Effects of an Occupational Therapy Program on Functional Outcomes in Older Stroke Patients

Occupation-based interventions to improve occupational performance and participation in the hospital setting: a systematic review

PURPOSE

To critically review the evidence for occupation-based interventions in improving occupational performance and participation outcomes in the hospital setting.

METHODS

Five databases were searched from 2000-2022. Peer-reviewed studies of any design investigating the impact of occupation-based interventions in the hospital setting were included. Methodological quality was assessed using the appropriate tool for each study design. Following data extraction, a narrative synthesis was conducted.

RESULTS

Thirty-three studies comprising of 26 experimental, five non-experimental, and two mixed methods studies were included (n = 1646 participants). Results indicate good evidence to support occupation-based interventions to improve occupational performance and participation outcomes in inpatient rehabilitation; it is unclear whether they are more effective than any control/alternative intervention. Research in the acute and mental health hospital settings were scarcer. Understanding the benefits of occupation-based interventions was enhanced through qualitative results including improving independence and confidence to discharge home, increasing motivation for therapy, connecting with others, and peer-based learning.

CONCLUSIONS

Heterogeneity and methodological weaknesses across existing studies limits the conclusions that can be drawn on the impact of occupation-based interventions in the hospital setting. More rigorous research should be conducted with better reporting of intervention design and the use of robust measures of occupational performance.Implications For RehabilitationThe use of occupation-based interventions should be considered to improve occupational performance and participation outcomes in the hospital setting.There is good evidence to support the impact of occupation-based interventions on improving occupational performance and participation outcomes in the inpatient rehabilitation setting; evidence in the acute and mental health settings is scarcer.Occupation-based interventions are valued by both patients and clinicians for their impact on patient outcomes and the patient experience.

Effect of Virtual Reality Therapy on Quality of Life and Self-Sufficiency in Post-Stroke Patients

Background and Objectives: The consequences of stroke have a significant impact on self-sufficiency and health-related quality of life (HRQoL). Virtual reality (VR)-based rehabilitation has the potential to impact these modalities, but information on timing, volume, and intensity is not yet available. The aim of this randomized controlled trial (1:1) was to evaluate the impact of conventional rehabilitation combined with VR on self-care and domains of HRQoL in patients ≤6 months post-stroke. Materials and Methods: The intervention group completed a total of 270 min of conventional VR + rehabilitation sessions. The control group underwent conventional rehabilitation only. Primary assessments with the WHO disability assessment schedule 2.0 (WHODAS 2) questionnaire were conducted before rehabilitation (T0), after completion of the intervention (T1), and at the 4-week follow-up (T2); secondary outcomes included self-sufficiency and balance assessments. Results: Fifty patients completed the study (mean age 61.2 ± 9.0 years, time since stroke 114.3 ± 39.4 days). There were no statistically significant differences between the groups in WHODAS 2, self-sufficiency, and balance scores (p > 0.05). Conclusions: In the experimental group, there was a statistically significant difference in WHODAS 2, assessment of self-sufficiency, and balance scores before and after therapy (p < 0.05). VR appears to be a suitable tool to supplement and modify rehabilitation in patients after stroke.

The effect of action observation training on gait and balance of patients with neurological and musculoskeletal disorders: A systematic review

Background

Various treatment approaches are being applied for recovery of gait after different medical conditions. Action observation is a new motor learning approach, which is considered as a complementary training to the conventional rehabilitation programs such as occupational therapy for this purpose.

Objective

To find out which patients benefit more from action observation training.

Methods

Electronic databases, including Scopus, PubMed, Web of Science, Science Direct, and PEDro were searched. Prospective studies published in peer-reviewed journals with full text available in English, which investigated the effect of action observation on gait and balance of patients with neurologic or musculoskeletal disorders, were included. The methodological quality of the studies was assessed by the Downs and Black checklist, and the information was presented based on the PICO style.

Results

Nineteen studies recruiting post-orthopedic patients (4 studies), patients with stroke (11 studies), and Parkinson’s disease (4 studies) fulfilled the eligibility criteria. Quality scores ranged from 51.85% to 81.48%. Balance and walking ability were the most reported primary outcomes.

Conclusion

Patients in the chronic phase of stroke might benefit more from action observation training plus occupational therapy in different aspects of gait than orthopedic patients and those with Parkinson’s disease.

Non-pharmacological interventions for the improvement of post-stroke activities of daily living and disability amongst older stroke survivors: A systematic review

Globally, stroke remains a leading cause of death and disability, with older adults disproportionately affected. Numerous non-pharmacological stroke rehabilitation approaches are in use to address impairments, but their efficacy in older persons is largely unknown. This systematic review examined the evidence for such interventions as part of the Optimal Evidence-Based Non-Drug Therapies in Older Persons (ONTOP) project conducted under an European Union funded project called the Software Engine for the Assessment and Optimisation of Drug and Non-Drug Therapies in Older Persons (SENATOR) [http://www.senator-project.eu]. A Delphi panel of European geriatric experts agreed activities of daily living and disability to be of critical importance as stroke rehabilitation outcomes. A comprehensive search strategy was developed and five databases (Pubmed, CINAHL, Embase, PsycInfo and Cochrane Database of Systematic Reviews) searched for eligible systematic reviews. Primary studies meeting our criteria (non-pharmacologic interventions, involving stroke survivors aged ≥65 years, assessing activities of daily living and/or disability as outcome) were then identified from these reviews. Eligible papers were double reviewed, and due to heterogeneity, narrative analysis performed. Cochrane risk of bias and GRADE assessment tools were used to assess bias and quality of evidence, allowing us to make recommendations regarding specific non-pharmacologic rehabilitation in older stroke survivors. In total, 72 primary articles were reviewed spanning 14 types of non-pharmacological intervention. Non-pharmacological interventions based on physiotherapy and occupational therapy techniques improved activities of daily living amongst older stroke survivors. However, no evidence was found to support use of any non-pharmacological approach to benefit older stroke survivors' disability. Evidence was limited by poor study quality and the small number of studies targeting older stroke survivors. We recommend future studies explore such interventions exclusively in older adult populations and improve methodological and outcome reporting.

Occupational therapy for adults with problems in activities of daily living after stroke

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.

Interventions affecting self-care, productivity, and leisure among adults: a scoping review

This study is a scoping review of 21 years of international occupational therapy literature. Its purpose is to identify and describe interventions used by occupational therapists to enable self-care, productivity, and leisure. The scoping review produced 59 articles published between 1990 and 2010. Nine articles evaluated the effectiveness of occupational therapy interventions focused on leisure outcomes, 21 on productivity outcomes, and 29 on self-care outcomes. The programs were classified according to eight types of interventions: training, education, skill development, task adaptation, occupational development, environmental modification, support provision, and support enhancement. Most studies produced at least one significant positive result (82%), indicating that occupational therapy programs were at least partially successful in improving self-care, productivity, or leisure. There is good evidence for task adaptation, training, and skill development interventions, and for the role of occupational therapy in multi-disciplinary teams.

Task-specific practice of dressing tasks in a hospital setting improved dressing performance post-stroke: a feasibility study

BACKGROUND

Practise of personal activities of daily living, including dressing improves outcomes for people living at home after a stroke. Less is known about dressing outcomes for hospital inpatients.

AIM

This study aimed to investigate the feasibility and outcomes of a group-based, task-specific dressing retraining programme for inpatients post-stroke.

METHODS

A pre-post single group study design was used. Retrospective data were collected for stroke inpatients admitted to one hospital between 2007 and 2009. Participants attended a one-hour dressing group twice weekly during admission, supervised by occupational therapists. Each participant had one or more dressing goals. Scores on the Functional Independence Measure (FIM) upper and lower body dressing items were compared at baseline and at discharge.

RESULTS

Of 119 participants who received group-based training, a mean improvement was found of 2.2 FIM points (95% CI 1.9-2.5, P = 0.0001) for upper body dressing (range 0-7), 2.7 FIM points (95% CI 2.3-3.1, P = 0.0001) for lower body dressing (range 0-7) and 5.2 FIM points (95% CI 4.5-6.0, P = 0.0001) for total dressing scores (range 0-14). Of 242 goals recorded, 48% focussed on shirt/upper body dressing, 35% on pants/shorts, 11% on socks and shoes and 13% involved buttons/fastenings.

CONCLUSIONS

Task-specific practice of dressing tasks in a group setting was feasible and made clinically significant differences to dressing performance during inpatient rehabilitation. More rigorous methods of investigation are required in future to minimise selection, measurement and intervention biases.

Occupational therapy in diabetic care-areas of need perceived by older adults with diabetes

This study explored the perception of older adults with diabetes regarding the areas of service considered helpful to their daily activities and routines. A survey questionnaire was designed and given to 52 community-dwelling older adults with diabetes. Results showed that cholesterol control, managing blood sugar, foot care, fatigue management and pacing, and pain management/reduction were the areas of most concern that deserve services. The findings suggest that, in providing holistic client-centered interventions to individuals with diabetes, occupational therapists need to be able to prioritize clients' concerns and help them incorporate diabetes management into their routines and lifestyle.