Cochrane for Clinicians

Putting Evidence into Practice

Occupational Therapy Improves Activities of Daily Living After Stroke

NATHAN HITZEMAN, MD, and MIMI REISS, MD,
Sutter Health Family Medicine Residency Program, Sacramento, California

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.

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.

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, Greenlund 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.

Cochrane Briefs

Fecal Occult Blood Tests Reduce Colorectal Cancer Mortality

Clinical Question

Should physicians use fecal occult blood testing to screen for colorectal cancer?

Evidence-Based Answer

Fecal occult blood testing reduces colorectal cancer mortality by 16 percent. Annual testing and rehydration of samples increases testing sensitivity but also increases the number of false-positive results.

Practice Pointers

Colorectal cancer is the third most common cancer in the United States, affecting 46 out of 10,000 women and 63 out of 10,000 men. U.S. Preventive Services Task Force and American Cancer Society guidelines recommend multiple options for screening average-risk patients. These options include annual fecal occult blood testing, flexible sigmoidoscopy, home fecal occult blood testing plus flexible sigmoidoscopy, colonoscopy, and double-contrast barium enema.1,2 Average-risk patients are those with no history of rectal bleeding, adenomatous polyps of the colon, or inflammatory bowel disease. There are specific screening guidelines for patients who have a family history of colorectal cancer or genetic cancer syndromes. Most higher-risk patients require a colonoscopy for initial screening.2

This Cochrane review included four randomized controlled trials (329,642 total patients) of fecal occult blood testing to screen for colorectal cancer. Outcomes included test sensitivity and reduction in all-cause and colorectal cancer mortality.

The review showed that fecal occult blood testing reduces colorectal cancer mortality by 16 percent (relative risk = 0.84; 95% confidence interval [CI], 0.78 to 0.90). Rates of patient compliance to testing ranged from 59 to 75 percent. Test sensitivity was highest in rehydrated samples, with 82 to 92 percent sensitivity for colorectal cancer or adenoma. Nonrehydrated samples had a sensitivity of 55 to 57 percent. Colorectal cancers were also detected earlier in the screening group. The positive predictive value of the fecal occult blood test (percentage of patients with a positive test who actually had cancer) ranged from 0.9 to 18.7 percent. Fecal occult blood testing did not reduce all-cause mortality.

Fecal occult blood testing is a cost-effective, noninvasive screening method for colon cancer. Although endoscopy has higher specificity for colorectal cancer, screening recommendations for colonoscopy and flexible sigmoidoscopy are based on case-control studies. In fact, there is no direct evidence that endoscopic screening reduces all-cause or colorectal cancer mortality.1 These tests also require more patient preparation and have a higher risk. Fecal occult blood testing remains a good screening option for average-risk, compliant patients.

CHRISTOPHER W. WALKER, maj, usaf, mc

Author disclosure: Nothing to disclose.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force Medical Department or the U.S. Air Force Service at large.

Source: Hewitson P, Glasziou P, Irwig L, Towler B, Watson E. Screening for colorectal cancer using the fecal occult blood test, Hemoccult. Cochrane Database Syst Rev 2007;(1):CD001216.

REFERENCES

1. U.S. Preventive Services Task Force. Screening for colorectal cancer: recommendations and rationale. Ann Intern Med 2002;137:129-31.

2. Smith RA, Cokkinides V, Eyre HJ. American Cancer Society guidelines for the early detection of cancer, 2006. CA Cancer J Clin 2006;56:11-25.

Adenosine vs. Calcium Channel Blockers for Supraventricular Tachycardia

Clinical Question

How do the safety and effectiveness of adenosine (Adenocard) and calcium channel blockers compare in the treatment of supraventricular tachycardia?

Evidence-Based Answer

Adenosine and verapamil (Calan, Isoptin SR) are equally effective for treating acute supraventricular tachycardia in adults. Patients treated with adenosine have a higher rate of minor, transient adverse effects than patients treated with verapamil; however, rare but serious adverse effects may be more common with verapamil, especially in children. Although both agents are appropriate options, adenosine is generally the preferred initial agent.

Practice Pointers

Paroxysmal supraventricular tachycardia is usually caused by the development of a reentry circuit from anterograde and retrograde conduction through the atrioventricular node. In hemodynamically stable patients, initial management is focused on interrupting or modifying conduction in the atrioventricular node with vagal techniques
(e.g., Valsalva maneuver, carotid artery massage, facial immersion in cold water). These techniques will terminate approximately 20 to 25 percent of episodes.1 If paroxysmal supraventricular tachycardia persists, adenosine and the nondihydropyridine calcium channel blockers verapamil and diltiazem (Cardizem) have been widely used for the condition.

This Cochrane review, which included eight studies and 577 total patients, found that adenosine and calcium channel blockers are equally effective in patients with paroxysmal supraventricular tachycardia. Only one study included children. Treatment groups in all studies were balanced in age and physiologic characteristics. However, most studies did not provide sufficient information about allocation concealment, blinding, and intention-to-treat analysis.

Minor adverse effects were more common in patients receiving adenosine, although the effects were typically short-lived. Conversely, major adverse effects, although uncommon, occurred only in patients treated with verapamil. These effects included two cardiac arrests (both occurred in children) and three episodes of hypotension.

Because of adenosine's rapid onset, short half-life, and favorable safety profile, the American College of Cardiology, American Heart Association (AHA), and European Society of Cardiology recommend adenosine as the preferred agent for the pharmacologic management of paroxysmal supraventricular tachycardia.2 The AHA Advanced Cardiac Life Support guideline recommends initially administering a 6-mg adenosine bolus over one to three seconds followed by a 20-mL saline flush.1 If this does not convert the rhythm, a 12-mg bolus should follow; a second 12-mg bolus may be given if the first is ineffective.1 Before adenosine is administered, patients should be counseled about the common adverse effects associated with the drug.

Nondihydropyridine calcium channel blockers should be second-line agents or used in patients with contraindications to adenosine. If the patient initially improves with adenosine therapy, but paroxysmal supraventricular tachycardia quickly returns, verapamil and diltiazem may be useful because of their longer half-lives. Ultimately, good clinical judgment based on the patient's characteristics, comorbidities, and preferences should guide the choice of agents.

CHiNASA ANUGWOM, MD
SHERYL SULANGI, MD
ROBERT DACHS, MD

Author disclosure: Nothing to disclose.

Source: Holdgate A, Foo A. Adenosine versus intravenous calcium channel antagonists for the treatment of supraventricular tachycardia in adults. Cochrane Database Syst Rev 2006;(4):CD005154.

REFERENCES

1. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 7.3. Management of symptomatic bradycardia and tachycardia. Circulation 2005;112(suppl I):IV67-IV77.

2. Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ, et al. American College of Cardiology. American Heart Association. European Society of Cardiology. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias-executive summary. J Am Coll Cardiol 2003;42:1493-531.

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

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

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