Cochrane for Clinicians

Putting Evidence into Practice

Occupational Therapy Improves Activities of Daily Living After Stroke

Am Fam Physician. 2007 Jun 1;75(11):1651-1652.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). See Clinical Quiz on page 1617.

Clinical Scenario

A 74-year-old woman has continued left-sided hemiparesis after having a stroke one week ago. She is about to be discharged from the hospital, and her son has some questions about the benefit of outpatient occupational therapy to improve her function at home.

Clinical Question

Compared with usual care, how effective is occupational therapy focused specifically on activities of daily living (ADL) in improving ADL, morbidity, and mortality in patients who recently have had a stroke?

Evidence-Based Answer

Compared with standard rehabilitation, ADL-based occupational therapy significantly decreases death or institutionalization and deterioration in the ability to perform ADL after stroke. The optimal length and type of therapy is not well defined.1

Practice Pointers

Stroke is the leading cause of adult disability in the United States and has an estimated annual cost of $62.7 billion.2 Although thrombolytic therapy benefits some patients with ischemic stroke, many patients are left with significant impairment. Besides optimizing antiplatelet therapy and managing the underlying disease, physicians are often limited in what therapies they can provide. Studies showing that occupational therapy improves ADL after stroke may not be surprising; however, it is important to know the degree of benefit that this therapy can provide.

This Cochrane review included nine studies of home-based occupational therapy to improve ADL. Characteristics among these studies varied. Randomization was not fully described in one study, and another study included only bathing devices. Initiation of home therapy ranged from immediately after hospital discharge to between two weeks and six months after hospital discharge. In general, therapy sessions lasted 30 minutes, but the frequency of the sessions ranged from four to 18 visits over six months. Not all trials used the same scale for ADL scoring. Six trials used the Barthel index (minimal score 0, maximal score 20). In these trials, the average baseline Barthel index score ranged from 14 to 18, but one trial had a much lower average baseline score of 10.

The authors conclude that for every 11 patients treated with ADL-focused occupational therapy over a six-month period, one patient avoids death, institutionalization, or significant decline in ADL score. However, the largest study in the meta-analysis (including 37 percent of 1,258 total patients) did not show more benefit with occupational therapy than with standard rehabilitation.3 The authors also conclude that limiting the meta-analysis to the four studies with clear intention-to-treat protocols appears to reduce the effect of treatment.

Benefits in poststroke management have been better characterized for other treatments. Aspirin use and in-hospital stroke rehabilitation are beneficial after acute ischemic stroke.4 Antiplatelet, blood pressure, and cholesterol therapy are beneficial for secondary prevention of ischemic stroke.5 There is no evidence that any antiplatelet regimen is more cost-effective than aspirin alone. The American Heart Association has clinical guidelines for using physical activity and exercise to improve ADL after stroke.6 More information about ongoing stroke trials and downloadable clinical tools are available at http://www.strokecenter.org.

Cochrane Abstract

Background. Occupational therapy aims to help patients reach their maximal 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 (ADL) 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 (the Cochrane Library issue 1, 2006), Medline (1996 to March 2006), Embase (1980 to March 2006), Cinahl (1983 to March 2006), Psyclit (1974 to March 2006), Amed (1985 to March 2006), and Wilson Social Sciences Abstracts (1984 to March 2006). We also searched the following Web of Science databases: Science Citation Index (1975 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 manually searched relevant journals.

Selection Criteria. We identified randomized controlled trials of an occupational therapy intervention (compared with usual care or no care) in which stroke patients practiced personal ADL or in which performance in ADL was the focus of the intervention.

Data Collection and Analysis. Two review authors independently selected trials and extracted data for prespecified outcomes. The primary outcomes were the proportion of patients who had deteriorated or were dependent in personal ADL and performance in personal ADL at the end of follow-up.

Main Results. We identified 64 potentially eligible trials and included nine studies (1,258 participants). Occupational therapy interventions reduced the odds of poor outcomes (Peto odds ratio = 0.67; 95% confidence interval [CI], 0.51 to 0.87; P = .003), and increased personal ADL scores (standardized mean difference = 0.18; 95% CI, 0.04 to 0.32; P = .01). For every 11 patients (95% CI, 7 to 30) receiving an occupational therapy intervention to facilitate personal ADL, 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 ADL. However, the exact nature of an occupational therapy intervention to achieve maximal benefit needs to be defined.

Address correspondence to Nathan Hitzeman, MD, at hitzemn@sutterhealth.org. Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

REFERENCES

1. Legg LA, Drummond AE, Langhorne P. Occupational therapy for patients with problems in activities of daily living after stroke. Cochrane Database Syst Rev. 2006;(4):CD003585.

2. Rosamond W, Flegal K, Friday G, Furie K, Go A, Green-lund K, et al. Heart disease and stroke statistics—2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee [Published correction appears in Circulation 2007;115:e172]. Circulation. 2007;115:e69–171.

3. Parker CJ, Gladman JR, Drummond AE, Dewey ME, Lincoln NB, Barer D, et al., for the TOTAL Study Group. A multicentre randomized controlled trial of leisure therapy and conventional occupational therapy after stroke. Trial of Occupational Therapy and Leisure. Clin Rehabil. 2001;15:42–52.

4. Warburton E. Stroke management. Clin Evid 2006;15:229–42. Accessed March 29, 2007, at: http://www.clinicalevidence.com/ceweb/conditions/cvd/0201/0201_17.jsp.

5. Lip GH, Rothwell P, Sudlow C. Stroke prevention. Clin Evid 2005;14:173–97. Accessed March 29, 2007, at: http://www.clinicalevidence.com/ceweb/conditions/cvd/0207/0207_19.jsp.

6. Gordon NF, Gulanick M, Costa F, Fletcher G, Franklin BA, Roth EJ, et al. Physical activity and exercise recommendations for stroke survivors: an American Heart Association scientific statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Circulation. 2004;109:2031–41.

The Cochrane Abstract is a summary of a review from the Cochrane Library. It is accompanied by an interpretation that will help clinicians put evidence into practice. Drs. Hitzeman and Reiss present a clinical scenario and question based on the Cochrane Abstract, followed by an evidence-based answer and a critique of the review. The practice recommendations in this activity are available at http://www.cochrane.org/reviews/en/ab003585.html.

The series coordinator for AFP is Clarissa Kripke, MD, Department of Family and Community Medicine, University of California, San Francisco.


Copyright © 2007 by the American Academy of Family Physicians.
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