85.2%) were White individuals, and the mean (SD) age was 67.1 (17.4) years. The 30-day readmission rate was 18.4% (5645 patients), the 30-day death rate was 3.7% (1146 patients), and the rate of either outcome was 19.7% (6066 patients). Relative to no therapy visits, the risk of 30-day readmission or death decreased as therapy visits increased (1-3 visits: odds ratio, 0.98; 95% CI, 0.89-1.08; 4-6 visits: odds ratio, 0.89; 95% CI, 0.79-1.01; >6 visits: odds ratio, 0.86; 95% CI, 0.75-0.98). The association was stronger in the subgroup with low functional mobility and in individuals discharged to a community setting. CONCLUSIONS AND RELEVANCE In this study, the number of therapy visits received was inversely associated with the risk of readmission or death. The association was stronger in the subgroups of patients with greater mobility limitations and those discharged to the community.
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Affiliation(s)
- Janet K. Freburger
- Department of Physical Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Aileen Chou
- Department of Physical Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tracey Euloth
- University of Pittsburgh Medical Center Rehabilitation Services, Pittsburgh, Pennsylvania
| | - Beth Matcho
- University of Pittsburgh Medical Center Rehabilitation Services, Pittsburgh, Pennsylvania
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10
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Management of Cognitive Impairment After Stroke. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00627-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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11
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Abstract
SummaryThe demand for rehabilitation services has increased in recent years due to population aging. Due to the limitations of therapist’s time and healthcare resources, robot-assisted rehabilitation is becoming an appealing, powerful, and economical solution. In this paper, we propose a solution that combines Learning from Demonstration (LfD) and robotic rehabilitation to save the therapist’s time and reduce the therapy costs when the therapy involves periodic or semi-periodic motions.We begin by modeling the therapist’s behavior (a periodic or semi-periodic motion) using a Fourier Series (FS). Later, when the therapist is no longer involved, the system reproduces the learned behavior modeled by the FS using a robot. A second goal is to combine the above with Gaussian Mixture Model (GMM) and Gaussian Mixture Regression (GMR) to obtain a more flexible and generalizable reproduction of the therapist’s behavior. This algorithm allows learning and imitating repetitive movement tasks. Our experimental results show the application of these algorithms to repetitive motion task.
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12
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Ou YK, Wang YL, Chang HC, Chen CC. Design and Development of a Wearable Exoskeleton System for Stroke Rehabilitation. Healthcare (Basel) 2020; 8:E18. [PMID: 31952135 PMCID: PMC7151176 DOI: 10.3390/healthcare8010018] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/23/2019] [Accepted: 01/09/2020] [Indexed: 11/24/2022] Open
Abstract
For more than a decade, many countries have been actively developing robotic assistive devices to assist in the rehabilitation of individuals with limb disability to regain function in the extremities. The exoskeleton assistive device in this study has been designed primarily for hemiplegic stroke patients to aid in the extension of fingers to open up the palm to simulate the effects of rehabilitation. This exoskeleton was designed as an anterior-support type to achieve palmar extension and acts as a robotic assistive device for rehabilitation in bilateral upper limb task training. Testing results show that this wearable exoskeleton assistive device with human factor consideration using percentile dimensions can provide comfortable wear on patients as well as adequate torque to pull individual fingers into flexion towards the palm for rehabilitation. We hope this exoskeleton device can help stroke patients with loss of function in the upper extremities to resume motor activities in order to maintain activities of daily living.
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Affiliation(s)
- Yang-Kun Ou
- Department of Creative Product Design, Southern Taiwan University of Science and Technology, Tainan 71005, Taiwan;
| | - Yu-Lin Wang
- Department of Physical Medicine and Rehabilitation, Chi Mei Hospital, Tainan 71004, Taiwan;
- Center of General Education, Southern Taiwan University of Science and Technology, Tainan 71005, Taiwan
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Hua-Cheng Chang
- Department of Multimedia and Entertainment Science, Southern Taiwan University of Science and Technology, Tainan 71005, Taiwan;
| | - Chun-Chih Chen
- Research and Development, AirTAC International Group, Tainan 74148, Taiwan
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13
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Manna SK, Dubey VN. Comparative study of actuation systems for portable upper limb exoskeletons. Med Eng Phys 2018; 60:1-13. [PMID: 30122472 DOI: 10.1016/j.medengphy.2018.07.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 04/26/2018] [Accepted: 07/29/2018] [Indexed: 11/19/2022]
Abstract
During the last two decades, a large variety of upper limb exoskeletons have been developed. Out of these, majority are platform based systems which might be the reason for not being widely adopted for post-stroke rehabilitation. Despite the potential benefits of platform-based exoskeletons as being rugged and reliable, stroke patients prefer to have a portable and user-friendly device that they can take home. However, the types of actuator as well as the actuation mechanism used in the exoskeleton are the inhibiting factors why portable exoskeletons are mostly non-existent for patient use. This paper presents a quantitative analysis of the actuation systems available for developing portable upper arm exoskeletons with their specifications. Finally, it has been concluded from this research that there are not many stand-alone arm exoskeletons which can provide all forms of rehabilitation, therefore, a generic solution has been proposed as the rehabilitation strategy to get best out of the portable arm exoskeletons.
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Affiliation(s)
- Soumya K Manna
- Faculty of Science and Technology, Bournemouth University Talbot Campus, Poole BH12 5BB, United Kingdom.
| | - Venketesh N Dubey
- Faculty of Science and Technology, Bournemouth University Talbot Campus, Poole BH12 5BB, United Kingdom.
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14
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Lynch EA, Cadilhac DA, Luker JA, Hillier SL. Inequities in access to inpatient rehabilitation after stroke: an international scoping review. Top Stroke Rehabil 2017; 24:619-626. [PMID: 28835194 DOI: 10.1080/10749357.2017.1366010] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background Inequities in accessing inpatient rehabilitation after stroke have been reported in many countries and impact on patient outcomes. Objective To explore variation in international recommendations regarding which patients should receive inpatient rehabilitation after stroke and to describe reported access to rehabilitation. Methods A scoping review was conducted to identify clinical guidelines with recommendations regarding which patients should access inpatient rehabilitation after stroke, and data regarding the proportion of patients accessing stroke rehabilitation. Four bibliographic databases and grey literature were searched. Results Twenty-eight documents were included. Selection criteria for post-acute inpatient rehabilitation were identified for 14 countries or regions and summary data on the proportion of patients receiving inpatient rehabilitation were identified for 14 countries. In Australia, New Zealand, and the United Kingdom, it is recommended that all patients with stroke symptoms should access rehabilitation, whereas guidelines from the United States, Canada, and Europe did not consistently recommend rehabilitation for people with severe stroke. Access to inpatient rehabilitation ranged from 13% in Sweden to 57% in Israel. Differences in availability of early supported discharge/home rehabilitation programs and variations in reporting methods may influence the ability to reliably compare access to rehabilitation between regions. Conclusion Recommendations regarding which patients with moderate and severe strokes should access ongoing rehabilitation are inconsistent. Clinical practice guidelines from different countries regarding post-stroke rehabilitation do not always reflect the evidence regarding the likely benefits to people with stroke. Inequity in access to rehabilitation after stroke is an international issue.
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Affiliation(s)
- Elizabeth A Lynch
- a Sansom Institute for Health Research, University of South Australia , Adelaide , Australia.,b Stroke Division , The Florey Institute of Neuroscience and Mental Health , Heidelberg , Australia.,c NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery , Melbourne , Australia.,d Adelaide Nursing School , University of Adelaide , Adelaide , Australia
| | - Dominique A Cadilhac
- b Stroke Division , The Florey Institute of Neuroscience and Mental Health , Heidelberg , Australia.,c NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery , Melbourne , Australia.,e Stroke and Ageing Research Centre, Department of Medicine , Monash University , Melbourne , Australia
| | - Julie A Luker
- a Sansom Institute for Health Research, University of South Australia , Adelaide , Australia.,b Stroke Division , The Florey Institute of Neuroscience and Mental Health , Heidelberg , Australia.,c NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery , Melbourne , Australia
| | - Susan L Hillier
- a Sansom Institute for Health Research, University of South Australia , Adelaide , Australia
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15
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Legg LA, Lewis SR, Schofield-Robinson OJ, Drummond A, Langhorne P. Occupational therapy for adults with problems in activities of daily living after stroke. Cochrane Database Syst Rev 2017; 7:CD003585. [PMID: 28721691 PMCID: PMC6483548 DOI: 10.1002/14651858.cd003585.pub3] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND A stroke occurs when the blood supply to part of the brain is cut off. Activities of daily living (ADL) are daily home-based activities that people carry out to maintain health and well-being. ADLs include the ability to: eat and drink unassisted, move, go to the toilet, carry out personal hygiene tasks, dress unassisted, and groom. Stroke causes impairment-related functional limitations that may result in difficulties participating in ADLs independent of supervision, direction, or physical assistance.For adults with stroke, the goal of occupational therapy is to improve their ability to carry out activities of daily living. Strategies used by occupational therapists include assessment, treatment, adaptive techniques, assistive technology, and environmental adaptations. This is an update of the Cochrane review first published in 2006. OBJECTIVES To assess the effects of occupational therapy interventions on the functional ability of adults with stroke in the domain of activities of daily living, compared with no intervention or standard care/practice. SEARCH METHODS For this update, we searched the Cochrane Stroke Group Trials Register (last searched 30 January 2017), the Cochrane Controlled Trials Register (The Cochrane Library, January 2017), MEDLINE (1946 to 5 January 2017), Embase (1974 to 5 January 2017), CINAHL (1937 to January 2017), PsycINFO (1806 to 2 November 2016), AMED (1985 to 1 November 2016), and Web of Science (1900 to 6 January 2017). We also searched grey literature and clinical trials registers. SELECTION CRITERIA We identified randomised controlled trials of an occupational therapy intervention (compared with no intervention or standard care/practice) where people with stroke practiced activities of daily living, or where performance in activities of daily living was the focus of the occupational therapy intervention. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, assessed risk of bias, and extracted data for prespecified outcomes. The primary outcomes were the proportion of participants who had deteriorated or were dependent in personal activities of daily living and performance in activities of daily living at the end of follow-up. MAIN RESULTS We included nine studies with 994 participants in this update. Occupational therapy targeted towards activities of daily living after stroke increased performance scores (standardised mean difference (SMD) 0.17, 95% confidence interval (CI) 0.03 to 0.31, P = 0.02; 7 studies; 749 participants; low-quality evidence) and reduced the risk of poor outcome (death, deterioration or dependency in personal activities of daily living) (odds ratio (OR) 0.71, 95% CI 0.52 to 0.96; P = 0.03; 5 studies; 771 participants; low-quality evidence). We also found that those who received occupational therapy were more independent in extended activities of daily living (OR 0.22 (95% CI 0.07 to 0.37); P = 0.005; 5 studies; 665 participants; low-quality evidence). Occupational therapy did not influence mortality (OR: 1.02 (95% CI 0.65 to 1.61); P = 0.93; 8 studies; 950 participants), or reduce the combined odds of death and institutionalisation (OR 0.89 (95% CI 0.60 to 1.32); P = 0.55; 4 studies; 671 participants), or death and dependency (OR 0.89 (95% CI 0.64 to 1.23); P = 0.47; 4 trials; 659 participants). Occupational therapy did not improve mood or distress scores (OR 0.08 (95% CI -0.09 to 0.26); P = 0.35; 4 studies; 519 participants; low-quality evidence). There were insufficient data to determine the effects of occupational therapy on health-related quality of life. We found no studies of consenting carers prior to study participation and therefore there were no carer-related outcomes in our review. There were insufficient data to determine participants' and carers' satisfaction with services.Using GRADE, the quality of evidence was low. The major limitation was the number of studies at unclear risk of selection bias and an inevitable high risk of performance and detection bias, as both participants and occupational therapists could not be blinded to the intervention. In addition, there was a sparseness of data for our outcomes of interest and we downgraded the quality of our evidence for these reasons. AUTHORS' CONCLUSIONS We found low-quality evidence that occupational therapy targeted towards activities of daily living after stroke can improve performance in activities of daily living and reduce the risk of deterioration in these abilities. Because the included studies had methodological flaws, this research does not provide a reliable indication of the likely effect of occupational therapy for adults with stroke.
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Affiliation(s)
- Lynn A Legg
- NHS Greater Glasgow and Clyde Health Board, Royal Alexandra Hospital, Paisley, UK, PA2 9PN
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16
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Lai CL, Tsai MM, Luo JY, Liao WC, Hsu PS, Chen HY. Post-acute care for stroke - a retrospective cohort study in Taiwan. Patient Prefer Adherence 2017; 11:1309-1315. [PMID: 28814838 PMCID: PMC5546822 DOI: 10.2147/ppa.s136041] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Stroke often causes functional decline in patients. Therefore, after the acute phase, many patients require post-acute care (PAC) to maximize their functional progress, reduce disability, and make it possible for them to return to their home and community. PAC can be provided in different settings. Taiwan's National Health Insurance (NHI) proposed a PAC pilot program, effective since 2014, for stroke patients that allowed patients with the potential for functional improvement to receive PAC rehabilitation in regional or community hospitals. The purpose of this study was to explore the initial achievements and clinical impact of this program in Taiwan. METHODS This was a retrospective cohort study that mainly analyzed basic hospitalization data and scores for function and quality of life, as recorded immediately after admission and before discharge, for stroke patients in the PAC program in a hospital in Taiwan. RESULTS This study collected complete data from a total of 168 patients. After an average of 43.57 days in the program, patients showed significant improvement in the Modified Rankin Scale (MRS), the Barthel Activity Daily Living Index (B-ADL), the Lawton-Brody Instrumental Activity Daily Living Scale (LB-IADL), the Functional Oral Intake Scale (FOIS), and the Mini Nutrition Assessment (MNA), in mobility, self-care, and usual activity, as well as on anxiety/depression in the EuroQol Five Dimensions Questionnaire (EQ-5D) and in the Mini Mental State Examination (MMSE). After discharge, 76.8% of the patients could return to their home and community. CONCLUSION This study showed that the pilot PAC program significantly promoted recovery of function in stroke patients and helped them to return to their home and community. Patients with the potential for functional recovery should consider receiving PAC service in a hospital after discharge from acute stroke care.
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Affiliation(s)
| | | | - Jia-Yuan Luo
- Department of Physical Medicine and Rehabilitation
| | | | - Pi-Shan Hsu
- Department of Family Medicine, Taichung Hospital, Ministry of Health and Welfare
- Graduate Institute of Microbiology and Public Health, College of Veterinary Medicine, National Chung-Hsing University
| | - Han-Yu Chen
- Department of Physical Therapy, Hungkuang University, Taichung, Taiwan
- Correspondence: Han-Yu Chen, Department of Physical Therapy, Hungkuang University, No 1018, Section 6, Taiwan Boulevard, Shalu, Taichung 43302, Taiwan, Tel +886 4 2631 8652 (ext 3313), Email
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Zhao L, Liao L, Hu F. Comparing Cerebralcare Granule and aspirin for neurological dysfunction in acute stroke in real-life practice. Psychogeriatrics 2017; 17:3-8. [PMID: 26757022 DOI: 10.1111/psyg.12180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 10/26/2015] [Accepted: 11/06/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cerebralcare Granule (CG) is a polyherbal Chinese medicine that has been shown to have neuroprotective effects in experimental models of stroke. We compared the efficacy and safety of CG with aspirin in patients with acute stroke. METHODS For this open-label, controlled trial, we recruited patients with angiographically confirmed strokes and US National Institutes of Health Stroke Scale (NIHSS) scores of 4-22 within 2 weeks of symptom onset; recruitment was performed at 55 sites in China. Patients received CG or aspirin. The primary efficacy end-point was neurological function. Analyses were done by intention to treat. Patients were measured for NIHSS, Montreal Cognitive Assessment, and Mini-Mental State Examination scores and Barthel index at baseline and at 4, 8, and 12 weeks after treatment. RESULTS Between January 2013 and January 2014, we treated 1963 patients with CG and 1288 patients with aspirin. Baseline NIHSS, Mini-Mental State Examination, and Montreal Cognitive Assessment scores were comparable between the two groups. Patients in the CG group had a greater improvement than the aspirin group in terms of NIHSS (P < 0.01) and Barthel index at 4, 8, and 12 weeks. At 12 weeks, patients in the CG group had a greater improvement than the aspirin group in terms of Mini-Mental State Examination (P < 0.01) and Montreal Cognitive Assessment (P < 0.05). Adverse reactions were similar between the two groups. CONCLUSIONS This large-scale, controlled trial indicated that CG may be a useful treatment in the management of post-stroke patients.
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Affiliation(s)
- Luqing Zhao
- Department of Neurology, People's Hospital of Shanxi Province, Shanxi Medical University, Taiyuan, China
| | - Lianming Liao
- Central Laboratory, The Union Hospital of Fujian Medical University, Fuzhou, China
| | - Fengyun Hu
- Department of Neurology, People's Hospital of Shanxi Province, Shanxi Medical University, Taiyuan, China
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18
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Whitehead PJ, Walker MF, Parry RH, Latif Z, McGeorge ID, Drummond AER. Occupational Therapy in HomEcare Re-ablement Services (OTHERS): results of a feasibility randomised controlled trial. BMJ Open 2016; 6:e011868. [PMID: 27531732 PMCID: PMC5013368 DOI: 10.1136/bmjopen-2016-011868] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The objective of this study was to test the feasibility of conducting a randomised controlled trial (RCT) of an intervention targeted at activities of daily living (ADL), delivered by an occupational therapist, in homecare reablement. DESIGN Feasibility parallel group RCT. SETTING Single-site local authority homecare reablement service. PARTICIPANTS People referred for homecare reablement with ability to consent. Exclusion criteria were as follows: inability to speak English, receiving other community therapy services, needing two or more to assist transfer and receiving end-of-life care. CONTROL 'Usual care' was 6 weeks of homecare reablement delivered by social care workers (no routine health professional input). INTERVENTION A targeted ADL programme, delivered by an occupational therapist incorporating goal setting, teaching/practising techniques, equipment/adaptations and provision of advice/support. This was in addition to usual care. OUTCOME MEASURES Aspects of feasibility including eligibility, recruitment, intervention delivery, attrition and suitability and sensitivity of outcome measures. Participant outcomes were personal and extended ADL, quality of life, falls and use of health and social care services. RESULTS 30 participants were recruited, 15 to each arm, which was 60% of those eligible. Data from 22 (73%) were analysed at 6 months. Of the 15 participants, 13 (86%) received the intervention and were able to set one or more ADL goals. There were improvements from baseline in both groups, although overall improvements were greater in the occupational therapy (OT) intervention group. The biggest threat to feasibility was a change in service configuration during the trial, involving additional occupational therapy input, affecting usual care and recruitment. CONCLUSIONS Despite the service reconfiguration, it was feasible to recruit and retain participants, deliver the intervention and collect outcome data that were responsive to change. The choice of primary outcome measure remains unclear. A further powered study is feasible and warranted; however, the design will require careful consideration because of ongoing national changes in service configurations. TRIAL REGISTRATION NUMBER ISRCTN21710246; Results.
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Affiliation(s)
| | - Marion F Walker
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Ruth H Parry
- School of Health Sciences, University of Nottingham, Nottingham, UK
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Huertas Hoyas E, Pedrero Pérez EJ, Águila Maturana AM, Rojo Mota G, Martínez Piédrola R, Pérez de Heredia Torres M. Outcomes of a multicomponent intervention on occupational performance in persons with unilateral acquired brain injury. FUNCTIONAL NEUROLOGY 2016; 31:109-15. [PMID: 27358224 DOI: 10.11138/fneur/2016.31.2.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Complications after unilateral acquired brain injury (ABI) can affect various areas of expertise causing (depending on the location of the lesion) impairment in occupational performance. The aim of this study was to analyze and compare the concepts of occupational performance and functional independence, both before and after a multicomponent intervention including occupational therapy, in persons with unilateral brain damage. This was a longitudinal quasi-experimental pretest post-test study in a sample of 58 patients with unilateral brain injury (28 with traumatic brain injury and 30 with ischemic stroke). The patients' level of independence was measured using the short version of the International Classification of Functioning, Disability and Health. We also measured quality of performance using the Assessment of Motor and Process Skills. The findings of this study showed that patients with injury in the right hemisphere improved more than those with left hemisphere damage (p<0.001). All the patients with ABI, especially those with right-sided injury, derived benefit from the multicomponent intervention, except in the area of motor skills. More research is needed on the specific techniques that might address such skills.
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20
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Pergolotti M, Williams GR, Campbell C, Munoz LA, Muss HB. Occupational Therapy for Adults With Cancer: Why It Matters. Oncologist 2016; 21:314-9. [PMID: 26865588 PMCID: PMC4786355 DOI: 10.1634/theoncologist.2015-0335] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 12/28/2015] [Indexed: 11/17/2022] Open
Abstract
Adults with cancer may be at risk for limitations in functional status and quality of life (QOL). Occupational therapy is a supportive service with the specific mission to help people functionally engage in life as safely and independently as possible with the primary goal of improving QOL. Unfortunately, for people with cancer, occupational therapy remains underused. The overall purpose of this review is to provide an understanding of what occupational therapy is and its relevance to patients with cancer, highlight the reasons to refer, and, last, provide general advice on how to access services.
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Affiliation(s)
- Mackenzi Pergolotti
- Gillings School of Global Public Health, Department of Health Policy and Management, Cancer Care Quality Training Program University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Lineberger Comprehensive Cancer Center, Geriatric Oncology Program, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Grant R Williams
- Lineberger Comprehensive Cancer Center, Geriatric Oncology Program, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Claudine Campbell
- Memorial Sloan Kettering Cancer Center, Department of Occupational Therapy, New York, New York, USA
| | - Lauro A Munoz
- MD Anderson Cancer Center, Department of Occupational Therapy, Houston, Texas, USA
| | - Hyman B Muss
- Lineberger Comprehensive Cancer Center, Geriatric Oncology Program, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Ng L, Reid I, Gorelik A, Galea M, Khan F. Environmental enrichment for stroke and other non-progressive brain injury. Hippokratia 2015. [DOI: 10.1002/14651858.cd011879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Louisa Ng
- Royal Melbourne Hospital, Royal Park Campus; Department of Rehabilitation Medicine; Poplar Road Parkville Melbourne Victoria Australia 3052
| | - Isabella Reid
- Royal Melbourne Hospital, Royal Park Campus; Department of Rehabilitation Medicine; Poplar Road Parkville Melbourne Victoria Australia 3052
| | - Alexandra Gorelik
- Royal Melbourne Hospital; Melbourne EpiCentre Melbourne Health; Grattan Street, Parkville Melbourne Australia
| | - Mary Galea
- The University of Melbourne; Department of Medicine (Royal Melbourne Hospital); Royal Park Campus 34-54 Poplar Road Parkville Victoria Australia 3052
| | - Fary Khan
- Royal Melbourne Hospital, Royal Park Campus; Department of Rehabilitation Medicine; Poplar Road Parkville Melbourne Victoria Australia 3052
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22
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Parke HL, Epiphaniou E, Pearce G, Taylor SJC, Sheikh A, Griffiths CJ, Greenhalgh T, Pinnock H. Self-Management Support Interventions for Stroke Survivors: A Systematic Meta-Review. PLoS One 2015. [PMID: 26204266 PMCID: PMC4512724 DOI: 10.1371/journal.pone.0131448] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is considerable policy interest in promoting self-management in patients with long-term conditions, but it remains uncertain whether these interventions are effective in stroke patients. DESIGN Systematic meta-review of the evidence for self-management support interventions with stroke survivors to inform provision of healthcare services. METHODS We searched MEDLINE, EMBASE, CINAHL, PsychINFO, AMED, BNI, Database of Abstracts of Reviews for Effectiveness, and Cochrane Database of Systematic Reviews for systematic reviews of self-management support interventions for stroke survivors. Quality was assessed using the R-AMSTAR tool, and data extracted using a customised data extraction form. We undertook a narrative synthesis of the reviews' findings. RESULTS From 12,400 titles we selected 13 systematic reviews (published 2003-2012) representing 101 individual trials. Although the term 'self-management' was rarely used, key elements of self-management support such as goal setting, action planning, and problem solving were core components of therapy rehabilitation interventions. We found high quality evidence that supported self-management in the context of therapy rehabilitation delivered soon after the stroke event resulted in short-term (< 1 year) improvements in basic and extended activities of daily living, and a reduction in poor outcomes (dependence/death). There is some evidence that rehabilitation and problem solving interventions facilitated reintegration into the community. CONCLUSIONS Self-management terminology is rarely used in the context of stroke. However, therapy rehabilitation currently successfully delivers elements of self-management support to stroke survivors and their caregivers with improved outcomes. Future research should focus on managing the emotional, medical and social tasks of long-term survivorship.
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Affiliation(s)
- Hannah L. Parke
- Multidisciplinary Evidence Synthesis Hub (mEsh), Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, United Kingdom
| | - Eleni Epiphaniou
- Multidisciplinary Evidence Synthesis Hub (mEsh), Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, United Kingdom
| | - Gemma Pearce
- Centre for Technology Enabled Health Research (CTEHR), Coventry University, Coventry, United Kingdom
| | - Stephanie J. C. Taylor
- Multidisciplinary Evidence Synthesis Hub (mEsh), Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, United Kingdom
| | - Aziz Sheikh
- Usher Institute of Medical Informatics and Population Health Sciences, The University of Edinburgh, Edinburgh, United Kingdom
| | - Chris J. Griffiths
- Multidisciplinary Evidence Synthesis Hub (mEsh), Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, United Kingdom
| | - Trish Greenhalgh
- Nuffield Department of Primary Care Health Sciences, Medical Sciences division, University of Oxford, Oxford, United Kingdom
| | - Hilary Pinnock
- Usher Institute of Medical Informatics and Population Health Sciences, The University of Edinburgh, Edinburgh, United Kingdom
- * E-mail:
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Pergolotti M, Deal AM, Lavery J, Reeve BB, Muss HB. The prevalence of potentially modifiable functional deficits and the subsequent use of occupational and physical therapy by older adults with cancer. J Geriatr Oncol 2015; 6:194-201. [PMID: 25614296 PMCID: PMC4459887 DOI: 10.1016/j.jgo.2015.01.004] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 10/30/2014] [Accepted: 01/06/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Occupational and physical therapy (OT/PT) services seek to reduce morbidity, mortality, and improve the quality of life of individuals; however, little is known about the needs and use of OT/PT for older adults with cancer. The goal of this study was to describe the functional deficits and their associations with other factors, and to examine the use of OT/PT after a noted functional deficit. MATERIALS AND METHODS This study analyzed data from an institution-based registry that included geriatric assessments of older adults with cancer linked to billing claims data. Logistic regression was used to model predictors of functional deficits. Use of OT/PT was determined and validated with medical chart review. RESULTS 529 patients with cancer, a median age of 71, 78% were female, 87% Caucasian, 57% married, 53% post-secondary education, and 63% with breast cancer were included. In a multivariable model, the odds of having any functional deficits increased with age [5 year OR: 1.31, 95% CI: (1.10, 1.57)] were higher for those with a high school diploma versus those with advanced degrees [OR: 1.66, 95% CI: (1.00, 2.77)] and were higher for patients with comorbidities [OR: 1.15, 95% CI: (1.10, 1.21)]. Of patients with functional deficits only 9% (10/111) received OT/PT within 12 months of a noted deficit. DISCUSSION The odds of having any potentially modifiable functional deficit were higher in patients with increasing age, comorbid conditions, and with less than a college degree. Few were referred for OT/PT services suggesting major underutilization of these potentially beneficial services.
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Affiliation(s)
- Mackenzi Pergolotti
- Cancer Care Quality Training Program, Department of Health Policy and Management, 1102G McGavran-Greenberg Hall, CB# 7411, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
| | - Allison M Deal
- Biostatistics and Clinical Data Management Core, University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, 450 West Drive, CB#7295, Chapel Hill, NC 27599, USA.
| | - Jessica Lavery
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, 630 West 168th Street, New York, NY 10032, USA.
| | - Bryce B Reeve
- Department of Health Policy and Management, 1101D McGavran-Greenberg Hall, Campus Box 7411, UNC Gillings School of Global Public Health, 135 Dauer Drive, Chapel Hill, NC 27599, USA.
| | - Hyman B Muss
- Department of Geriatric Oncology, University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, 170 Manning Drive, Chapel Hill, NC 27599, USA.
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Whitehead PJ, Worthington EJ, Parry RH, Walker MF, Drummond AER. Interventions to reduce dependency in personal activities of daily living in community dwelling adults who use homecare services: a systematic review. Clin Rehabil 2015; 29:1064-76. [PMID: 25587088 PMCID: PMC4607918 DOI: 10.1177/0269215514564894] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 11/29/2014] [Indexed: 11/30/2022]
Abstract
Objectives: To identify interventions that aim to reduce dependency in activities of daily living (ADL) in homecare service users. To determine: content; effectiveness in improving ability to perform ADL; and whether delivery by qualified occupational therapists influences effectiveness. Data sources: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, AMED, CINAHL, PsycINFO, OTseeker, PEDro, Web of Science, CIRRIE, and ASSIA. Review methods: We included: randomised controlled trials, non-randomised controlled trials and controlled before and after studies. Two reviewers independently screened studies for inclusion, assessed risk of bias and extracted data. A narrative synthesis of the findings was conducted. Results: Thirteen studies were included, totalling 4975 participants. Ten (77%) were judged to have risk of bias. Interventions were categorised as those termed ‘re-ablement’ or ‘restorative homecare’ (n=5/13); and those involving separate components which were not described using this terminology (n=8/13). Content of the intervention and level of health professional input varied within and between studies. Effectiveness on ADL: eight studies included an ADL outcome, five favoured the intervention group, only two with statistical significance, both these were controlled before and after studies judged at high risk of bias. ADL outcome was reported using seven different measures. Occupational therapy: there was insufficient evidence to determine whether involvement of qualified occupational therapists influenced effectiveness. Conclusion: There is limited evidence that interventions targeted at personal ADL can reduce homecare service users’ dependency with activities, the content of evaluated interventions varies greatly.
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Affiliation(s)
| | | | - Ruth H Parry
- Faculty of Medicine and Health Sciences, University of Nottingham, UK
| | - Marion F Walker
- Faculty of Medicine and Health Sciences, University of Nottingham, UK
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Wolf TJ, Chuh A, Floyd T, McInnis K, Williams E. Effectiveness of occupation-based interventions to improve areas of occupation and social participation after stroke: an evidence-based review. Am J Occup Ther 2015; 69:6901180060p1-11. [PMID: 25553745 PMCID: PMC4281705 DOI: 10.5014/ajot.2015.012195] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This evidence-based review examined the evidence supporting the use of occupation-based interventions to improve areas of occupation and social participation poststroke. A total of 39 studies met the inclusion criteria and were critically evaluated. Most of the literature targeted activity of daily living (ADL)-based interventions and collectively provided strong evidence for the use of occupation-based interventions to improve ADL performance. The evidence related to instrumental ADLs was much more disparate, with limited evidence to support the use of virtual reality interventions and emerging evidence to support driver education programs to improve occupational performance poststroke. Only 6 studies addressed leisure, social participation, or rest and sleep, with sufficient evidence to support only leisure-based interventions. The implications of this review for research, education, and practice in occupational therapy are also discussed.
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Affiliation(s)
- Timothy J Wolf
- Timothy J. Wolf, OTD, MSCI, OTR/L, is Assistant Professor, Program in Occupational Therapy and Department of Neurology, School of Medicine, Washington University, St. Louis, MO;
| | - Adrianna Chuh
- Adrianna Chuh, MSOT, is Graduate Student, Program in Occupational Therapy, School of Medicine, Washington University, St. Louis, MO
| | - Tracy Floyd
- Tracy Floyd, MS, OTR/L, is Battalion Rehab Manager, U.S. Army, Warrior Transition Battalion, Fort Belvoir, VA
| | - Karen McInnis
- Karen McInnis, MSOT, is Graduate Student, Program in Occupational Therapy, School of Medicine, Washington University, St. Louis, MO
| | - Elizabeth Williams
- Elizabeth Williams, MSOT, is Graduate Student, Program in Occupational Therapy, School of Medicine, Washington University, St. Louis, MO
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Müller C, Glässel A, Marotzki U, Voigt-Radloff S. [Potential analyses for research on occupational therapy-led training of activities of daily living in stroke patients]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2014; 108 Suppl 1:S36-44. [PMID: 25458397 DOI: 10.1016/j.zefq.2014.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 09/04/2014] [Accepted: 09/04/2014] [Indexed: 11/26/2022]
Abstract
HEALTH PROBLEM Every year about 200,000 people in Germany suffer from a first stroke and 65,000 persons from a recurrent stroke. Stroke is one of the major causes of acquired life-long disability. It is associated with multiple limitations in functioning, activities of daily living and social participation. People with stroke must develop and apply considerable coping and adaptation strategies to manage the consequences of disabilities in daily life. Insufficient adaptations may result in social isolation, depressive disorders, need for medical and nursing care and subsequently lead to increasing costs for care. Thus occupational therapy-led treatment addressing social participation as well as skills training, adaptation strategies and assistive technology for activities of daily living is essential for stroke patients after hospital discharge. CORPUS OF EVIDENCE Based on nine randomised comparisons, a Cochrane review from 2006 revealed that occupational therapy-led training after stroke had positive effects on personal activities of daily living (8 studies; 961 participants; 0.18 SMD; 95 % CI [0.04 to 0.32]), on extended activities of daily living (6 studies; 847 participants; 0.21 SMD; 95 % CI [0.03 to 0.39]), and on poor outcome (7 studies; 1,065 participants; odds ratio 0.67; 95 % CI [0.51 to 0.87]). However, direct implementation into the German healthcare context is not recommendable due to (1) different settings and heterogeneity within the primary studies, (2) lack of manualisation of treatment programmes and (3) insufficient evaluation of client-oriented outcomes. IMPLICATION FOR RESEARCH It is recommended to manualise client-centred standardised modules of a stage-specific occupational therapy-led training of activities of daily living and to pilot-test this intervention programme in a feasibility study. If this trial results in a set of reliable and valid client-oriented outcome measurements applicable within the German care context and in a feasible treatment programme well accepted by stroke patients and their treating occupational therapists, a large-scaled randomised clinical trial in terms of comparative effectiveness research may follow.
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Affiliation(s)
- Christian Müller
- Medizinische Psychologie und Medizinische Soziologie, Medizinische Fakultät, Albert-Ludwigs-Universität, Freiburg, Deutschland; Berufsakademie für Gesundheits- und Sozialwesen Saarland, Saarbrücken, Deutschland.
| | - Andrea Glässel
- Swiss Paraplegic Research, Human Functioning Sciences, Nottwil, Schweiz
| | - Ulrike Marotzki
- Hochschule für angewandte Wissenschaft und Kunst Hildesheim/Holzminden/Göttingen, Deutschland
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Whitehead PJ, Drummond AER, Walker MF, Parry RH, McGeorge ID, Latif Z. Occupational Therapy in HomEcare Re-ablement Services (OTHERS): study protocol for a randomized controlled trial. Trials 2014; 15:447. [PMID: 25406858 PMCID: PMC4247640 DOI: 10.1186/1745-6215-15-447] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 11/07/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Homecare re-ablement services have been developed by local authorities in England in response to the government agenda for health and social care. These services aim to optimize users' independence and ability to cope at home, and reduce the need for ongoing health and social care services. However, there is currently limited evidence and guidance regarding the optimum configuration and delivery of re-ablement services. In particular, the impact of occupational therapy input on service user outcomes has been highlighted as a specific research priority. METHODS/DESIGN This feasibility randomized controlled trial (RCT) will recruit 50 people from one local authority led homecare re-ablement service in England. Those who provide informed consent will be randomized to receive either usual homecare re-ablement (without routine occupational therapy input) or usual homecare re-ablement plus an enhanced program targeted at activities of daily living (ADL), delivered by an occupational therapist. The primary aim of this study is to assess the feasibility of conducting a further, powered study. The participant outcomes assessed will be independence in personal and extended ADL, health and social care-related quality of life, number of care support hours, falls, acute and residential admissions and use of health and social care services. These will be assessed at two weeks, three months and six months post-discharge from the re-ablement service. DISCUSSION To our knowledge, this is the first RCT of occupational therapy in homecare re-ablement services. The results of this study will lay the foundations for a further powered study. The findings will be relevant to researchers, clinicians, commissioners and users of adult social care services. TRIAL REGISTRATION Current Controlled Trials registration number: ISRCTN21710246 (registered on 31March 2014).
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Affiliation(s)
- Phillip J Whitehead
- Division of Rehabilitation and Ageing, University of Nottingham, B Floor, The Medical School, Queens Medical Centre, Derby Road, Nottingham NG7 2UH, UK.
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Pollock A, Farmer SE, Brady MC, Langhorne P, Mead GE, Mehrholz J, van Wijck F. Interventions for improving upper limb function after stroke. Cochrane Database Syst Rev 2014; 2014:CD010820. [PMID: 25387001 PMCID: PMC6469541 DOI: 10.1002/14651858.cd010820.pub2] [Citation(s) in RCA: 346] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Improving upper limb function is a core element of stroke rehabilitation needed to maximise patient outcomes and reduce disability. Evidence about effects of individual treatment techniques and modalities is synthesised within many reviews. For selection of effective rehabilitation treatment, the relative effectiveness of interventions must be known. However, a comprehensive overview of systematic reviews in this area is currently lacking. OBJECTIVES To carry out a Cochrane overview by synthesising systematic reviews of interventions provided to improve upper limb function after stroke. METHODS SEARCH METHODS We comprehensively searched the Cochrane Database of Systematic Reviews; the Database of Reviews of Effects; and PROSPERO (an international prospective register of systematic reviews) (June 2013). We also contacted review authors in an effort to identify further relevant reviews. SELECTION CRITERIA We included Cochrane and non-Cochrane reviews of randomised controlled trials (RCTs) of patients with stroke comparing upper limb interventions with no treatment, usual care or alternative treatments. Our primary outcome of interest was upper limb function; secondary outcomes included motor impairment and performance of activities of daily living. When we identified overlapping reviews, we systematically identified the most up-to-date and comprehensive review and excluded reviews that overlapped with this. DATA COLLECTION AND ANALYSIS Two overview authors independently applied the selection criteria, excluding reviews that were superseded by more up-to-date reviews including the same (or similar) studies. Two overview authors independently assessed the methodological quality of reviews (using a modified version of the AMSTAR tool) and extracted data. Quality of evidence within each comparison in each review was determined using objective criteria (based on numbers of participants, risk of bias, heterogeneity and review quality) to apply GRADE (Grades of Recommendation, Assessment, Development and Evaluation) levels of evidence. We resolved disagreements through discussion. We systematically tabulated the effects of interventions and used quality of evidence to determine implications for clinical practice and to make recommendations for future research. MAIN RESULTS Our searches identified 1840 records, from which we included 40 completed reviews (19 Cochrane; 21 non-Cochrane), covering 18 individual interventions and dose and setting of interventions. The 40 reviews contain 503 studies (18,078 participants). We extracted pooled data from 31 reviews related to 127 comparisons. We judged the quality of evidence to be high for 1/127 comparisons (transcranial direct current stimulation (tDCS) demonstrating no benefit for outcomes of activities of daily living (ADLs)); moderate for 49/127 comparisons (covering seven individual interventions) and low or very low for 77/127 comparisons.Moderate-quality evidence showed a beneficial effect of constraint-induced movement therapy (CIMT), mental practice, mirror therapy, interventions for sensory impairment, virtual reality and a relatively high dose of repetitive task practice, suggesting that these may be effective interventions; moderate-quality evidence also indicated that unilateral arm training may be more effective than bilateral arm training. Information was insufficient to reveal the relative effectiveness of different interventions.Moderate-quality evidence from subgroup analyses comparing greater and lesser doses of mental practice, repetitive task training and virtual reality demonstrates a beneficial effect for the group given the greater dose, although not for the group given the smaller dose; however tests for subgroup differences do not suggest a statistically significant difference between these groups. Future research related to dose is essential.Specific recommendations for future research are derived from current evidence. These recommendations include but are not limited to adequately powered, high-quality RCTs to confirm the benefit of CIMT, mental practice, mirror therapy, virtual reality and a relatively high dose of repetitive task practice; high-quality RCTs to explore the effects of repetitive transcranial magnetic stimulation (rTMS), tDCS, hands-on therapy, music therapy, pharmacological interventions and interventions for sensory impairment; and up-to-date reviews related to biofeedback, Bobath therapy, electrical stimulation, reach-to-grasp exercise, repetitive task training, strength training and stretching and positioning. AUTHORS' CONCLUSIONS Large numbers of overlapping reviews related to interventions to improve upper limb function following stroke have been identified, and this overview serves to signpost clinicians and policy makers toward relevant systematic reviews to support clinical decisions, providing one accessible, comprehensive document, which should support clinicians and policy makers in clinical decision making for stroke rehabilitation.Currently, no high-quality evidence can be found for any interventions that are currently used as part of routine practice, and evidence is insufficient to enable comparison of the relative effectiveness of interventions. Effective collaboration is urgently needed to support large, robust RCTs of interventions currently used routinely within clinical practice. Evidence related to dose of interventions is particularly needed, as this information has widespread clinical and research implications.
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Affiliation(s)
- Alex Pollock
- Glasgow Caledonian UniversityNursing, Midwifery and Allied Health Professions Research UnitBuchanan HouseCowcaddens RoadGlasgowUKG4 0BA
| | - Sybil E Farmer
- Glasgow Caledonian UniversityNursing, Midwifery and Allied Health Professions Research UnitBuchanan HouseCowcaddens RoadGlasgowUKG4 0BA
| | - Marian C Brady
- Glasgow Caledonian UniversityNursing, Midwifery and Allied Health Professions Research UnitBuchanan HouseCowcaddens RoadGlasgowUKG4 0BA
| | - Peter Langhorne
- University of GlasgowAcademic Section of Geriatric MedicineLevel 2, New Lister BuildingGlasgow Royal InfirmaryGlasgowUKG31 2ER
| | - Gillian E Mead
- University of EdinburghCentre for Clinical Brain SciencesRoom S1642, Royal InfirmaryLittle France CrescentEdinburghUKEH16 4SA
| | - Jan Mehrholz
- Private Europäische Medizinische Akademie der Klinik Bavaria in Kreischa GmbHWissenschaftliches InstitutAn der Wolfsschlucht 1‐2KreischaGermany01731
| | - Frederike van Wijck
- Glasgow Caledonian UniversityInstitute for Applied Health Research and the School of Health and Life SciencesGlasgowUK
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Abstract
BACKGROUND Interventions to improve driving ability after stroke, including driving simulation and retraining visual skills, have limited evaluation of their effectiveness to guide policy and practice. OBJECTIVES To determine whether any intervention, with the specific aim of maximising driving skills, improves the driving performance of people after stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials register (August 2013), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 3), MEDLINE (1950 to October 2013), EMBASE (1980 to October 2013), and six additional databases. To identify further published, unpublished and ongoing trials, we handsearched relevant journals and conference proceedings, searched trials and research registers, checked reference lists and contacted key researchers in the area. SELECTION CRITERIA Randomised controlled trials (RCTs), quasi-randomised trials and cluster studies of rehabilitation interventions, with the specific aim of maximising driving skills or with an outcome of assessing driving skills in adults after stroke. The primary outcome of interest was the performance in an on-road assessment after training. SECONDARY OUTCOMES included assessments of vision, cognition and driving behaviour. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials based on pre-defined inclusion criteria, extracted the data and assessed risk of bias. A third review author moderated disagreements as required. The review authors contacted all investigators to obtain missing information. MAIN RESULTS We included four trials involving 245 participants in the review. Study sample sizes were generally small, and interventions, controls and outcome measures varied, and thus it was inappropriate to pool studies. Included studies were at a low risk of bias for the majority of domains, with a high/unclear risk of bias identified in the areas of: performance (participants not blinded to allocation), and attrition (incomplete outcome data due to withdrawal) bias. Intervention approaches included the contextual approach of driving simulation and underlying skill development approach, including the retraining of speed of visual processing and visual motor skills. The studies were conducted with people who were relatively young and the timing after stroke was varied. PRIMARY OUTCOME there was no clear evidence of improved on-road scores immediately after training in any of the four studies, or at six months (mean difference 15 points on the Test Ride for Investigating Practical Fitness to Drive - Belgian version, 95% confidence intervals (CI) 4.56 to 34.56, P value = 0.15, one study, 83 participants). SECONDARY OUTCOMES road sign recognition was better in people who underwent training compared with control (mean difference 1.69 points on the Road Sign Recognition Task of the Stroke Driver Screening Assessment, 95% CI 0.51 to 2.87, P value = 0.007, one study, 73 participants). Significant findings were in favour of a simulator-based driving rehabilitation programme (based on one study with 73 participants) but these results should be interpreted with caution as they were based on a single study. Adverse effects were not reported. There was insufficient evidence to draw conclusions on the effects on vision, other measures of cognition, motor and functional activities, and driving behaviour with the intervention. AUTHORS' CONCLUSIONS There was insufficient evidence to reach conclusions about the use of rehabilitation to improve on-road driving skills after stroke. We found limited evidence that the use of a driving simulator may be beneficial in improving visuocognitive abilities, such as road sign recognition that are related to driving. Moreover, we were unable to find any RCTs that evaluated on-road driving lessons as an intervention. At present, it is unclear which impairments that influence driving ability after stroke are amenable to rehabilitation, and whether the contextual or remedial approaches, or a combination of both, are more efficacious.
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Affiliation(s)
- Stacey George
- Flinders UniversityDepartment of Rehabilitation, Aged and Extended CareDaws RoadDaw ParkAustralia5041
| | - Maria Crotty
- Flinders University, Repatriation General HospitalDepartment of Rehabilitation and Aged CareDaws RoadDaw ParkAustralia5042
| | - Isabelle Gelinas
- McGill UniversitySchool of Physical and Occupational Therapy3654 Promenade Sir‐William‐OslerMontrealCanadaH3G 1Y5
| | - Hannes Devos
- Georgia Regents UniversityDepartment of Physical Therapy1120 15th StreetEC‐1304AugustaUSA30912
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30
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Abstract
Stroke is a major cause of death and disability. International and national guidelines are available to help clinicians provide evidence-based care for stroke prevention, acute treatment, and rehabilitation. Stroke is a medical emergency and rapid assessment is needed to establish the diagnosis, identify the underlying cause, provide acute treatment, and prevent complications. Although stroke is a clinical diagnosis based upon a history of sudden onset of neurological symptoms, which include unilateral weakness or sensory loss, dysphasia, hemianopia, inattention, and reduced coordination, brain imaging with CT or MRI scan is needed to distinguish cerebral infarction from primary intracerebral haemorrhage. Stroke units are the cornerstones of stroke care and should be available to all stroke patients throughout their inpatient stay. Multidisciplinary stroke care should address the physical, psychological, and social consequences of stroke and consider the needs of both patients and carers. Good communication with patients and carers and between members of the multidisciplinary team is fundamental to quality care. Ongoing assessment and treatment may be needed for: dysphagia; nutrition and hydration; continence and skin care; mobility and upper limb function; comprehension and communication; concentration and memory; spatial awareness and inattention; mood; pain and spasticity. Patients and carers should be fully informed about the diagnosis, prognosis, treatment and available care. Discharge requires careful planning and consultation. Early supported discharge can improve outcome for carefully selected patients. It is important to recognize and address the long-term needs in order to maximize choice, independence, and wellbeing. Targeted rehabilitation to address issues such as mobility and leisure may be effective.
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Affiliation(s)
- Helen Rodgers
- Institute of Ageing and Health, Medical School, Newcastle upon Tyne, UK.
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Whitehead PJ, Drummond AEE, Walker MF, Parry RH. Interventions to reduce dependency in personal activities of daily living in community-dwelling adults who use homecare services: protocol for a systematic review. Syst Rev 2013; 2:49. [PMID: 23816279 PMCID: PMC3706298 DOI: 10.1186/2046-4053-2-49] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 06/21/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There is a growing demand for services whereby individuals receive assistance from care workers for personal care within the home. This has led to the development of re-ablement or restorative homecare services that provide time-limited input aimed at reducing dependency in personal activities of daily living, and preventing or delaying the need for further homecare support. However, little is currently known about how such interventions are configured, or how they may affect individuals' ability to carry out personal care independently. METHODS/DESIGN We will seek to identify studies that compare an intervention designed to reduce dependency in personal activities of daily living with routine input or usual care as the control. We will include randomised controlled trials, nonrandomised controlled trials, and controlled before and after studies. We will also include interrupted time series studies. We shall search electronic databases in addition to searching for ongoing and unpublished studies, and where appropriate will contact key authors. Two reviewers will independently screen articles for inclusion; will assess risk of bias using quality assessment tools; and will carry out data extraction using pre-prepared forms. Any disagreements, at any stage, will be resolved by discussion and the involvement of a third reviewer if needed. We will produce a narrative summary of the results. A meta-analysis will be conducted if sufficient data are available of appropriate quality and comparability. DISCUSSION The findings from this review will inform future practice within homecare re-ablement services; will inform policy decisions about the structure, organisation and content of such services; and will identify areas where further research is warranted. TRIAL REGISTRATION This review protocol has been registered on the PROSPERO database (CRD42013004163).
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Affiliation(s)
- Phillip J Whitehead
- Division of Rehabilitation and Ageing, University of Nottingham, B Floor, The Medical School, Queens Medical Centre, Nottingham NG7 2UH, UK.
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Fletcher-Smith JC, Walker MF, Cobley CS, Steultjens EMJ, Sackley CM. Occupational therapy for care home residents with stroke. Cochrane Database Syst Rev 2013; 2013:CD010116. [PMID: 23740541 PMCID: PMC6464854 DOI: 10.1002/14651858.cd010116.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Stroke is a worldwide problem and is a leading cause of adult disability, resulting in dependency in activities of daily living (ADL) for around half of stroke survivors. It is estimated that up to 25% of all care home residents in the USA and in the UK have had a stroke. Stroke survivors who reside in care homes are likely to be more physically and cognitively impaired and therefore more dependent than those able to remain in their own home. Overall, 75% of care home residents are classified as severely disabled, and those with stroke are likely to have high levels of immobility, incontinence and confusion, as well as additional co-morbidities. It is not known whether this clinically complex population could benefit from occupational therapy in the same way as community-dwelling stroke survivors. The care home population with stroke differs from the general stroke population living at home, and a review was needed to examine the benefits of occupational therapy provided to this specific group. This review therefore focused on occupational therapy interventions for ADL for stroke survivors residing in care homes. OBJECTIVES To measure the effects of occupational therapy interventions (provided directly by an occupational therapist or under the supervision of an occupational therapist) targeted at improving, restoring and maintaining independence in ADL among stroke survivors residing in long-term institutional care, termed collectively as 'care homes'. As a secondary objective, we aimed to evaluate occupational therapy interventions for reducing complications such as depression and low mood. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (August 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, September 2012), MEDLINE (1948 to September 2012), EMBASE (1980 to September 2012), CINAHL (1982 to September 2012) and 10 additional bibliographic databases and six trials registers. We also handsearched seven journals, checked reference lists and obtained further information from individual trialists. SELECTION CRITERIA Randomised controlled trials investigating the impact of an occupational therapy intervention for care home residents with stroke versus standard care. DATA COLLECTION AND ANALYSIS The lead review author performed all searches. Two review authors then independently assessed all titles and abstracts of studies and selected trials for inclusion, with a third review author resolving any discrepancies. The same two review authors independently extracted data from all included published sources to ensure reliability. Primary outcomes were performance in ADL at the end of scheduled follow-up and death or a poor outcome. Secondary outcomes aimed to reflect the domains targeted by an occupational therapy intervention. MAIN RESULTS We included in the review one study involving 118 participants. We found one ongoing study that also met the inclusion criteria for the review, but the data were not yet available. AUTHORS' CONCLUSIONS We found insufficient evidence to support or refute the efficacy of occupational therapy interventions for improving, restoring or maintaining independence in ADL for stroke survivors residing in care homes. The effectiveness of occupational therapy for the population of stroke survivors residing in care homes remains unclear, and further research in this area is warranted.
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Wales K, Clemson L, Lannin NA, Cameron ID. Functional assessments used by occupational therapists with older adults at risk of activity and participation limitations: a systematic review and evaluation of measurement properties. Syst Rev 2012; 1:45. [PMID: 23067564 PMCID: PMC3582570 DOI: 10.1186/2046-4053-1-45] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Accepted: 09/24/2012] [Indexed: 11/21/2022] Open
Abstract
UNLABELLED BACKGROUND Older adults experience activity and participation limitations that are associated with ageing. Activity and participation limitations affect an older adult's ability to engage in meaningful daily activities and valued life roles. Occupational therapists provide interventions to reduce such limitations and monitor client change to ensure that interventions are effective. Client change should be measured through the use of valid and reliable assessments. Yet occupational therapists can favour the use of non-standardised assessments leading to inaccurate reflections of client change and difficulties in comparing the effectiveness of interventions. A number of reasons have been suggested as to why therapists may favour non-standardised assessments, including a lack of knowledge (of assessments and their properties) and lack of skill. METHODS/DESIGN This paper describes the systematic review protocol that will be used to identify functional assessments used in randomised trials of occupational therapy interventions for older adults (≥70 years of age). Interventions will focus on enhancing functional independence for either older adults transitioning from hospital to home, or community dwelling older adults. We will search Medline, EBSCO and OTseeker using a pre-determined search strategy to identify Functional assessments. These assessments will be recorded and, in phase two, their measurement properties analysed. DISCUSSION This protocol provides a comprehensive guideline for conducting the proposed systematic review. The results of this systematic review will provide a thorough and unbiased identification and evaluation of measurement properties of functional assessment tools used in randomised trials to evaluate occupational therapy intervention. This information can be used to determine which assessment has superior measurement properties and will inform occupational therapy practice.
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Affiliation(s)
- Kylie Wales
- Ageing Work and Health Research Unit and The Centre for Excellence in Population Ageing Research, Faculty of Health Sciences, The University of Sydney, PO BOX 170, Lidcombe, NSW, 2141, Australia
| | - Lindy Clemson
- Ageing Work and Health Research Unit and The Centre for Excellence in Population Ageing Research, Faculty of Health Sciences, The University of Sydney, PO BOX 170, Lidcombe, NSW, 2141, Australia
| | - Natasha A Lannin
- Occupational Therapy Department, Alfred Health, and Faculty of Health Sciences, Alfred Clinical School, La Trobe University, The Alfred, 55 Commercial Road, Prahran, VIC, 3181, Australia
| | - Ian D Cameron
- Rehabilitation Studies Unit, Sydney Medical School, The University of Sydney, PO BOX 6, Sydney, NSW, 2112, Australia
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Systematic reviews identify important methodological flaws in stroke rehabilitation therapy primary studies: review of reviews. J Clin Epidemiol 2012; 65:358-67. [PMID: 22360987 DOI: 10.1016/j.jclinepi.2011.10.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 10/17/2011] [Accepted: 10/30/2011] [Indexed: 11/22/2022]
Abstract
OBJECTIVE A "review of reviews" was undertaken to assess methodological issues in studies evaluating nondrug rehabilitation interventions in stroke patients. STUDY DESIGN AND SETTING MEDLINE, CINAHL, PsycINFO, and the Cochrane Database of Systematic Reviews were searched from January 2000 to January 2008 within the stroke rehabilitation setting. Electronic searches were supplemented by reviews of reference lists and citations identified by experts. Eligible studies were systematic reviews; excluded citations were narrative reviews or reviews of reviews. Review characteristics and criteria for assessing methodological quality of primary studies within them were extracted. RESULTS The search yielded 949 English-language citations. We included a final set of 38 systematic reviews. Cochrane reviews, which have a standardized methodology, were generally of higher methodological quality than non-Cochrane reviews. Most systematic reviews used standardized quality assessment criteria for primary studies, but not all were comprehensive. Reviews showed that primary studies had problems with randomization, allocation concealment, and blinding. Baseline comparability, adverse events, and co-intervention or contamination were not consistently assessed. Blinding of patients and providers was often not feasible and was not evaluated as a source of bias. CONCLUSIONS The eligible systematic reviews identified important methodological flaws in the evaluated primary studies, suggesting the need for improvement of research methods and reporting.
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Kristensen HK, Borg T, Hounsgaard L. Facilitation of Research-Based Evidence within Occupational Therapy in Stroke Rehabilitation. Br J Occup Ther 2011. [DOI: 10.4276/030802211x13182481841949] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose: This study investigated the facilitation of evidence-based practice with the use of everyday life occupations and client-centred practice within occupational therapy in three settings of stroke rehabilitation. Method: The study was based on a phenomenological hermeneutical research approach, and inspired by participatory action research methods. Participant observations, focus group discussions and individual interviews took place over a period of 20 months. Text interpretation, developed by Ricoeur, was used in data analysis. Findings: The key role of the facilitator in the implementation of evidence-based practice as a change process was stressed. During the implementation, it was crucial that the therapists as a group had the opportunity to discuss local practice knowledge, and to appraise the knowledge use critically, in order to develop their practice knowledge and new skills adapted to local contexts. The implementation resulted in various new working routines. Learning processes became part of developing the occupational therapists' professional identities, expressed in more professional confidence. Collaboration in the organisation of the implementation process was significant. Conclusion: The main findings indicated that the use of participatory action research methods and theory of situated learning interacting with the Promoting Action on Research Implementation in Health Services framework provided useful perspectives and structures for the investigation of the implementation of evidence-based occupational therapy.
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Affiliation(s)
- Hanne Kaae Kristensen
- Head Research Therapist, Rehabilitation Unit, Odense University Hospital, Odense, Denmark
| | - Tove Borg
- Senior Scientist and Occupational Therapist, Research Unit for Neurorehabilitation, Hammel, Denmark
| | - Lise Hounsgaard
- Associate Professor, Research Unit of Nursing, University of Southern Denmark, Institute of Clinical Research, Odense, Denmark
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Abstract
Stroke is a common, serious, and disabling global health-care problem, and rehabilitation is a major part of patient care. There is evidence to support rehabilitation in well coordinated multidisciplinary stroke units or through provision of early supported provision of discharge teams. Potentially beneficial treatment options for motor recovery of the arm include constraint-induced movement therapy and robotics. Promising interventions that could be beneficial to improve aspects of gait include fitness training, high-intensity therapy, and repetitive-task training. Repetitive-task training might also improve transfer functions. Occupational therapy can improve activities of daily living; however, information about the clinical effect of various strategies of cognitive rehabilitation and strategies for aphasia and dysarthria is scarce. Several large trials of rehabilitation practice and of novel therapies (eg, stem-cell therapy, repetitive transcranial magnetic stimulation, virtual reality, robotic therapies, and drug augmentation) are underway to inform future practice.
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Affiliation(s)
- Peter Langhorne
- Academic Section of Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Royal Infirmary, Glasgow, UK.
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Bowen A, Knapp P, Gillespie D, Nicolson DJ, Vail A. Non-pharmacological interventions for perceptual disorders following stroke and other adult-acquired, non-progressive brain injury. Cochrane Database Syst Rev 2011; 2011:CD007039. [PMID: 21491397 PMCID: PMC6465074 DOI: 10.1002/14651858.cd007039.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Stroke and other adult-acquired brain injury may impair perception leading to distress and increased dependence on others. Perceptual rehabilitation includes functional training, sensory stimulation, strategy training and task repetition. OBJECTIVES To examine the evidence for improvement in activities of daily living (ADL) six months post randomisation for active intervention versus placebo or no treatment. SEARCH STRATEGY We searched the trials registers of the Cochrane Stroke Group and the Cochrane Infectious Diseases Group (May 2009) but not the Injuries Group, the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 3), MEDLINE (1950 to August 2009), EMBASE (1980 to August 2009), CINAHL (1982 to August 2009), PsycINFO (1974 to August 2009), REHABDATA and PsycBITE (May to June 2009). We also searched trials and research registers, handsearched journals, searched reference lists and contacted authors. SELECTION CRITERIA Randomised controlled trials of adult stroke or acquired brain injury. Our definition of perception excluded visual field deficits, neglect/inattention and apraxia. DATA COLLECTION AND ANALYSIS One review author assessed titles, abstracts and keywords for eligibility. At least two review authors independently extracted data. We requested unclear or missing information from corresponding authors. MAIN RESULTS We included six single-site trials in rehabilitation settings, involving 338 participants. Four trials included people with only stroke. All studies provided sensory stimulation, sometimes with another intervention. Sensory stimulation typically involved practising tasks that required visuo-perceptual processing with occupational therapist assistance. Repetition was never used and only one study included functional training. No trials provided data on longer term improvement in ADL scores. Only three trials provided any data suitable for analysis. Two of these trials compared active to placebo intervention. There was no evidence of a difference in ADL scores at the scheduled end of intervention: mean difference (95% confidence interval (CI)) was 0.9 (-1.6 to 3.5) points on a self-care ADL scale in one study and odds ratio (95% CI) was 1.3 (0.56 to 3.1) for passing a driving test in the other, both in favour of active intervention. The trial that compared two active interventions did not find evidence of difference in any of the review outcomes. AUTHORS' CONCLUSIONS There is insufficient evidence to support or refute the view that perceptual interventions are effective. Future studies should be sufficiently large, include a standard care comparison and measure longer term functional outcomes. People with impaired perception problems should continue to receive neurorehabilitation according to clinical guidelines.
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Affiliation(s)
- Audrey Bowen
- University of ManchesterHCD, School of Psychological Sciences, Ellen Wilkinson BuildingOxford RoadManchesterUKM13 9PL
| | - Peter Knapp
- University of LeedsSchool of HealthcareLeedsUKLS2 9LN
| | - David Gillespie
- Astley Ainslie HospitalDepartment of Neuropsychology133 Grange LoanEdinburghUKEH9 2HL
| | - Donald J Nicolson
- University of DundeeThe Health Informatics Centre, Division of Clinical & Population Sciences & EducationThe Mackenzie BuildingKirsty Semple WayDundeeUKDD2 4BF
| | - Andy Vail
- University of ManchesterHealth Methodology Research GroupR & D Support Unit, Salford Royal HospitalStott LaneSalfordUKM6 8HD
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Affiliation(s)
- Kate Laver
- Department of Rehabilitation and Aged Care, Flinders University, Daw Park, South Australia, Australia
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Abstract
BACKGROUND Cognitive impairment is a frequent consequence of stroke and can impact on a person's ability to perform everyday activities. There are a number of different intervention strategies that occupational therapists may use when working with people who have cognitive impairment post-stroke. OBJECTIVES To determine whether occupational therapy improves functional performance of basic activities of daily living (ADL) and specific cognitive abilities in people who have cognitive impairment following a stroke. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (last searched May 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2009), MEDLINE (1966 to April 2009), EMBASE (1980 to April 2009), CINAHL (1982 to April 2009), PsycINFO (1840 to April 2009), PsycBITE, OTseeker and Dissertation Abstracts (the latest three were searched up to April 2009). In an effort to identify further published, unpublished, and ongoing trials, we also tracked relevant references through the cited reference search in Science Citation Index (SCI) and Social Science Citation Index (SSCI), reviewed the reference lists of relevant studies and reviews, handsearched relevant occupational therapy journals, and contacted key researchers in the area. SELECTION CRITERIA Randomised and quasi-randomised controlled trials that evaluated an intervention focused on providing cognitive retraining to adults with clinically defined stroke and confirmed cognitive impairment. The intervention needed either to be provided by an occupational therapist or given under the supervision of an occupational therapist. DATA COLLECTION AND ANALYSIS Two review authors independently examined the abstracts that might meet the inclusion criteria, assessed the quality and extracted data. We have presented results using mean differences. MAIN RESULTS We included one trial with 33 participants in this review. We found no difference between groups for the two relevant outcomes that were measured: improvement in time judgement skills and improvement in basic ADLs on the Barthel Index. AUTHORS' CONCLUSIONS The effectiveness of occupational therapy for cognitive impairment post-stroke remains unclear. The potential benefits of cognitive retraining delivered as part of occupational therapy on improving basic daily activity function or specific cognitive abilities, or both, of people who have had a stroke cannot be supported or refuted by the evidence included in this review. More research is required.
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Affiliation(s)
- Tammy Hoffmann
- University of QueenslandDivision of Occupational Therapy, School of Health and Rehabilitation SciencesBrisbaneAustralia4072
| | - Sally Bennett
- University of QueenslandDivision of Occupational Therapy, School of Health and Rehabilitation SciencesBrisbaneAustralia4072
| | - Chia‐Lin Koh
- National Taiwan UniversitySchool and Graduate Institute of Occupational Therapy, College of MedicineTaipeiTaiwan100
| | - Kryss T McKenna
- Deceased, formerly of the University of QueenslandBrisbaneAustralia
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Kelly F, Nikopoulos CK. Facilitating independence in personal activities of daily living after a severe traumatic brain injury. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2010. [DOI: 10.12968/ijtr.2010.17.9.78037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Aims This study examined the effectiveness of two components of a treatment programme typically used by occupational therapists (OTs) in personal activities of daily living (PADL) rehabilitation. Methods A multiple baseline probe design across PADL tasks was used, one which is particularly suited to the examination of the effects of complex interventions on skill performance. The subjects were two male adults with severe brain injuries and cognitive impairments who were in the acute stages of recovery. The OT treatment program consisted of a combination of errorless learning and strategy training approaches. The impact of the program was measured by the number of steps completed independently in each of these tasks, the level and type of assistance required, and by administering the UK Functional Independence Measure and the Assessment of Motor and Process Skills. Findings Errorless learning and strategy training, as used within an OT programme, was demonstrated to be effective in reducing the amount of assistance both participants required to complete the targeted PADL tasks. Further, there was evidence of generalization of training effects among trained and untrained activities. Conclusions Selecting and combining treatment techniques based on detailed assessment of functional performance is an area of high clinical importance but with limited research; the current study stands as an attempt towards that direction.
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Affiliation(s)
- Fiona Kelly
- Neurosciences Clinical Lead Rehabilitation, Royal Free Hospital, Pond Street, London; and
| | - Christos K Nikopoulos
- Occupational Therapy, School of Health Sciences and Social Care, Mary Seacole Building, Brunel University, Uxbridge, UK
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Drummond A. The Elizabeth Casson Memorial Lecture 2010: ‘Jack of All Trades and Master of None’: The Future of Occupational Therapy? Br J Occup Ther 2010. [DOI: 10.4276/030802210x12759925544263] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The Elizabeth Casson Memorial Lecture 2010, given on 24 June at the 34th Annual Conference and Exhibition of the College of Occupational Therapists, held at the Brighton Centre, Brighton, Sussex.
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George S, Crotty M, Gelinas I, Devos H. Rehabilitation for improving automobile driving after stroke. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Mew M. Normal Movement and Functional Approaches to Rehabilitate Lower Limb Dressing following Stroke: A Pilot Randomised Controlled Trial. Br J Occup Ther 2010. [DOI: 10.4276/030802210x12658062793807] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Dressing difficulties are common following stroke. However, specific interventions lack evidence. This pilot single-blind randomised controlled trial investigated normal movement and functional approaches to rehabilitate lower limb dressing, given to four eligible stroke inpatients. The Nottingham Stroke Dressing Assessment, Rivermead Motor Assessment and Canadian Occupational Performance Measure were taken at baseline, discharge and 8 weeks. The small sample lacked power. Preliminary results indicated that while all patients improved with occupational therapy, approaches may differ in rates of motor recovery, independence and treatment duration. A total sample of 30 is required for more conclusive research to inform lower limb dressing interventions.
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Affiliation(s)
- Melissa Mew
- Formerly Poole Hospital NHS Foundation Trust and Bournemouth University, UK
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Szczerbińska K, Topinková E, Čeremnych J, Gindin J, Maggi S. Trajectory of care for an elderly stroke patient in the new EU member countries – based on CLESA project. Eur Geriatr Med 2010. [DOI: 10.1016/j.eurger.2010.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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45
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Use of physical and occupational therapy by Medicare beneficiaries within five conditions: 1994-2001. Am J Phys Med Rehabil 2009; 88:308-21. [PMID: 19190486 DOI: 10.1097/phm.0b013e318198a791] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the use of physical therapy and occupational therapy among Medicare beneficiaries nationwide before and after the 1997 Balanced Budget Act, which introduced prospective payment for rehabilitation services. DESIGN We analyzed responses from the longitudinal Medicare Current Beneficiary Survey, merged with Medicare claims, to track physical therapy and occupational therapy rates and intensity (units of service) from 1994 through 2001. This observational study focused on elderly and disabled Medicare beneficiaries within five conditions: stroke, acute myocardial infarction, chronic obstructive pulmonary disease, arthritis, and lower-limb mobility problems. We used cubic smoothing spline functions to describe trends in service intensity over time and generalized estimating equations to assess changes in service intensity. RESULTS Controlling for demographic characteristics, adjusted mean level of physical therapy and occupational therapy intensity rose significantly between 1994 and 2001 for all five conditions. Service intensity leveled off in 1999 for occupational therapy and 2000 for physical therapy. With few exceptions, physical therapy and occupational therapy intensity was not significantly associated with patients' demographic characteristics. CONCLUSIONS Medicare beneficiaries with conditions that can potentially benefit from physical therapy or occupational therapy or both continued to get these services at similar-and sometimes increasing-intensity during years after passage of the Balanced Budget Act.
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Latham NK, Jette AM, Ngo LH, Soukup J, Iezzoni LI. Did the 1997 balanced budget act reduce use of physical and occupational therapy services? Arch Phys Med Rehabil 2008; 89:807-14. [PMID: 18452725 DOI: 10.1016/j.apmr.2008.02.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate whether use of physical therapy (PT) and occupational therapy (OT) services decreased after the passage of the 1997 Balanced Budget Act (BBA). DESIGN Data from the nationally representative Medicare Current Beneficiary Survey (MCBS) were merged with Medicare claims data. We conducted cross-sectional analyses of data from 1995 (n=7978), 1999 (n=7863), and 2001 (n=7973). All analyses used MCBS sampling weights to provide estimates that can be generalized to the Medicare population with 5 common conditions. SETTINGS Skilled nursing facilities (SNFs), home health agencies, inpatient rehabilitation facilities (IRFs), and outpatient rehabilitation settings. PARTICIPANTS Medicare beneficiaries who participated in the MCBS survey in each of the study years and had 1 or more of the following conditions: acute stroke, acute myocardial infarction, chronic obstructive pulmonary disease, arthritis or degenerative joint disease, or mobility problems. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Percentage of persons meeting our inclusion criteria who received PT or OT in each setting, and total units of PT and OT received in each setting. RESULTS Multivariable logistic regression revealed no statistically significant differences in the proportion of people who met our inclusion criteria who used PT or OT from home health agencies across the 3 time points. For SNFs, an increase in the odds of receiving PT was statistically significant from 1995 to 1999 (odds ratio [OR]=1.42; 95% confidence interval [CI], 1.19-1.69) and 1995 to 2001 (OR=1.69; 95% CI, 1.39-2.05). For IRF and outpatient settings, a significant increase was observed between 1995 and 2001 (OR=1.71, OR=1.27, respectively). For OT, a statistically significant increase was observed for IRF and outpatient rehabilitation settings from 1995 to 2001. For SNF, the increase was statistically significant from 1995 to 1999 and 1995 to 2001. Mean total PT and OT units received also increased across all settings from 1995 to 2001 except for IRFs. CONCLUSIONS Despite BBA mandates restricting postacute care expenditures, this nationally representative study showed no decreases in the percentage of Medicare beneficiaries with 5 common diagnoses receiving PT and/or OT across all settings and no decreases in units of PT and/or OT services received between 1995 and 2001 except for those in IRFs. This study suggests that the delivery of PT and OT services did not decline among persons with conditions for which rehabilitation services are often clinically indicated.
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Affiliation(s)
- Nancy K Latham
- Health and Disability Research Institute, School of Public Health, Boston University, Boston, MA 02118-2639, USA.
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Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008; 25:457-507. [PMID: 18477843 DOI: 10.1159/000131083] [Citation(s) in RCA: 1679] [Impact Index Per Article: 104.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Accepted: 03/27/2008] [Indexed: 12/13/2022] Open
Abstract
This article represents the update of the European Stroke Initiative Recommendations for Stroke Management. These guidelines cover both ischaemic stroke and transient ischaemic attacks, which are now considered to be a single entity. The article covers referral and emergency management, Stroke Unit service, diagnostics, primary and secondary prevention, general stroke treatment, specific treatment including acute management, management of complications, and rehabilitation.
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Legg L, Drummond A, Leonardi-Bee J, Gladman JRF, Corr S, Donkervoort M, Edmans J, Gilbertson L, Jongbloed L, Logan P, Sackley C, Walker M, Langhorne P. Occupational therapy for patients with problems in personal activities of daily living after stroke: systematic review of randomised trials. BMJ 2007; 335:922. [PMID: 17901469 PMCID: PMC2048861 DOI: 10.1136/bmj.39343.466863.55] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2007] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Lynn Legg
- Academic Section of Geriatric Medicine, Glasgow Royal Infirmary University NHS Trust, Glasgow G31 2ER.
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French B, Thomas LH, Leathley MJ, Sutton CJ, McAdam J, Forster A, Langhorne P, Price CIM, Walker A, Watkins CL. Repetitive task training for improving functional ability after stroke. Cochrane Database Syst Rev 2007:CD006073. [PMID: 17943883 DOI: 10.1002/14651858.cd006073.pub2] [Citation(s) in RCA: 187] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The active practice of task-specific motor activities is a component of current approaches to stroke rehabilitation. OBJECTIVES To determine if repetitive task training after stroke improves global, upper or lower limb function, and if treatment effects are dependent on the amount, type or timing of practice. SEARCH STRATEGY We searched the Cochrane Stroke Trials Register (October 2006), The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, SportDiscus, Science Citation Index, Index to Theses, ZETOC, PEDro, and OT Seeker (to September 2006), and OT search (to March 2006). We also searched for unpublished/non-English language trials, conference proceedings, combed reference lists, requested information on bulletin boards, and contacted trial authors. SELECTION CRITERIA Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal, and where the amount of practice could be quantified. DATA COLLECTION AND ANALYSIS Two authors independently screened abstracts, extracted data and appraised trials. Assessment of methodological quality was undertaken for allocation concealment, blinding, loss to follow up and equivalence of treatment. We contacted trial authors for additional information. MAIN RESULTS Fourteen trials with 17 intervention-control pairs and 659 participants were included. PRIMARY OUTCOMES results were statistically significant for walking distance (mean difference (MD) 54.6, 95% CI 17.5 to 91.7); walking speed (standardised mean difference (SMD) 0.29, 95% CI 0.04 to 0.53); sit-to-stand (standard effect estimate 0.35, 95% CI 0.13 to 0.56); and of borderline statistical significance for functional ambulation (SMD 0.25, 95% CI 0.00 to 0.51), and global motor function (SMD 0.32, 95% CI -0.01 to 0.66). There were no statistically significant differences for hand/arm function, or sitting balance/reach. SECONDARY OUTCOMES results were statistically significant for activities of daily living (SMD 0.29, 95% CI 0.07 to 0.51), but not for quality of life or impairment measures. There was no evidence of adverse effects. Follow-up measures were not significant for any outcome at six or twelve months. Treatment effects were not modified by intervention amount or timing, but were modified by intervention type for lower limbs. AUTHORS' CONCLUSIONS Repetitive task training resulted in modest improvement in lower limb function, but not upper limb function. Training may be sufficient to impact on daily living function. However, there is no evidence that improvements are sustained once training has ended. The review potentially investigates task specificity rather more than repetition. Further research should focus on the type and amount of training, and how to maintain functional gain.
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Affiliation(s)
- B French
- University of Central Lancashire, Department of Nursing, Preston, UK, PR1 2HE.
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