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NIHR Signal Occupational therapy several years after stroke does not improve function in severely ill care home residents

Published on 21 August 2015

doi: 10.3310/signal-000111

This trial found that a three-month individualised occupational therapy programme did not significantly improve the daily functioning (dressing, using the toilet and overall mobility) of severely physically and cognitively impaired people living in residential care who had a stroke on average three years before.

About a quarter of stroke survivors in the UK cannot return home and need residential care. Occupational therapy is recommended immediately after a stroke for those likely to benefit.

As occupational therapy did not help this severely disabled group, alternative approaches are needed.

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Why was this study needed?

Stroke is the third most common cause of disability worldwide. Around a quarter of stroke survivors in the UK require long-term stays in care homes. There is evidence, from systematic reviews of randomised controlled trials, that occupational therapy is effective for stroke survivors when delivered in their own home. However, a 2013 systematic review of occupational therapy in care homes found only one trial, including 118 people, and was therefore unable to draw firm conclusions. The NIHR funded this study to help the NHS and social care services decide whether providing occupational therapy for stroke survivors in care homes might be worthwhile.

What did this study do?

This was a randomised control trial carried out in 228 UK care homes. It included 1,042 residents who had previously suffered a stroke. The trial compared a three-month occupational therapy package with usual care. Most of the participants were severely or very severely physically disabled and had significant cognitive impairment. The average time between their stroke and starting the treatment was three years.

The tailored occupational therapy package involved occupational therapists working with residents to help them to maintain or improve their ability to carry out everyday tasks – such as dressing, using the toilet and overall mobility. In addition, care home staff were given training to raise awareness of stroke-related disabilities and how to manage them over the long term. Usual care was the standard care provided in care homes, either by nursing or non-nursing staff.

Potential bias was minimised by concealing treatment allocation from those assessing changes in disability, and by lessening the impact of the type of care home or its location.

What did it find?

  • There was no difference in disability, mood, mobility or quality of life in those receiving occupational therapy compared with usual care at three, six or 12 month assessments. Changes in scores on these scales were not considered statistically or clinically significant.
  • Adjusting for factors like residents’ age, type of care home, degree of disability and level of cognitive impairment did not alter the main results.
  • There were no adverse events from the occupational therapy.
  • Occupational therapy was not cost-effective compared with usual care, and involved care homes having to buy equipment.

What does current guidance say on this issue?

2013 NICE guideline on stroke rehabilitation recommends that occupational therapists are part of the core multidisciplinary team and that occupational therapy is offered immediately to stroke survivors likely to benefit. Occupational therapy may consist of either restorative therapy, such as encouraging the person to use their weaker arm more, or compensatory therapy, such as teaching the person to dress one-handed. The guideline does not include criteria detailing which patients are “likely to benefit” from occupational therapy.

What are the implications?

This trial shows that stroke survivors in care homes with severe disability and cognitive impairment do not benefit from occupational therapy given more than a year after stroke.  The funds that might be used on this therapy might be better spent on other ways of improving well-being and, perhaps, ensuring that equipment and services are available in care homes for people sooner after their stroke.

Citation

Sackley, CM, Walker MF, Burton CR et al. An occupational therapy intervention for residents with stroke related disabilities in UK care homes (OTCH): cluster randomised controlled trial. BMJ 2015;350:h468.

This project was funded by the National Institute for Health Research Health Technology Assessment programme (project number 08/14/30)

Bibliography

Fletcher-Smith JC, Walker MF, Cobley CS et al. Occupational therapy for care home residents with stroke. Cochrane Database Syst Rev. 2013;6:CD010116.

NICE. Stroke rehabilitation: Long-term rehabilitation after stroke. CG162. London: National Institute for Health and Care Excellence; 2013.

Why was this study needed?

Stroke is the third most common cause of disability worldwide. Around a quarter of stroke survivors in the UK require long-term stays in care homes. There is evidence, from systematic reviews of randomised controlled trials, that occupational therapy is effective for stroke survivors when delivered in their own home. However, a 2013 systematic review of occupational therapy in care homes found only one trial, including 118 people, and was therefore unable to draw firm conclusions. The NIHR funded this study to help the NHS and social care services decide whether providing occupational therapy for stroke survivors in care homes might be worthwhile.

What did this study do?

This was a randomised control trial carried out in 228 UK care homes. It included 1,042 residents who had previously suffered a stroke. The trial compared a three-month occupational therapy package with usual care. Most of the participants were severely or very severely physically disabled and had significant cognitive impairment. The average time between their stroke and starting the treatment was three years.

The tailored occupational therapy package involved occupational therapists working with residents to help them to maintain or improve their ability to carry out everyday tasks – such as dressing, using the toilet and overall mobility. In addition, care home staff were given training to raise awareness of stroke-related disabilities and how to manage them over the long term. Usual care was the standard care provided in care homes, either by nursing or non-nursing staff.

Potential bias was minimised by concealing treatment allocation from those assessing changes in disability, and by lessening the impact of the type of care home or its location.

What did it find?

  • There was no difference in disability, mood, mobility or quality of life in those receiving occupational therapy compared with usual care at three, six or 12 month assessments. Changes in scores on these scales were not considered statistically or clinically significant.
  • Adjusting for factors like residents’ age, type of care home, degree of disability and level of cognitive impairment did not alter the main results.
  • There were no adverse events from the occupational therapy.
  • Occupational therapy was not cost-effective compared with usual care, and involved care homes having to buy equipment.

What does current guidance say on this issue?

2013 NICE guideline on stroke rehabilitation recommends that occupational therapists are part of the core multidisciplinary team and that occupational therapy is offered immediately to stroke survivors likely to benefit. Occupational therapy may consist of either restorative therapy, such as encouraging the person to use their weaker arm more, or compensatory therapy, such as teaching the person to dress one-handed. The guideline does not include criteria detailing which patients are “likely to benefit” from occupational therapy.

What are the implications?

This trial shows that stroke survivors in care homes with severe disability and cognitive impairment do not benefit from occupational therapy given more than a year after stroke.  The funds that might be used on this therapy might be better spent on other ways of improving well-being and, perhaps, ensuring that equipment and services are available in care homes for people sooner after their stroke.

Citation

Sackley, CM, Walker MF, Burton CR et al. An occupational therapy intervention for residents with stroke related disabilities in UK care homes (OTCH): cluster randomised controlled trial. BMJ 2015;350:h468.

This project was funded by the National Institute for Health Research Health Technology Assessment programme (project number 08/14/30)

Bibliography

Fletcher-Smith JC, Walker MF, Cobley CS et al. Occupational therapy for care home residents with stroke. Cochrane Database Syst Rev. 2013;6:CD010116.

NICE. Stroke rehabilitation: Long-term rehabilitation after stroke. CG162. London: National Institute for Health and Care Excellence; 2013.

An occupational therapy intervention for residents with stroke related disabilities in UK care homes (OTCH): cluster randomised controlled trial

Published on 7 February 2015

Sackley, C. M.,Walker, M. F.,Burton, C. R.,Watkins, C. L.,Mant, J.,Roalfe, A. K.,Wheatley, K.,Sheehan, B.,Sharp, L.,Stant, K. E.,Fletcher-Smith, J.,Steel, K.,Wilde, K.,Irvine, L.,Peryer, G.

BMJ Volume 350 , 2015

OBJECTIVE: To evaluate the clinical efficacy of an established programme of occupational therapy in maintaining functional activity and reducing further health risks from inactivity in care home residents living with stroke sequelae. DESIGN: Pragmatic, parallel group, cluster randomised controlled trial. SETTING: 228 care homes (>10 beds each), both with and without the provision of nursing care, local to 11 trial administrative centres across the United Kingdom. PARTICIPANTS: 1042 care home residents with a history of stroke or transient ischaemic attack, including those with language and cognitive impairments, not receiving end of life care. 114 homes (n=568 residents, 64% from homes providing nursing care) were allocated to the intervention arm and 114 homes (n=474 residents, 65% from homes providing nursing care) to standard care (control arm). Participating care homes were randomised between May 2010 and March 2012. INTERVENTION: Targeted three month programme of occupational therapy, delivered by qualified occupational therapists and assistants, involving patient centred goal setting, education of care home staff, and adaptations to the environment. MAIN OUTCOME MEASURES: Primary outcome at the participant level: scores on the Barthel index of activities of daily living at three months post-randomisation. Secondary outcome measures at the participant level: Barthel index scores at six and 12 months post-randomisation, and scores on the Rivermead mobility index, geriatric depression scale-15, and EuroQol EQ-5D-3L questionnaire, at all time points. RESULTS: 64% of the participants were women and 93% were white, with a mean age of 82.9 years. Baseline characteristics were similar between groups for all measures, personal characteristics, and diagnostic tests. Overall, 2538 occupational therapy visits were made to 498 participants in the intervention arm (mean 5.1 visits per participant). No adverse events attributable to the intervention were recorded. 162 (11%) died before the primary outcome time point, and 313 (30%) died over the 12 months of the trial. The primary outcome measure did not differ significantly between the treatment arms. The adjusted mean difference in Barthel index score at three months was 0.19 points higher in the intervention arm (95% confidence interval -0.33 to 0.70, P=0.48). Secondary outcome measures also showed no significant differences at all time points. CONCLUSIONS: This large phase III study provided no evidence of benefit for the provision of a routine occupational therapy service, including staff training, for care home residents living with stroke related disabilities. The established three month individualised course of occupational therapy targeting stroke related disabilities did not have an impact on measures of functional activity, mobility, mood, or health related quality of life, at all observational time points. Providing and targeting ameliorative care in this clinically complex population requires alternative strategies.Trial registration Current Controlled Trials ISRCTN00757750.

Adaptive equipment plays a vital role in supporting and improving stroke survivors’ daily functioning and lives. Adaptive equipment includes grab rails to help people move around, raised toilet seats to make it easier to go to the loo, and modified cutlery to help people feed themselves. Lots of adaptive equipment is available on loan from the NHS or local councils, and stroke survivors can apply for funding for adaptations to their home up to £1,000. But this RCT found the provision of adaptive equipment was generally low and varied amongst care homes. This potentially limits rehabilitation and worsens outcomes for stroke survivors in care homes, who are already more impaired than community-based stroke survivors.

Expert commentary

This study shows that very elderly frail people with cognitive impairment years after stroke do not seem to benefit from an occupational therapy programme that does appear to work for people living at home soon after stroke. The patients in this study were very frail and cognitively impaired and it is not at all clear whether their frailty is stroke related or due to other co morbidities such as dementia. This does not mean that people in care homes should not be encouraged to be independent or participate in activities, but it does suggest that a rehabilitation approach does not work for people with significant co morbidities and impairments. It is likely that other participatory activities such as exercise and music may improve peoples’ well-being in care homes but this study clearly demonstrates that occupational therapy to everyone in care homes with a history of stroke is of no benefit.

Professor Pippa Tyrrell, Professor of Stroke Medicine, Salford Royal Hospitals' Foundation Trust