Effect of home-based interventions on basic activities of daily living for patients who had a stroke: a systematic review with meta-analysis

OBJECTIVES

To investigate the effectiveness of home-based interventions in improving the ability to do basic activities of daily living in patients who had a stroke.

METHODS

Randomised controlled trials were searched through MEDLINE, Embase and CINAHL from their inception to 31 December 2021. We included studies involving home-based intervention prescribed by professionals and implemented at patients' homes. The characteristics of these studies were collected. Risk of bias of individual study was assessed by Physiotherapy Evidence Database scale. Meta-analyses were performed where studies reported comparable interventions and outcomes.

RESULTS

In total, 49 studies were included in the systematic review and 16 studies had sufficient data for meta-analyses. The short-term effect of home-based intervention showed no significant difference when compared with institution-based intervention (standardised mean difference (SMD)=0.24, 95% CI -0.15 to 0.62, I²=0%). No significant difference was found between home-based intervention and usual care for long-term effect (SMD=0.02; 95% CI -0.17 to 0.22; I²=0%). Home-based rehabilitation combined with usual care showed a significant short-term effect on the ability to do basic daily activities, compared with usual care alone (SMD=0.55; 95% CI 0.22 to 0.87; p=0.001; I²=3%).

CONCLUSION

Home-based rehabilitation with usual care, which varied from no therapy to inpatient or outpatient therapy, may have a short-term effect on the ability to do basic activities of daily living for patients who had a stroke compared with usual care alone. However, the evidence quality is low because of the limited number of studies and participants included in the meta-analysis and the possible publication bias. Future research is needed to investigate the effectiveness of home-based rehabilitation in groups with stratification by stroke severity and time since stroke onset, with elaboration of details of the home-based and the control interventions. Moreover, more high-quality studies are required to prove the cost-effectiveness of newly developed strategies like caregiver-mediated rehabilitation and telerehabilitation.

THE PRIMARY SOURCE OF FUNDING

The Medical Research Fund of Guangdong Province (No: A2021041).

Is Discordance Between Recommended and Actual Postacute Discharge Setting a Risk Factor for Readmission in Patients With Congestive Heart Failure?

Background

Readmissions in patients with congestive heart failure are common and often preventable. Limited data suggest that patients discharged to a less intensive postacute care setting than recommended are likely to readmit. We examined whether postacute setting discordance (discharge to a less intensive postacute setting than recommended by a physical and occupational therapist) was associated with hospital readmission in patients with congestive heart failure. We also assessed sociodemographic and clinical predictors of setting discordance.

Methods and Results

Retrospective analysis of administrative claims and electronic health record data was conducted on 25 500 adults with a discharge diagnosis of congestive heart failure from 12 acute care hospitals in Western Pennsylvania. Generalized linear mixed models were estimated to examine the association between postacute setting discordance and 30‐day hospital readmission and to identify predictors of setting discordance. The 30‐day readmission and postacute setting discordance rates were high (23.7%, 20.6%). While controlling for demographic and clinical covariates, patients in discordant postacute settings were more likely to be readmitted within 30 days (adjusted odds ratio [OR], 1.12; 95% CI, 1.04–1.20). The effect was also seen in the subgroup of patients with low mobility scores (adjusted OR, 1.20; 95% CI, 1.08–1.33). Factors associated with setting discordance were lower‐income, higher comorbidity burden, therapist recommendation disagreement, and midrange mobility limitations.

Conclusions

Postacute setting discordance was associated with an increased readmission risk in patients hospitalized with congestive heart failure. Maximizing concordance between therapist recommended and actual postacute discharge setting may decrease readmissions. Understanding factors associated with post‐acute setting discordance can inform strategies to improve the quality of the discharge process.

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.

Occupational Therapy for Stroke Patients: A Survey of Current Practice

A survey was carried out in order to ascertain the treatment approaches used in stroke care by senior I occupational therapists in the Trent Region of the United Kingdom. A random selection of these therapists was subsequently interviewed using semi-structured interviews and a case vignette in order to obtain more detailed information. Of the 83 questionnaires sent, 61 (73%) were returned; 14 therapists were interviewed.

The two most common approaches identified were the functional approach and the Bobath approach. The main indications for the choice of approach were the age of the patient, progress with other approaches and discharge date. Of concern in the current climate of evidence-based practice was the high number of occupational therapists who were unfamiliar with standardised assessments and unable to describe adequately the theoretical basis for the treatment used.

Occupational Therapy Predischarge Home Visits: A Study from a Community Hospital

The characteristics of 79 patients in a community hospital having an occupational therapy home visit during a period of one year were monitored. The processes of the home visit were examined and, in particular, the relationships of diagnosis and overall measures of levels of functioning – the Physical Self-Maintenance (PSM) and Instrumental Activities of Daily Living (IADL) scales – with the recommendations of the occupational therapists were analysed.

The 79 patients had a mean age of 78.5 years; 27 (34.2%) were male and 58 (73.4%) lived alone. The mean time spent in the home by the occupational therapist was 49 minutes and the mean time for the whole visit including travelling time was 108.4 minutes. Only one patient (1.3%) was completely independent in all six PSM categories and no patient was completely independent in all eight IADL items. Seventy-two (91.6%) patients were eventually discharged to a non-institutional setting, mainly the patient's own home.

Current diagnosis, except for cerebrovascular disease, was not significantly related to higher overall dependency, recommended equipment or carer visit frequency. Higher overall dependency showed significant relationships with recommended carer frequency and time spent assessing the patient in the home, but not consistently with recommended equipment or home adaptations. When specific categories of equipment were considered, for example that for use in the kitchen, overall low dependency was significantly related to the recommendation for this type of equipment.

The study confirms the need for assessments beyond those of diagnosis alone in rehabilitation. Overall measures of levels of functioning, although useful in measuring outcomes, are of less certain value for assessment. Specific subcategories of dependency scales are probably of more value than overall scores for occupational therapy assessment.

Home-Based Occupational Therapy: Stroke Patients' Satisfaction with Occupational Performance and Service Provision

This study evaluated a short post-discharge home-based occupational therapy service for stroke patients, including an assessment of the patients' satisfaction with occupational performance and service provision.

A single-site, blind randomised controlled trial was conducted. One hundred and thirty-eight patients were randomly allocated to either a conventional outpatient follow-up or conventional services plus 6 weeks of home-based occupational therapy. The data were collected before discharge and at 7 weeks and 6 months after discharge using the Canadian Occupational Performance Measure (COPM), the Dartmouth COOP Charts, the London Handicap Scale and a patient satisfaction questionnaire.

At 7 weeks the intervention group reported significantly greater changes in performance and satisfaction on the COPM, better emotional scores (Dartmouth COOP Charts) and improved work and leisure activity scores (London Handicap Scale). No other differences in subjective health status were described. By 6 months, the intervention group was more satisfied with several aspects of service provision but no other differences in subjective health experience were reported.

A 6-week post-discharge home-based occupational therapy service can improve patients' perceptions of their occupational performance and satisfaction with services but may not have a long-term effect on subjective health outcomes.

Occupational Therapy in Nursing and Residential Care Settings: A Description of a Randomised Controlled Trial Intervention

This article describes an occupational therapy intervention for stroke that was provided as part of a randomised controlled trial in order to evaluate the effects of the intervention of an occupational therapist in a nursing and residential home setting. The intervention was developed and described to enable it to be reproduced in further evaluations, as recommended by the Medical Research Council's guidelines for clinical trials.

Initially, the published evidence was reviewed and advice was sought to identify the process, content and recording methods needed to treat clients in a care home setting. This resulted in a clearly defined, evidence-based treatment package and a predetermined recording system.

Sixty residents received occupational therapy: the mean number of visits was 8.5 and the mean total time per participant was 4.7 hours. During 508 visits, the majority of time was spent on activities of daily living training and mobility practice (40%), followed by assessment and goal setting (31%), communication with residents, staff, relatives and other agencies (15%), adaptive equipment (10%) and the treatment of impairments (4%).

It is possible to develop evidence-based targeted occupational therapy interventions to be used in the context of a controlled clinical trial. Further work is required to examine the validity of the recording methods and the reproducibility of the intervention.

Examining the Evidence Base for Occupational Therapy with Clients following Stroke

In order to conduct occupational therapy services that are evidence based, studies are urgently required which demonstrate the effectiveness of interventions offered. This paper presents the findings of a study undertaken to determine occupational therapy outcomes for clients with stroke during inpatient rehabilitation.

The participants were 43 clients with stroke and four occupational therapists. Therapy outcomes for personal activities of daily living were measured using the Functional Independence Measure (Adult FIMSM); instrumental activities of daily living were measured using the Assessment of Living Skills and Resources (ALSAR); and quality of life was measured using the Quality of Life Index (Q-L Index) and a semi-structured interview. The semi-structured interview was also used to understand clients' perceptions of the outcome of their participation in occupational therapy. The data were collected at client admission, discharge and 3 months' follow-up.

The results indicated that the clients believed that their ability to perform activities of daily living (Adult FIMSM t (38) = −7.80, p = 0.000, and ALSAR t (35) = 4.82, p = 0.000) and their quality of life (Q-L Index t (39) = −7.23, p = 0.000) improved over the course of their inpatient rehabilitation. The therapists also rated the clients as improving during their rehabilitation in relation to activities of daily living (Adult FIMSM t (42) = −9.71, p = 0.000, and ALSAR t (40) = 7.75, p = 0.000) and quality of life (Q-L Index t (39) = −11.20, p = 0.000). Many of the clients interviewed attributed these gains to participation in the occupational therapy programme.

In conclusion, this study demonstrated that a triangulated approach to data collection and analysis was useful in providing evidence that occupational therapy, as part of comprehensive rehabilitation, made a difference to the lives of many of the clients studied.

Consulting Service Users: The Stroke Association Home Therapy Project

In 1999, the Stroke Association set up a project to promote home-based occupational therapy for patients who had had a stroke and been discharged home from hospital. As part of the service evaluation, focus groups for service users and carers were set up in two of the sites to consult users about the changes in their quality of life during the period of the home therapy. A total of 11 service users and 9 carers attended the groups, representing 30% of the service users and 27% of the carers involved in the project. The group discussion was taped and transcribed and then analysed using a framework approach.

The group members described their personal experiences of recovery from and limitations after the stroke and reported improvements in life issues during the period of their home therapy. The content and organisation of the service and the relationships with project staff were felt to influence the effectiveness of the occupational therapy. Other issues that affected the perceived outcome for the service users included individual choice, age, stroke consequences, other rehabilitation and community services and social limitations. This consultation process allowed the service users to describe the strengths and weaknesses of the service and provided valuable feedback that could be used to design the content and application of future home therapy services.

Effective Measurement of the Functional Progress of Stroke Clients

There is a need for occupational therapists to establish a range of outcome measures that can measure change effectively. The aim of this study was to identify effective methods of measuring the functional performance of individuals who had experienced a stroke and had been discharged from a rehabilitation ward. Measures with recorded validity and reliability and in clinical use were selected. The measures were the Barthel Index (Shah version), Nottingham Extended Activities of Daily Living scale, Motricity Index (Upper and Lower Limb), Rivermead Mobility Index and Nine-Hole Peg Test. Assessments were carried out at the point of discharge from hospital and 6 months later.

Responsiveness was analysed using effect size and relative efficiency statistics. The practicality (feasibility) was established by comparing completion rates. The Nottingham Extended Activities of Daily Living scale and the Rivermead Mobility Index were found to be more responsive than the Barthel Index and Lower Limb Motricity Index respectively and to be practical after discharge from hospital. The Nine-Hole Peg Test was found to be more responsive than the Upper Limb Motricity Index but less practical. The analysis suggested that some measures are more suitable than others for tracking change in function after discharge from hospital for a wide case mix of people who have experienced a stroke.

Challenges to Measuring Outcomes in Occupational Therapy: A Qualitative Focus Group Study

The aim of this study was to explore the process used by occupational therapists to measure the effect of their interventions. A second aim was to explore the challenges associated with this process. Stroke rehabilitation was chosen as the focus for the study.

This qualitative study was conducted in Sydney, Australia. Ten occupational therapists from both hospital and community-based services participated in one of three focus groups. The data were analysed using constant comparison techniques.

The participants struggled when describing the process used to measure outcomes. They focused more on the challenges to measuring outcomes, which were described as focusing on occupation, deconstructing occupation and lacking knowledge, skills and assistance.

The participants in this study had difficulty in articulating and setting measurable goals linked to interventions. As a result, they could not easily select appropriate outcome measures. Education is needed to help such occupational therapists to develop the required skills and to begin to measure clinical outcomes. Further research should determine if similar experiences and challenges are faced in other areas of practice and by occupational therapists in other countries.

Does a short period of rehabilitation in the home setting facilitate functioning after stroke? A randomized controlled trial

Objective: To assess the effect of three weeks of rehabilitation in the home setting for younger patients with stroke with the aim of improving activity level.

Design: A randomized controlled study with blinded evaluations at discharge, three weeks, three months and one year after discharge.

Setting: Home of the patient or the ordinary day rehabilitation clinic at the university hospital.

Subjects: Fifty-eight patients (median age 53 years) consecutively discharged from inpatient rehabilitation with a first occurrence of stroke participated in training directly after discharge.

Intervention: Rehabilitation was given for 9 hours/week over three weeks. The home group received individually tailored training, based on the patient's needs and desires, with a focus on activities in their natural context. Support and information were also given. The intervention in the day clinic group was aimed mainly at improved functions.

Main measures: The main outcome was activity, assessed with the Assessment of Motor and Process Skill (AMPS). The impairment level was also evaluated. Costs were estimated.

Result: There were no significant differences between the groups on any of the four assessments. However, there seemed to be an earlier improvement on some measures (including AMPS) for the home group. For both groups there was a greater improvement on the activity level than on the impairment level. The costs of the home group were less than half of the costs of the day clinic group.

Conclusion: With the present results, both rehabilitation programmes could be recommended, however, further studies are needed to define patients who may specifically benefit from the home rehabilitation programme. Costs should be taken into consideration.

Combined analysis of two randomized trials of community physiotherapy for patients more than one year post stroke

Background: Some patients continue to have mobility problems as a long-term consequence of stroke and it is unclear whether routine, further contact with a physiotherapy service is beneficial. Two single-centre, randomized controlled trials of physiotherapy for patients more than one year post stroke have been undertaken in Oxford and Bradford in the UK and the results from these two trials have been combined to give a more precise estimate of effectiveness.

Method: The computerized databases from both trials were combined for a joint analysis. Outcome measures common to both trials were: Rivermead Mobility Index; gait speed measured over 10 metres; Barthel Index; Frenchay Activities Index; Hospital Anxiety and Depression Scale.

Results: There were 264 patients available for the combined analysis (Oxford= 94; Bradford= 170). There was a significant but clinically small improvement in mobility at three months in the combined treatment group measured by the Rivermead Mobility Index (median of the differences= 0 (95% confidence interval (CI) 0, 1); interpolated values= 0.43 (95% CI 0.08, 0.80)) and gait speed (treatment effect 2.7 m/min (95% CI 0.94, 4.46)). There were no other significant differences. Intervention given in both studies was at the discretion of the physiotherapists and was of similar and low intensity (mean visits Oxford= 4 (SD 2.5); Bradford= 5 (SD 4.5)).

Conclusion: A more effective physiotherapy intervention is required for stroke patients with persisting mobility problems after stroke.

Occupational Therapy for Adults With Cancer: Why It Matters

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.

Functional Assessments Used by Occupational Therapists with Older Adults at Risk of Activity and Participation Limitations: A Systematic Review

Introduction

The use of functional assessments to evaluate patient change is complicated by a lack of consensus as to which assessment is most suitable for use with older adults. Objective: To identify and appraise the properties of assessments used to evaluate functional abilities in older adults.

Methods

A systematic review of randomised controlled trials of occupational therapy interventions was conducted up to 2012 to identify assessments used to measure function. Two authors screened and extracted data independently. A second search then identified papers investigating measurement properties of each assessment. Studies from the second search were included if: i) published in English, ii) the assessment was not modified from its original published form, iii) study aim was to evaluate the quality of the tool, iv) and was original research. Translated versions of assessments were excluded. Measurement quality was rated using the COSMIN checklist and Terwee criteria.

Results

Twenty-eight assessments were identified from the systematic search of occupational therapy interventions provided to older adults. Assessments were of varied measurement quality and many had been adapted (although still evaluated as though the original tool had been administered) potentially altering the conclusions drawn about measurement quality. Synthesis of best evidence established 15 functional assessments have not been tested in an older adult population.

Conclusions

The Functional Autonomy Measurement System (SMAF) appears to be a promising assessment for use with older adults. Only two tools (the SMAF and the Assessment of Motor and Process Skills (AMPS)) were deemed to be responsive to change when applied to older adults. Health professionals should use functional assessments that have been validated with their population and in their setting. There are reliable and valid assessments to capture the functional performance of older adults in community and hospital settings, although further refinement of these assessments may be necessary.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation

BACKGROUND AND PURPOSE

The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA).

METHOD

Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale.

RESULTS

The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation.

DISCUSSION AND CONCLUSION

The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.

Evidence-Based Practice and Setting Basic Standards for Stroke Rehabilitation in Canada

It is a concern that the consistency of care in stroke rehabilitation appears to vary significantly among practice settings within Canada. Based upon an evidence-based review of stroke rehabilitation, a group of physiatrists from across Canada agreed to some basic standards for stroke rehabilitation. The following standards were deemed to be critical to providing effective stroke rehabilitation care: early assessment and quick access to specialized interdisciplinary rehabilitation, appropriate intensity of therapies, availability of outpatient therapy, appropriate community supports, and careful attention to secondary prevention of stroke. Providing stroke rehabilitation care consistently within these standards remains a challenge, particularly given the potential initial costs, despite significant improvements in patient outcomes and quality of life. Nevertheless, these standards should be the expectation of stroke patients, essentially forming a stroke rehabilitation "bill of rights."

A Pilot Randomized Controlled Trial of Community-Based Occupational Therapy in Late Stroke Rehabilitation

Chronic participation deficits are common following stroke. We hypothesized that a brief period of occupation-focused, client-centered occupational therapy would lead to improved participation in valued activities for individuals who had experienced strokes 6 or more months previously. Sixteen individuals were randomized to the intervention or no-treatment control group. All participants identified up to five activities in which they wished to improve. Following intervention, both groups rated their performance of these activities similarly. However, those who received the intervention rated their satisfaction with these activities significantly higher than did the participants who did not receive the occupational therapy intervention. There were no differences between postintervention measures of well-being or overall participation. Further evaluation of such a program of late stroke rehabilitation is recommended.

Individuals with stroke reporting unmet need for occupational therapy following discharge from hospital

ABSTRACT The purpose of this study was to identify the characteristics and needs of individuals with stroke who report an unmet need for occupational therapy following discharge from hospital. Needs were assessed using a semi-structured interview and a survey in a sample of 209 adults hospitalized with a stroke. Participants were divided into three groups-those needing occupational therapy; those receiving occupational therapy, and those neither needing nor receiving occupational therapy. Thirteen percent (n = 28) reported an unmet need for occupational therapy and were more dependent in activities of daily living (ADL) before and after their stroke and had lower acute functional independence measure (FIM) scores than the comparison groups (p < .05). Participants with unmet needs for occupational therapy were more likely to report unmet needs related to upper extremity function, basic and instrumental ADL, leisure, assistive devices, and the resumption of social roles.

Occupational therapy for care home residents with stroke

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.

A disability prevention programme for community-dwelling frail older persons

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is ‘The trainee consistent demonstrates a knowledge of how evidence based methods and strategies can be incorporated in an integral and multidisciplinary programme for community-dwelling frail elderly.’

Abstract

Objective: To describe and justify a primary care interdisciplinary programme for community-dwelling frail older people aimed to prevent disability.

Background: Disability is a negative outcome of frailty among older persons. Policy reports and research studies emphasize the need for programmes to reduce disability progression. Between 2008 and 2010 we developed such a programme.

Development: Following the Intervention Mapping protocol, a research team and a multidisciplinary professional developed the programme. Literature reviews and an expert meeting led to identification of basic elements, theory-based methods and practical tools.

The programme: The general practitioner and the practice nurse comprise the core team that can be extended by other professionals such as occupational and physical therapist. The programme includes six steps: (1) screening, (2) assessment, (3) analysis and preliminary action plan, (4) agreement on an action plan, (5) execution of the action plan (toolbox parts) and (6) evaluation and follow-up. The main features are: identifying risks for developing disability and targeting risk factors using professional standards and the 5A Behavioural Change Model to support self management, and identifying problems in performing activities and enhancing meaningful activities based on the Model of Human Occupation. Screening, individual assessment, tailor-made and client-centred care, self-management support, case management and interdisciplinary cooperation are important principles in delivering the programme.

Discussion: The disability-prevention programme seems promising for addressing the needs of frail older people for independent living and for targeting risk factors. Its feasibility and effects are currently being tested in a randomized controlled trial.

VISTA-Rehab: A Resource for Stroke Rehabilitation Trials

Background

Stroke rehabilitation is a complex intervention. Many factors influence the interaction between the patient and the elements of the intervention. Rehabilitation interventions are aimed at altering different domains of patient outcome including body functions, activity and participation. As a consequence, randomised clinical trials in this area are difficult to design. We developed an archive of stroke rehabilitation trials (VISTA-Rehab) to act as a resource to help trialists model and design future rehabilitation studies.

Methods

We developed specific eligibility criteria for the entry of stroke rehabilitation trials into the archive. We established a Steering Committee to oversee projects and publications and commenced the recruitment of rehabilitation trials into this resource.

Results

As of August 2009, VISTA-Rehab contains data from 23 stroke rehabilitation trials (>3400 patients). Demographic data, including age [median=73, interquartile range (63,79)], gender (male=53%) and initial dependency [median baseline Barthel index score=6, interquartile range ( 9 , 19 )], are available for all patients. Outcome measures include the modified Rankin Scale, Barthel Index, Rivermead Motor Assessment, Fugl-Meyer Assessment, General Health Questionnaire and Nottingham Extended Activities of Daily Living Scale.

Conclusion

VISTA-Rehab expands the Virtual International Stroke Trials Archive to include rehabilitation trials. Anonymised data can be used to examine questions specific to stroke rehabilitation and to generate novel hypotheses.

Psychosocial interventions for the prevention of depression in older adults: systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of psychosocial interventions for the prevention of depression in older people.

METHOD

Systematic review and meta-analysis of prospective controlled trials.

RESULTS

Thirty studies were included. Overall, psychosocial interventions had a small but statistically significant effect on depressive symptoms (17 trials, standardized mean difference = -0.17, 95% CI = -0.31 to -0.03). In comparison with no-intervention controls, social activities were effective in reducing depressive symptoms, but results should be interpreted with caution due to the small number of trials. No statistically significant effect on depressive symptoms was found for physical exercise, skill training, reminiscence, or for multicomponent interventions.

DISCUSSION

Psychosocial interventions have a small but statistically significant effect in reducing depressive symptoms among older adults. The current evidence base for psychosocial interventions for primary prevention of depression in older people is weak, and further trials warranted especially for the most promising type of interventions evaluated, that is, social activities.

The reduction of disability in community-dwelling frail older people: design of a two-arm cluster randomized controlled trial

BACKGROUND

Frailty among older people is related to an increased risk of adverse health outcomes such as acute and chronic diseases, disability and mortality. Although many intervention studies for frail older people have been reported, only a few have shown positive effects regarding disability prevention. This article presents the design of a two-arm cluster randomized controlled trial on the effectiveness, cost-effectiveness and feasibility of a primary care intervention that combines the most promising elements of disability prevention in community-dwelling frail older people.

METHODS/DESIGN

In this study twelve general practitioner practices were randomly allocated to the intervention group (6 practices) or to the control group (6 practices). Three thousand four hundred ninety-eight screening questionnaires including the Groningen Frailty Indicator (GFI) were sent out to identify frail older people. Based on their GFI score (≥5), 360 participants will be included in the study. The intervention will receive an interdisciplinary primary care intervention. After a comprehensive assessment by a practice nurse and additional assessments by other professionals, if needed, an individual action plan will be defined. The action plan is related to a flexible toolbox of interventions, which will be conducted by an interdisciplinary team. Effects of the intervention, both for the frail older people and their informal caregivers, will be measured after 6, 12 and 24 months using postal questionnaires and telephone interviews. Data for the process evaluation and economic evaluation will be gathered continuously over a 24-month period.

DISCUSSION

The proposed study will provide information about the usefulness of an interdisciplinary primary care intervention. The postal screening procedure was conducted in two cycles between December 2009 and April 2010 and turned out to be a feasible method. The response rate was 79.7%. According to GFI scores 29.3% of the respondents can be considered as frail (GFI ≥ 5). Nearly half of them (48.1%) were willing to participate. The baseline measurements started in January 2010. In February 2010 the first older people were approached by the practice nurse for a comprehensive assessment. Data on the effect, process, and economic evaluation will be available in 2012.

TRIAL REGISTRATION

ISRCTN31954692.

Interventions for treating depression after stroke

BACKGROUND

Depression is an important consequence of stroke that impacts on recovery yet is often not detected or inadequately treated. This is an update of a Cochrane review first published in 2004.

OBJECTIVES

To determine whether pharmaceutical, psychological, or electroconvulsive treatment (ECT) of depression in patients with stroke can improve outcome.

SEARCH STRATEGY

We searched the trials registers of the Cochrane Stroke Group (last searched October 2007) and the Cochrane Depression Anxiety and Neurosis Group (last searched February 2008). In addition, we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2008), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), CINAHL (1982 to May 2006), PsycINFO (1967 to May 2006) and other databases. We also searched reference lists, clinical trials registers, conference proceedings and dissertation abstracts, and contacted authors, researchers and pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials comparing pharmaceutical agents with placebo, or various forms of psychotherapy or ECT with standard care (or attention control), in patients with stroke, with the intention of treating depression.

DATA COLLECTION AND ANALYSIS

Two review authors selected trials for inclusion and assessed methodological quality; three review authors extracted, cross-checked and entered data. Primary analyses were the prevalence of diagnosable depressive disorder at the end of treatment. Secondary outcomes included depression scores on standard scales, physical function, death, recurrent stroke and adverse effects.

MAIN RESULTS

Sixteen trials (17 interventions), with 1655 participants, were included in the review. Data were available for 13 pharmaceutical agents, and four trials of psychotherapy. There were no trials of ECT. The analyses were complicated by the lack of standardised diagnostic and outcome criteria, and differing analytic methods. There was some evidence of benefit of pharmacotherapy in terms of a complete remission of depression and a reduction (improvement) in scores on depression rating scales, but there was also evidence of an associated increase in adverse events. There was no evidence of benefit of psychotherapy.

AUTHORS' CONCLUSIONS

A small but significant effect of pharmacotherapy (not psychotherapy) on treating depression and reducing depressive symptoms was found, as was a significant increase in adverse events. More research is required before recommendations can be made about the routine use of such treatments.

Interventions for preventing depression after stroke

BACKGROUND

Depression is an important consequence of stroke that impacts on recovery yet often is not detected or is inadequately treated.

OBJECTIVES

To determine if pharmaceutical or psychological interventions can prevent depression and improve physical and psychological outcomes in patients with stroke.

SEARCH STRATEGY

We searched the Trials Registers of the Cochrane Stroke Group (October 2007) and the Cochrane Depression Anxiety and Neurosis Group (February 2008). In addition, we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2008), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), CINAHL (1982 to May 2006), PsycINFO (1967 to May 2006), Applied Science and Technology Plus (1986 to May 2006), Arts and Humanities Index (1991 to September 2002), Biological Abstracts (1969 to September 2002), BIOSIS Previews (2002 to May 2006), General Science Plus (1994 to September 2002), Science Citation Index (1992 to May 2006), Social Sciences Citation Index (1991 to May 2006), SocioFile (1974 to May 2006) ISI Web of Science (2002 to February 2008), reference lists, trial registers, conference proceedings and dissertation abstracts, and contacted authors, researchers and pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials comparing pharmaceutical agents with placebo, or psychotherapy against standard care (or attention control) to prevent depression in patients with stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data and assessed trial quality. Primary analyses were the proportion of patients who met the standard diagnostic criteria for depression applied in the trials at the end of follow up. Secondary outcomes included depression scores on standard scales, physical function, death, recurrent stroke and adverse effects.

MAIN RESULTS

Fourteen trials involving 1515 participants were included. Data were available for 10 pharmaceutical trials (12 comparisons) and four psychotherapy trials. The time from stroke to entry ranged from a few hours to seven months, but most patients were recruited within one month of acute stroke. The duration of treatment ranged from two weeks to one year. There was no clear effect of pharmacological therapy on the prevention of depression or other endpoints. A significant improvement in mood and the prevention of depression was evident for psychotherapy, but the treatment effects were small.

AUTHORS' CONCLUSIONS

A small but significant effect of psychotherapy on improving mood and preventing depression was identified. More evidence is required before recommendations can be made about the routine use of such treatments after stroke.

Therapy-based rehabilitation services for patients living at home more than one year after stroke

BACKGROUND

Current practice of rehabilitation intervention mainly concentrates on the first six months of stroke. At present, there is no agreed consensus about the benefits of such a service more than one year after stroke.

OBJECTIVES

To ascertain whether therapy-based rehabilitation services can influence outcome one year or more after stroke.

SEARCH STRATEGY

We searched the trials registers of the following Cochrane Review Groups: Stroke Group (last searched September 2007), Effective Practice and Organisation of Care Group (last searched October 2006) and Dementia and Cognitive Improvement Group (last searched October 2006). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2006), MEDLINE (1966 to October 2006), EMBASE (1980 to October 2006), CINAHL (1982 to October 2006), AMED (1985 to October 2006), PEDro (1952 to October 2006), British Nursing Index (1993 to October 2006), DARE (1994 to October 2006), HMIC (1979 to October 2006) and NHS EED (1991 to October 2006). We also searched dissertation databases and ongoing trials and research registers, scanned reference lists and contacted researchers and experts in the field.

SELECTION CRITERIA

All randomised controlled trials of community-based stroke patients, in which at least 75% were recruited one year after stroke and received a therapy-based rehabilitation intervention that was compared with conventional care.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials and extracted data on a number of pre-specified outcomes. The primary outcomes were the proportion of participants who had deteriorated or were dependent in personal activities of daily living at the end of scheduled follow up.

MAIN RESULTS

We identified five trials of 487 participants that were eligible for the review. Overall, there was inconclusive evidence as to whether therapy-based rehabilitation intervention one year after stroke was able to influence any relevant patient or carer outcome. Trials varied in design, type of interventions provided, quality, and outcomes assessed.

AUTHORS' CONCLUSIONS

This review highlights the dearth of evidence investigating long-term therapy-based rehabilitation interventions for patients with stroke.

Social Services Occupational Therapists' View of Practice and Integration with Health: A Survey

There is little known about social services occupational therapy provision within Scotland and England. This information is important when planning strategically for the future.

The aim of this study was to understand the views of social services occupational therapists on their practice and integration with health services. Systematic random sampling of social work/social services departments was completed (n = 10) and 57 occupational therapists within these departments received a mailed questionnaire. There was a 72% response rate.

The therapists received ‘on average 40 referrals' each month and 98% of the therapists retained the client for over 4 weeks, within which they had 3–6 contacts of 45–90 minutes each. Ninety-five per cent of the referrals were perceived to be appropriate and the clients benefited from the occupational therapy services. Fifty-four per cent of the therapists focused on self-care, equipment/adaptations and discussion with family/carers for more than half of their time, with 76% stating that they did not address all the clients' occupational needs. Eighty-eight per cent stated that there was an overlap with health service occupational therapists in the areas of assessment, equipment provision and family/carer advice. Forty-four per cent stated that there were some changes towards integration with health; however, 98% felt that more integration would benefit clients. The article sets out recommendations for consideration.

Community-based treatment of late life depression an expert panel-informed literature review

OBJECTIVES

To present findings from an expert panel-informed literature review on community-based treatment of late-life depression.

METHODS

A systematic literature review was conducted to appraise publications on community-based interventions for depression in older adults. The search was conducted between March and October 2005. An expert panel of mental health, aging, health services, and epidemiology researchers guided the review and voted on quality and effectiveness of these interventions.

RESULTS

A total of 3,543 articles were found with publication dates from 1967 to October 2005; of these, 116 were eligible for inclusion. Adequate data existed to determine effectiveness for the following interventions: depression care management, group and individual psychotherapy for depression, psychotherapy targeting mental health, psychotherapy for caregivers, education and skills training (to manage health problems besides depression; and for caregivers), geriatric health evaluation and management, exercise, and physical rehabilitation and occupational therapy. After reviewing the data, panelists rated the depression care management interventions as effective. Education and skills training, geriatric health evaluation and management, and physical rehabilitation and occupational therapy received ineffective ratings. Other interventions received mixed effectiveness ratings. Insufficient data availability and poor study quality prevented the panelists from rating several reviewed interventions.

CONCLUSIONS

While several well-described interventions were found to treat depression effectively in community-dwelling older adults, significant gaps still exist. Interventions that did not target depression specifically may be of benefit to older adults, but they should not be presumed to treat depression by themselves. Treating depressed elders may require a multifaceted approach to ensure effectiveness. More research in this area is needed.

Can we improve the statistical analysis of stroke trials? Statistical reanalysis of functional outcomes in stroke trials

BACKGROUND AND PURPOSE

Most large acute stroke trials have been neutral. Functional outcome is usually analyzed using a yes or no answer, eg, death or dependency versus independence. We assessed which statistical approaches are most efficient in analyzing outcomes from stroke trials.

METHODS

Individual patient data from acute, rehabilitation and stroke unit trials studying the effects of interventions which alter functional outcome were assessed. Outcomes included modified Rankin Scale, Barthel Index, and "3 questions". Data were analyzed using a variety of approaches which compare 2 treatment groups. The results for each statistical test for each trial were then compared.

RESULTS

Data from 55 datasets were obtained (47 trials, 54,173 patients). The test results differed substantially so that approaches which use the ordered nature of functional outcome data (ordinal logistic regression, t test, robust ranks test, bootstrapping the difference in mean rank) were more efficient statistically than those which collapse the data into 2 groups (chi(2); ANOVA, P<0.001). The findings were consistent across different types and sizes of trial and for the different measures of functional outcome.

CONCLUSIONS

When analyzing functional outcome from stroke trials, statistical tests which use the original ordered data are more efficient and more likely to yield reliable results. Suitable approaches included ordinal logistic regression, t test, and robust ranks test.

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

BACKGROUND

Occupational therapy aims to help people reach their maximum level of function and independence in all aspects of daily life.

OBJECTIVES

To determine whether occupational therapy focused specifically on personal activities of daily living improves recovery for patients following stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched January 2006). In addition, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2006), MEDLINE (1966 to March 2006), EMBASE (1980 to March 2006), CINAHL (1983 to March 2006), PsycLIT (1974 to March 2006), AMED (1985 to March 2006), Wilson Social Sciences Abstracts (1984 to March 2006) and the following Web of Science databases: Science Citation Index (1945 to March 2006), Social Science Citation Index (1956 to March 2006) and Arts and Humanities Citation Index (1975 to March 2006). In an effort to identify further published, unpublished and ongoing trials we searched The Occupational Therapy Research Index and Dissertation Abstracts register, scanned reference lists of relevant articles, contacted authors and researchers and handsearched relevant journals.

SELECTION CRITERIA

We identified randomised controlled trials of an occupational therapy intervention (compared to usual care or no care) where stroke patients practiced personal activities of daily living, or performance in activities of daily living was the focus of the occupational therapy intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials and extracted data for pre-specified outcomes. The primary outcomes were the proportion of patients who had deteriorated or were dependent in personal activities of daily living and performance in personal activities of daily living at the end of follow up.

MAIN RESULTS

We identified 64 potentially eligible trials and included 10 studies (1348 participants). Occupational therapy interventions reduced the odds of a poor outcome (Peto odds ratio 0.67 (95% confidence interval (CI) 0.51 to 0.87; P = 0.003). and increased personal activity of daily living scores (standardised mean difference 0.18 (95% CI 0.04 to 0.32; P = 0.01). For every 11 (95% CI 7 to 30) patients receiving an occupational therapy intervention to facilitate personal activities of daily living, one patient was spared a poor outcome.

AUTHORS' CONCLUSIONS

Patients who receive occupational therapy interventions are less likely to deteriorate and are more likely to be independent in their ability to perform personal activities of daily living. However, the exact nature of the occupational therapy intervention to achieve maximum benefit needs to be defined.

Model of Hospital-Supported Discharge After Stroke

Background and Purpose— Readmission rate within 6 months after a stroke is 40% to 50%. The purpose of the project was to evaluate whether an interdisciplinary stroke team could reduce length of hospital stay, readmission rate, increase patient satisfaction and reduce dependency of help.

Methods— One hundred and ninety-eight patients with acute stroke were randomized into 103 patients whose discharge was supported by an interdisciplinary stroke team and 95 control patients who received standard aftercare. Baseline characteristics were comparable in the 2 groups. The patients were evaluated after 6 and 12 months regarding functional status and need for help.

Results— Length of hospital admission was insignificantly shorter in the intervention compared with the control group (35.2 versus 39.8 days). There was no significant difference in readmission, GP-visits, and primary health care services. Furthermore, there was no significant difference in functional scores or patient satisfaction.

Conclusions— In this setting we could not show benefit of an interdisciplinary stroke team supporting patients at discharge perhaps because standard aftercare was very efficient already.

Poststroke depression: a biopsychosocial approach

Poststroke depression (PSD) is a form of geriatric depression that is associated with various negative outcomes. This article reviews existing research concerning the etiology, treatment, and prevention of PSD with particular emphasis on the development of a biopsychosocial conceptualization of PSD etiology and treatment. Existing intervention trials are reviewed. A behavioral model of PSD treatment is presented based on a biopsychosocial understanding of PSD that highlights the potential utility of the lesion location hypothesis in the early poststroke period and the behavioral and social changes that may be linked to depression in the postacute period after stroke.

Kontrollierte Studien zur Wirksamkeit von Ergotherapie bei �lteren

OBJECTIVE

To identify the evidence for the efficacy of occupational therapy on prioritized diseases and disabilities of the elderly.

METHOD

Reviews, meta-analyses and clinical trials with control group design regarding "occupational therapy" were identified by an electronic search of pubmed and reviewed based on the CONSORT-Statement. The study results were summarised in regard to diseases and commented considering further literature.

RESULTS

A total of 31 studies were identified: 10 on stroke, 6 on dementia, 5 on prevention of falls, growing loneliness or inactivity, 4 on need of nursing care, and 6 on other diseases or disabilities. There is evidence for a positive efficacy of occupational therapy on the level of several controlled trials or reviews.

CONCLUSION

Especially in Germany, further research specific to occupational therapy is needed in the fields of depression, diabetes mellitus and nursing care in the community.

Individual Patient Data Meta-Analysis of Randomized Controlled Trials of Community Occupational Therapy for Stroke Patients

BACKGROUND AND PURPOSE

Trials of occupational therapy for stroke patients living in the community have varied in their findings. It is unclear why these discrepancies have occurred.

METHODS

Trials were identified from searches of the Cochrane Library and other sources. The primary outcome measure was the Nottingham Extended Activities of Daily Living (NEADL) score at the end of intervention. Secondary outcome measures included the Barthel Index or the Rivermead ADL (Personal ADL), General Health Questionnaire (GHQ), Nottingham Leisure Questionnaire (NLQ), and death. Data were analyzed using linear or logistic regression with a random effect for trial and adjustment for age, gender, baseline dependency, and method of follow-up. Subgroup analyses compared any occupational therapy intervention with control.

RESULTS

We included 8 single-blind randomized controlled trials incorporating 1143 patients. Occupational therapy was associated with higher NEADL scores at the end of intervention (weighted mean difference [WMD], 1.30 points, 95% confidence intervals [CI], 0.47 to 2.13) and higher leisure scores at the end of intervention (WMD, 1.51 points; 95% CI, 0.24 to 2.79). Occupational therapy emphasizing activities of daily living (ADL) was associated with improved end of intervention NEADL (WMD, 1.61 points; 95% CI, 0.72 to 2.49) and personal activities of daily living (odds ratio [OR], 0.65; 95% CI, 0.46 to 0.91), but not NLQ. Leisure-based occupational therapy improved end of intervention NLQ (WMD, 1.96 points; 95% CI, 0.27 to 3.66) but not NEADL or PADL.

CONCLUSIONS

Community occupational therapy significantly improved personal and extended activities of daily living and leisure activity in patients with stroke. Better outcomes were found with targeted interventions.

Effectiveness of home rehabilitation after stroke in Israel

On discharge from an acute general hospital after a stroke, 191 patients were in need of, and were appropriate for, multidisciplinary rehabilitation. One-hundred-and-one patients (52.4%) received it in a rehabilitation institution as inpatients (the institutional rehabilitation group (IR) group) and 91 patients received it at home (the home rehabilitation (HR) group). Patients in the HR group had their mobility, activities of daily living (ADL), range of movements, tonus, coordination and sensation determined on admission to home rehabilitation and on discharge from it, 6 weeks to 2 months later. This group contained more women and more patients able to walk with devices and who were partially independent in ADL. The IR group consisted of more men and more patients with diabetes and marked difficulties in ADL and ambulation. In both groups the Barthel index and the Frenchay activities index were determined 1 year after the stroke by way of a telephone interview and no meaningful differences were found between the two groups. IR was considerably more expensive than HR. In Israel there exists a subpopulation of acute stroke survivors in need of, and appropriate for, multidisciplinary rehabilitation that can be provided at home; such rehabilitation was found to be effective in the short and long term, as well as cost effective.

Rehabilitation therapy services for stroke patients living at home: systematic review of randomised trials

BACKGROUND

Stroke-unit care can be valuable for stroke patients in hospital, but effectiveness of outpatient care is less certain. We aimed to assess the effects of therapy-based rehabilitation services targeted at stroke patients resident in the community within 1 year of stroke onset or discharge from hospital.

METHODS

We did a systematic review of randomised trials of outpatient services, including physiotherapy, occupational therapy, and multidisciplinary teams. We used Cochrane collaboration methodology.

FINDINGS

We identified a heterogeneous group of 14 trials (1617 patients). Therapy-based rehabilitation services for stroke patients living at home reduced the odds of deteriorating in personal activities of daily living (odds ratio 0.72 [95% CI 0.57-0.92], p=0.009) and increased ability of patients to do personal activities of daily living (standardised mean difference 0.14 [95% CI 0.02-0.25], p=0.02). For every 100 stroke patients resident in the community receiving therapy-based rehabilitation services, seven (95% CI 2-11) would not deteriorate.

INTERPRETATION

Therapy-based rehabilitation services targeted at selected patients resident in the community after stroke improve ability to undertake personal activities of daily living and reduce risk of deterioration in ability. These findings should be considered in future service planning.

Interventions for treating depression after stroke

BACKGROUND

Depressive and anxiety disorders following stroke are often undiagnosed or inadequately treated. This may reflect difficulties with the diagnosis of abnormal mood among older people with stroke-related disability, but may also reflect uncertainty about the effectiveness of such therapies in this setting.

OBJECTIVES

To determine whether pharmacological, psychological, or electroconvulsive treatment (ECT) of depression in patients with stroke can improve outcome.

SEARCH STRATEGY

The Cochrane Stroke Group Trials Register (last searched June 2003). The Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2002), MEDLINE (1966 to September 2002), EMBASE (1980 to September 2002), CINAHL (1982 to September 2002), PsychINFO (1967 to September 2002), Applied Science and Technology Plus (1986 to September 2002), Arts and Humanities Index (1991 to September 2002), Biological Abstracts (1969 to September 2002), General Science Plus (1994 to September 2002), Science Citation Index (1992 to September 2002), Social Sciences Citation Index (1991 to September 2002), and Sociofile (1974 to September 2002). Reference lists from relevant articles and textbooks were searched, and authors of known studies and pharmaceutical companies who manufacture psychotropic medications were contacted.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing different types of pharmaceutical agents with placebo, or various forms of psychotherapy with standard care (or attention control), in patients with recent, clinically diagnosed, acute stroke, where treatment was explicitly intended of treat depression.

DATA COLLECTION AND ANALYSIS

Primary analyses focussed on the prevalence of diagnosable depressive disorder at the end of treatment. Secondary outcomes included depression or mood scores on standard scales, disability or physical function, death, recurrent stroke, and adverse effects. We did not pool the data for summary scores. We performed meta-analysis for only some binary endpoints and data on adverse events.

MAIN RESULTS

Nine trials, with 780 participants, were included in the review. Data were available for seven trials of pharmaceutical agents, and two trials of psychotherapy. There were no trials of ECT. The analyses were complicated by the lack of standardised diagnostic and outcome criteria, and differing analytic methods. There was no strong evidence of benefit of either pharmacotherapy or psychotherapy in terms of a complete remission of depression following stroke. There was evidence of a reduction (improvement) in scores on depression rating scales, and an increase in the proportion of participants with anxiety at the end of follow up.

REVIEWERS' CONCLUSIONS

This review found no evidence to support the routine use of pharmacotherapeutic or psychotherapeutic treatment for depression after stroke. More research is required before recommendations can be made about the most appropriate management of depression following stroke.

Interventions for preventing depression after stroke

BACKGROUND

Abnormal mood is an important consequence of stroke and may affect recovery and outcome. However, depression and anxiety are often not detected or inadequately treated. This may in part be due to doubts about whether anti-depressant treatments commenced early after the onset of stroke will prevent depression and improve outcome.

OBJECTIVES

To determine if pharmaceutical or psychological interventions can prevent the onset of depression, including depressive illness and abnormal mood, and improve physical and psychological outcomes, in patients with stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group trials register (June 2003). In addition we searched the following electronic databases: Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2002), MEDLINE (1966 to September 2002), EMBASE (1980 to September 2002), CINAHL (1982 to September 2002), PsychINFO (1967 to September 2002), Applied Science and Technology Plus (1986 to September 2002), Arts and Humanities Index (1991 to September 2002), Biological Abstracts (1969 to September 2002), General Science Plus (1994 to September 2002), Science Citation Index (1992 to September 2002), Social Sciences Citation Index (1991 to September 2002), and Sociofile (1974 to September 2002). Reference lists from relevant articles and textbooks were searched, and authors of known studies and pharmaceutical companies who manufacture psychotropic medications were contacted.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing different types of pharmaceutical agents (eg selective serotonin reuptake inhibitors) with placebo, or various forms of psychotherapy against standard care (or attention control), in patients with a recent clinical diagnosis of stroke, where the treatment was undertaken with the explicit intention of preventing depression.

DATA COLLECTION AND ANALYSIS

The primary analyses focussed on the proportion of patients who met the standard diagnostic criteria for depression applied in the trials at the end of follow-up. Secondary outcomes included depression or mood scores on standard scales, disability or physical function, death, recurrent stroke, and adverse effects.

MAIN RESULTS

Twelve trials involving 1245 participants were included in the review. Data were available for nine trials (11 comparisons) involving different pharmaceutical agents, and three trials of psychotherapy. The time from stroke onset to entry ranged from a few hours to six months, but most patients were recruited within one month of acute stroke. The duration of treatments ranged from two weeks to one year. There was no clear effect of pharmacological therapy on the prevention of depression or on other measures. A significant improvement in mood was evident for psychotherapy, but this treatment effect was small and from a single trial. There was no effect on diagnosed depression.

REVIEWERS' CONCLUSIONS

This review identified a small but significant effect of psychotherapy on improving mood, but no effect of either pharmacotherapy or psychotherapy on the prevention of depressive illness, disability, or other outcomes. More evidence is therefore required before any recommendations can be made about the routine use of such treatments to improve recovery after stroke.

Quality of the stroke rehabilitation research

The Stroke Rehabilitation Evidence-Based Review revealed a wide range of quality scores across primary studies. The aim of this section is to determine what differences there are across studies and to provide a detailed examination of methodological issues in the stroke rehabilitation literature. Methodology of each article was assessed using the Physiotherapy Evidence Database (PEDro) quality scale. Mean PEDro scores and percentage of studies meeting individual PEDro criteria were determined for all studies, for therapy-based studies only, and for drug-based studies only. It was noted that the stroke rehabilitation literature lacked rigor in the area of concealed allocation, blinding of the assessor, and intention-to-treat analysis. Investigation of the methodological quality of stroke rehabilitation literature emphasizes the need for improved treatment protocols, taking into account previous deficits, during research.

An evidence-based review of stroke rehabilitation

A comprehensive evidence-based review of stroke rehabilitation was created to be an up-to-date review of the current evidence in stroke rehabilitation and to provide specific conclusions based on evidence that could be used to help direct stroke care at the bedside and at home. A literature search using multiple data-bases was used to identify all trials from 1968 to 2001. Methodological quality of the individual randomized controlled trials was assessed using the Physiotherapy Evidence Database (PEDro) quality assessment scale. A five-stage level-of-evidence approach was used to determine the best practice in stroke rehabilitation. Over 403 treatment-based articles investigating of various areas of stroke rehabilitation were identified. This included 272 randomized controlled trials.

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

OBJECTIVE

To undertake a detailed analysis of therapy provided in a multicentred randomized controlled trial of activities of daily living (ADL) and leisure (TOTAL), testing the hypothesis that specific interventions given in the trial affected specific aspects of outcome.

SUBJECTS

Three hundred and nine stroke patients who had been randomly allocated to receive either occupational therapy aimed at ADL activities (n = 156) or leisure (n = 153).

MEASURES

Number, duration and type of activity undertaken per patient. Barthel Index, Extended Activities of Daily Living Scale (EADL) and Nottingham Leisure Questionnaire (NLQ) six months after entry to the study.

METHOD

Activities that had been used in treatment were coded and categorized. Frequently used activities identified. These activities were matched to items from the six-month outcome measures. Patient independence in these outcome items was compared between the leisure and ADL groups.

RESULTS

Three hundred and nine therapy record forms were returned. Patients received a median of ten sessions with a median duration of 55 minutes. The ADL group received significantly more, mobility training, transfer training, cleaning, dressing, cooking and bathing training (chi-squared, p < 0.05). Sport, creative activities, games, hobbies, gardening, entertainment and shopping were used significantly more in the leisure group (chi-squared, p < 0.05) than the ADL group. Fifteen items from the outcome measures were identified as specific to these interventions. There were no statistically significant differences in outcome on these 15 items between the ADL and leisure groups (chi-squared, p > 0.05).

CONCLUSIONS

We found no evidence that specific ADL or leisure interventions led to improvements in specific relevant outcomes. We believe that these findings should prompt a review of the relationship between process and outcome of occupational therapy.

Occupational therapy for stroke patients: a systematic review

BACKGROUND AND PURPOSE

Occupational therapy (OT) is an important aspect of stroke rehabilitation. The objective of this study was to determine from the available literature whether OT interventions improve outcome for stroke patients.

METHODS

An extensive search in MEDLINE, CINAHL, EMBASE, AMED, and SCISEARCH was performed. Studies with controlled and uncontrolled designs were included. Seven intervention categories were distinguished and separately analyzed. If a quantitative approach (meta-analysis) of data analysis was not appropriate, a qualitative approach (best-evidence synthesis), based on the type of design, methodological quality, and significant findings of outcome and/or process measures, was performed.

RESULTS

Thirty-two studies were included in this review, of which 18 were randomized controlled trials. Ten randomized controlled trials had a high methodological quality. For the comprehensive OT intervention, the pooled standardized mean difference for primary activities of daily living (ADL) (0.46; CI, 0.04 to 0.88), extended ADL (0.32; CI, 0.00 to 0.64), and social participation (0.33; CI, 0.03 to 0.62) favored treatment. For the training of skills intervention, some evidence for improvement in primary ADL was found. Insufficient evidence was found to indicate that the provision of splints is effective in decreasing muscle tone.

CONCLUSIONS

This review identified small but significant effect sizes for the efficacy of comprehensive OT on primary ADL, extended ADL, and social participation. These results correspond to the outcome of a systematic review of intensified rehabilitation for stroke patients. The amount of evidence with respect to specific interventions, however, is limited. More research is needed to enable evidence-based OT for stroke patients.