Occupational Therapy Improves
Personal Activities of Daily Living After Stroke
News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD
Release Date: October 2, 2007
October 2, 2007 — Occupational therapy focused on improving personal activities of daily living after stroke can improve performance and reduce the risk for deterioration in these abilities, according to the results of a meta-analysis and systematic review of randomized trials reported in the September 27 Online First issue of the BMJ.
"Stroke is the second leading cause of death in the world and the leading cause of serious, long term disability in adults; about half of those who survive are dependent on others for assistance with personal activities of daily living six months after the stroke," write Lynn Legg, CSO research training fellow, from the Glasgow Royal Infirmary University National Health Service Trust, and colleagues. "Personal activities of daily living are necessary for survival and include 'those tasks which all of us undertake every day of our lives in order to maintain our level of care' such as feeding, dressing, toileting, grooming, transferring, and mobilising.... Personal activities of daily living is a major component of treatment for people who have had a stroke."
The investigators searched and reviewed articles from the Cochrane stroke group trials register, the Cochrane central register of controlled trials, MEDLINE, EMBASE, CINAHL, PsycLIT, AMED, Wilson Social Sciences Abstracts, Science Citation Index, Social Science Citation, Arts and Humanities Citation Index, Dissertations Abstracts register, and Occupational Therapy Research Index. They also manually searched for articles, scanned reference lists, and communicated with the authors of these articles to obtain original trial data.
Inclusion criteria for these trials were evaluation of the effect of occupational therapy focused on practice of personal activities of daily living or use of performance in such activities as the target of the occupational therapy intervention in a stroke population. Two reviewers independently reviewed each trial for methodologic quality, and disagreements were resolved by consensus opinion.
There were 9 randomized controlled trials that met inclusion criteria, enrolling a total of 1258 participants. Occupational therapy focused on personal activities of daily living after a stroke was associated with increased scores on performance (standardized mean difference, 0.18; 95% confidence interval [CI], 0.04 - 0.32; P = .01) and with decreased risk for poor outcome (death, deterioration, or dependency in personal activities of daily living; odds ratio, 0.67; 95% CI, 0.51 - 0.87; P = .003). The study authors estimated that for every 100 people treated with occupational therapy focused on personal activities of daily living after a stroke, 11 (95% CI, 7 - 30) would be spared a poor outcome.
"Occupational therapy focused on improving personal activities of daily living after stroke can improve performance and reduce the risk of deterioration in these abilities," the study authors write. "Focused occupational therapy should be available to everyone who has had a stroke."
Limitations of the study include difficulty in masking; usual or standard care that may include interventions that promote activities, potentially reducing the estimate of the intervention effect; difficulty in performing randomized trials in an inpatient setting; lengthy follow-up periods with a risk for dropout from the study; and variations in the exact nature of the interventions in each study.
"Further work is required to define those individuals who are most likely to benefit from occupational therapy, and economic studies are required to examine the cost effectiveness of occupational therapy," the study authors conclude. "We believe that our findings should move the research agenda away from the questions surrounding whether occupational therapy (as a package of interventions) is effective to the identification of which specific interventions are effective for particular patients."
The Big Lottery Fund and Chest Heart and Stroke Scotland funded staff time. The study authors have disclosed no relevant financial relationships.
BMJ. Published online September 27, 2007.
Clinical Context
Although stroke remains a significant cause of mortality worldwide, the rate of stroke survival in the United States has been increasing. A study by Muntner and colleagues, which was published in the May 2002 issue of Stroke, found that the age-adjusted, race-adjusted, and sex-adjusted prevalence of stroke increased from 1.41% to 1.87% in the periods between 1971 and 1975 and 1988 and 1994. However, the estimated number of survivors of stroke who had not had institutional care increased by 930,000 during this same period.
Higher survival rates from stroke increase the number of adults living with disability. Occupational therapy has been used to improve function in daily activities and increase independence among survivors of stroke. The current meta-analysis by Legg and colleagues reviews the efficacy of occupational therapy in these outcomes.
Study Highlights
· The investigators searched multiple databases for randomized controlled trials of occupational therapy. Therapy had to be delivered by a qualified occupational therapist and focus on improving activities of daily living after a stroke. Two reviewers independently rated the methodology of the included studies.
· The primary outcome was independence in personal activities of daily living at the end of scheduled follow-up. The researchers were also interested in the outcomes of death, deterioration of ability, or dependency in personal activities. Collectively, these 3 results were labeled as "poor outcome."
· 65 trials were reviewed and assessed, and 9 studies were eventually included in the meta-analysis. These 9 trials comprised 1258 participants. The mean age of subjects varied between 55 and 87 years. 5 trials provided subjects' baseline functional data, and 4 of these trials had average Barthel index scores indicating mild or moderate disability.
· The median follow-up time was 6 months. Most studies used the Barthel index as the measure of personal activities of daily living. The mean pooled difference in the Barthel index score between the occupational therapy and control groups was 0.18, indicating a significant benefit of occupational therapy in the outcome of independence in activities of daily living. Evaluation of other means of measuring activities of daily living yielded a similar benefit associated with occupational therapy.
· The risk for a poor outcome was reduced by one third among subjects receiving occupational therapy vs control interventions. The study authors calculated that 11 patients with stroke would need to receive occupational therapy to prevent 1 additional poor outcome.
· Occupational therapy was associated with a nonsignificant benefit in mood and distress scores for participants and caregivers. Data on the use of institutional care and quality of life was incomplete and inconclusive.
Pearls for Practice
· Although the prevalence of stroke increased slightly in the United States between 1971 and 1975 and between 1988 and 1994, the rate of stroke survival also increased significantly in this interval.
· Occupational therapy improves independence in activities of daily living after a stroke and also reduces the risk for the combined outcome of death, deterioration of ability, and dependency in personal activities.