Occupational therapy for stroke survivors in UK care homes

Stroke is a major contributor to the global burden of disease. It is the third main cause of death and the largest cause of adult disability in the UK. Stroke is reported to be the second most common cause of disability after dementia in the UK care home population with an estimated 25% of residents living with the consequences of stroke. The aim of this PhD programme of research was to explore the current research evidence for the provision of occupational therapy to stroke survivors living in care homes; investigate current routine occupational therapy practice for this specific stroke population in UK care homes; and to contribute original new knowledge on the health outcomes of sub groups of the care home population with stroke. This study was divided into four distinct projects that were completed alongside a National Institute for Health Research funded phase III multi-centre cluster randomised controlled trial of occupational therapy for care home residents with stroke known as the ‘OTCH study’. The OTCH study evaluated the efficacy of delivering occupational therapy interventions targeted towards increasing and maintaining independent performance of personal self-care activities of daily living and mobility. The PhD student was a member of the OTCH study team with responsibility for delivering the intervention at the Nottingham site. A PhD studentship from the University of Nottingham enabled the development of this complimentary and integrated programme of research. Stage one (reported in chapter two) involved the completion of a Cochrane systematic review and meta-analysis as a means of systematically appraising published randomised controlled trials of occupational therapy interventions for care home residents with stroke to the highest gold standard. Systematic searching identified 1,436 unduplicated records however only 1 study met the inclusion criteria, with another trial ongoing. There was insufficient evidence from the reviewed randomised controlled trial to determine that occupational therapy improves outcomes for care home residents with stroke and therefore further high quality research in this area is needed. Stage two (reported in chapter three) involved a national online survey study to provide contextual demographic data, along with data on the aims, content, funding and provision of occupational therapy services currently being delivered to stroke survivors residing in UK care homes. Out of a total of 138 completed questionnaires, data were analysed from 114 respondents who met the eligibility criteria of providing assessment and treatment to residents in a care home setting. The survey findings confirmed that occupational therapy is being delivered in some care homes; however, interventions for residents with stroke are not routinely delivered by stroke specialist occupational therapists and are not routinely delivered using a systematic, evidence-based approach. Stage three (reported in chapter four) utilised the raw data from the 1,042 participants recruited to the OTCH study to perform subgroup analysis and predictive modelling (including regression modelling and generalised estimating equation (GEE) modelling) with the aim of further investigating the effect of occupational therapy on various subgroups of the participant sample. Subgroup analysis determined that age, time since stroke onset, cognitive status, mood and pain made no difference to the effect of a three month occupational therapy intervention aimed at improving or maintaining independence in basic ADLs (as measured by the Barthel Index (BI)). Predictive modelling found type of care home (residential or nursing) and cognitive status (dementia or normal cognition) to be a far greater predictor of ADL performance and mobility outcome than whether or not the resident had received the occupational therapy intervention. Stage four (reported in chapter five) involved analysis of the content of occupational therapy intervention delivered to the OTCH study participants and their performance in self-care ADLs to account for possible reasons why the trial produced neutral results by (1) exploring the content of the treatment that the intervention arm participants received from the study occupational therapists; and (2) investigating the performance of those participants who had received the allocated occupational therapy intervention, whilst accounting for possible predictor covariates. Binary logistic regression was used to model the relationship between the dependent outcome variable and the explanatory predictor variables. Results of the analyses demonstrated that the therapists did not allocate their time according to those with greater levels of disability and higher levels of need. Residents with dementia received less therapy input than those with mild cognitive impairment or normal cognition. Cognitive status was the strongest predictor of functional outcome. The thesis concludes by highlighting the implications of this new body of research evidence for occupational therapy clinical practice, policy, and future research

Recovery of dressing ability after stroke

The research programme was designed to coincide with a separate phase II randomised controlled trial (RCT) of a Neuropsychological approach to dressing rehabilitation after stroke entitled ‘Dressing Rehabilitation Evaluation Stroke Study’ (DRESS). This research programme incorporated the cohort of participants from the DRESS study. It was an original piece of work that involved three separate but related research studies. The first project involved an inter-rater reliability study of the Nottingham Stroke Dressing Assessment (NSDA) and accompanying error analysis form which is the primary outcome measure used in the DRESS RCT. The inter-rater reliability study measured agreement between three raters’ dressing assessments on twenty patients. Of the 44 items on the NSDA that could be tested, there was excellent agreement (k >0.75) on 29 items, good agreement (k >0.6) on 8 items, fair agreement (k >0.4) on 5 items, and poor agreement (k 0.75) on 2 items, good agreement (k >0.6) on 4 items, and fair agreement (k >0.4) on 1 items. The aim of the second study was to explore to what extent upper limb hemiparesis affects dressing performance in the presence of cognitive impairment. Using a cohort of 70 participants from the ‘DRESS study’, this study explored the dressing performance of cognitively impaired stroke survivors who had bilateral hand function as compared with unilateral hand function. A Chi-square test for independence indicated a strong association between dressing method and dressing success, χ2 (1, n=70) = 12.79, p<0.001, phi=0.47. Of those who were unsuccessful at dressing at baseline, a Mann-Whitney U test revealed a significant difference in NSDA scores between the bi-manual group (median=78) and the uni-manual group (median=29). U=118, Z=-4.045, p<0.001, r=0.6. The results indicated that the ability to use both hands in the presence of cognitive impairment had a positive effect on dressing performance. The final study was an acceptability study which was carried out to survey the participants on the DRESS study. An acceptability questionnaire was devised and used to conduct structured interviews with the DRESS study participants during their final outcome assessment. The aim was to explore patients’ experiences of being a participant on the DRESS study phase II randomised controlled trial and to ascertain their opinion on the importance of independent dressing, the usefulness and efficacy of the different dressing treatments, the frequency and duration of dressing treatment sessions, and their perceptions of the success of the DRESS study treatment approaches. The majority of participants felt that it was “very important” (n=34) or “quite important” (n=10) to be able to dress on their own without help. Similarly, the majority of participants (n=44) felt that dressing was an important part of their recovery from stroke. All aspects of the DRESS study were considered to be acceptable and there was no significant difference in participants’ responses between the two treatment groups

Occupational therapy for stroke survivors in UK care homes

Stroke is a major contributor to the global burden of disease. It is the third main cause of death and the largest cause of adult disability in the UK. Stroke is reported to be the second most common cause of disability after dementia in the UK care home population with an estimated 25% of residents living with the consequences of stroke. The aim of this PhD programme of research was to explore the current research evidence for the provision of occupational therapy to stroke survivors living in care homes; investigate current routine occupational therapy practice for this specific stroke population in UK care homes; and to contribute original new knowledge on the health outcomes of sub groups of the care home population with stroke. This study was divided into four distinct projects that were completed alongside a National Institute for Health Research funded phase III multi-centre cluster randomised controlled trial of occupational therapy for care home residents with stroke known as the ‘OTCH study’. The OTCH study evaluated the efficacy of delivering occupational therapy interventions targeted towards increasing and maintaining independent performance of personal self-care activities of daily living and mobility. The PhD student was a member of the OTCH study team with responsibility for delivering the intervention at the Nottingham site. A PhD studentship from the University of Nottingham enabled the development of this complimentary and integrated programme of research. Stage one (reported in chapter two) involved the completion of a Cochrane systematic review and meta-analysis as a means of systematically appraising published randomised controlled trials of occupational therapy interventions for care home residents with stroke to the highest gold standard. Systematic searching identified 1,436 unduplicated records however only 1 study met the inclusion criteria, with another trial ongoing. There was insufficient evidence from the reviewed randomised controlled trial to determine that occupational therapy improves outcomes for care home residents with stroke and therefore further high quality research in this area is needed. Stage two (reported in chapter three) involved a national online survey study to provide contextual demographic data, along with data on the aims, content, funding and provision of occupational therapy services currently being delivered to stroke survivors residing in UK care homes. Out of a total of 138 completed questionnaires, data were analysed from 114 respondents who met the eligibility criteria of providing assessment and treatment to residents in a care home setting. The survey findings confirmed that occupational therapy is being delivered in some care homes; however, interventions for residents with stroke are not routinely delivered by stroke specialist occupational therapists and are not routinely delivered using a systematic, evidence-based approach. Stage three (reported in chapter four) utilised the raw data from the 1,042 participants recruited to the OTCH study to perform subgroup analysis and predictive modelling (including regression modelling and generalised estimating equation (GEE) modelling) with the aim of further investigating the effect of occupational therapy on various subgroups of the participant sample. Subgroup analysis determined that age, time since stroke onset, cognitive status, mood and pain made no difference to the effect of a three month occupational therapy intervention aimed at improving or maintaining independence in basic ADLs (as measured by the Barthel Index (BI)). Predictive modelling found type of care home (residential or nursing) and cognitive status (dementia or normal cognition) to be a far greater predictor of ADL performance and mobility outcome than whether or not the resident had received the occupational therapy intervention. Stage four (reported in chapter five) involved analysis of the content of occupational therapy intervention delivered to the OTCH study participants and their performance in self-care ADLs to account for possible reasons why the trial produced neutral results by (1) exploring the content of the treatment that the intervention arm participants received from the study occupational therapists; and (2) investigating the performance of those participants who had received the allocated occupational therapy intervention, whilst accounting for possible predictor covariates. Binary logistic regression was used to model the relationship between the dependent outcome variable and the explanatory predictor variables. Results of the analyses demonstrated that the therapists did not allocate their time according to those with greater levels of disability and higher levels of need. Residents with dementia received less therapy input than those with mild cognitive impairment or normal cognition. Cognitive status was the strongest predictor of functional outcome. The thesis concludes by highlighting the implications of this new body of research evidence for occupational therapy clinical practice, policy, and future research

Recovery of dressing ability after stroke

The research programme was designed to coincide with a separate phase II randomised controlled trial (RCT) of a Neuropsychological approach to dressing rehabilitation after stroke entitled ‘Dressing Rehabilitation Evaluation Stroke Study’ (DRESS). This research programme incorporated the cohort of participants from the DRESS study. It was an original piece of work that involved three separate but related research studies. The first project involved an inter-rater reliability study of the Nottingham Stroke Dressing Assessment (NSDA) and accompanying error analysis form which is the primary outcome measure used in the DRESS RCT. The inter-rater reliability study measured agreement between three raters’ dressing assessments on twenty patients. Of the 44 items on the NSDA that could be tested, there was excellent agreement (k >0.75) on 29 items, good agreement (k >0.6) on 8 items, fair agreement (k >0.4) on 5 items, and poor agreement (k 0.75) on 2 items, good agreement (k >0.6) on 4 items, and fair agreement (k >0.4) on 1 items. The aim of the second study was to explore to what extent upper limb hemiparesis affects dressing performance in the presence of cognitive impairment. Using a cohort of 70 participants from the ‘DRESS study’, this study explored the dressing performance of cognitively impaired stroke survivors who had bilateral hand function as compared with unilateral hand function. A Chi-square test for independence indicated a strong association between dressing method and dressing success, χ2 (1, n=70) = 12.79, p<0.001, phi=0.47. Of those who were unsuccessful at dressing at baseline, a Mann-Whitney U test revealed a significant difference in NSDA scores between the bi-manual group (median=78) and the uni-manual group (median=29). U=118, Z=-4.045, p<0.001, r=0.6. The results indicated that the ability to use both hands in the presence of cognitive impairment had a positive effect on dressing performance. The final study was an acceptability study which was carried out to survey the participants on the DRESS study. An acceptability questionnaire was devised and used to conduct structured interviews with the DRESS study participants during their final outcome assessment. The aim was to explore patients’ experiences of being a participant on the DRESS study phase II randomised controlled trial and to ascertain their opinion on the importance of independent dressing, the usefulness and efficacy of the different dressing treatments, the frequency and duration of dressing treatment sessions, and their perceptions of the success of the DRESS study treatment approaches. The majority of participants felt that it was “very important” (n=34) or “quite important” (n=10) to be able to dress on their own without help. Similarly, the majority of participants (n=44) felt that dressing was an important part of their recovery from stroke. All aspects of the DRESS study were considered to be acceptable and there was no significant difference in participants’ responses between the two treatment groups

An occupational therapy intervention for residents with stroke living in care homes in the United Kingdom: A content analysis of occupational therapy records from the OTCH trial

Introduction: This study aimed to describe the content of occupational therapy delivered in a randomized controlled trial of United Kingdom care home residents with stroke (The Occupational Therapy in Care Homes (OTCH) trial). The trial intervention aimed to maintain or improve residents’ activity levels in relation to personal activities of daily living and mobility. Method: A qualitative design was adopted using content analysis to thematically code and analyse the occupational therapy notes of residents in the intervention arm of the trial. Treatment notes comprised of an initial assessment, a goal and treatment plan and a description of activities at each visit. A purposive sample of 50 sets of therapy notes was selected reflecting the geographical locations, care home types and resident characteristics observed in the OTCH trial intervention group. Findings: Occupational therapists individually assessed residents’ function and goals. Planning was sometimes client-centred, but not all residents were able to share personal goals. Carers impacted on the success of the intervention. Treatment outcomes in relation to increasing functional activity were noted in some cases, but not always fully realized in this frail population. Conclusion: Increasing functional activity is challenging in care home populations; future studies should assess occupational therapy for residents in relation to leisure or social activities

A systematic review of peer mentoring interventions for people with traumatic brain injury

Objective: This systematic review sought evidence concerning the effectiveness of peer mentoring for people with traumatic brain injury.Data sources: Fourteen electronic databases were searched, including PsycINFO, MEDLINE, CINAHL, EMBASE and the Cochrane Library, from inception to September 21 2016. Ten grey literature databases, PROSPERO, two trials registers, reference lists and author citations were also searched.Review methods: Studies which employed a model of one-to-one peer mentoring between traumatic brain injury survivors were included. Two reviewers independently screened all titles and abstracts before screening full texts of shortlisted studies. A third reviewer resolved disagreements. Two reviewers independently extracted data and assessed studies for quality and risk of bias.Results: The search returned 753 records, including one identified through hand searching. 495 records remained after removal of duplicates and 459 were excluded after screening. Full texts were assessed for the remaining 36 studies and six met the inclusion criteria. All were conducted in the United States between 1996 and 2012 and employed a variety of designs including two randomised controlled trials. A total of 288 people with traumatic brain injury participated in the studies. No significant improvements in social activity level or social network size were found, but significant improvements were shown in areas including behavioural control, mood, coping and quality of life.Conclusion: There is limited evidence for the effectiveness of peer mentoring after traumatic brain injury. The available evidence comes from small-scale studies, of variable quality, without detailed information on the content of sessions or the ‘active ingredient’ of the interventions

The ESCAPS study: a feasibility randomized controlled trial of early electrical stimulation to the wrist extensors and flexors to prevent post-stroke complications of pain and contractures in the paretic arm.

OBJECTIVE: To establish feasibility of initiating electrical stimulation treatment of wrist extensors and flexors in patients early after stroke to prevent muscle contractures and pain. DESIGN: Feasibility randomized controlled trial with economic evaluation. SETTING: A specialist stroke unit in Nottinghamshire. SUBJECTS: A total of 40 patients recruited within 72 hours post-stroke with arm hemiparesis. INTERVENTIONS: Participants were randomized to receive usual care or usual care and electrical stimulation to wrist flexors and extensors for 30 minutes, twice a day, five days a week for three months. Initial treatment was delivered by an occupational therapist or physiotherapist who trained participants to self-manage subsequent treatments. MEASURES: Measures of feasibility included recruitment and attrition rates, completion of treatment, and successful data collection. Outcome data on wrist range of motion, pain, arm function, independence, quality of life, and resource use were measured at 3-, 6-, and 12-months post-randomization. RESULTS: A total of 40 participants (of 215 potentially eligible) were recruited in 15 months (20 men; mean age: 72 (SD: 13.0)). Half the participants lacked mental capacity and were recruited by consultee consent. Attrition at three-month follow-up was 12.5% (death (n = 2), end-of-life care (n = 2), and unable to contact (n = 1)). Compliance varied (mean: 65 (SD: 53)) and ranged from 10 to 166 treatments per patient (target dosage was 120). Data for a valid economic analysis can be adequately collected. CONCLUSION: Early initiation of electrical stimulation was acceptable and feasible. Data collection methods used were feasible and acceptable to participants. A large definitive study is needed to determine if electrical stimulation is efficacious and cost effective

A systematic review of peer mentoring interventions for people with traumatic brain injury

Objective: This systematic review sought evidence concerning the effectiveness of peer mentoring for people with traumatic brain injury. Data sources: Fourteen electronic databases were searched, including PsycINFO, MEDLINE, CINAHL, EMBASE and the Cochrane Library, from inception to September 21 2016. Ten grey literature databases, PROSPERO, two trials registers, reference lists and author citations were also searched. Review methods: Studies which employed a model of one-to-one peer mentoring between traumatic brain injury survivors were included. Two reviewers independently screened all titles and abstracts before screening full texts of shortlisted studies. A third reviewer resolved disagreements. Two reviewers independently extracted data and assessed studies for quality and risk of bias. Results: The search returned 753 records, including one identified through hand searching. 495 records remained after removal of duplicates and 459 were excluded after screening. Full texts were assessed for the remaining 36 studies and six met the inclusion criteria. All were conducted in the United States between 1996 and 2012 and employed a variety of designs including two randomised controlled trials. A total of 288 people with traumatic brain injury participated in the studies. No significant improvements in social activity level or social network size were found, but significant improvements were shown in areas including behavioural control, mood, coping and quality of life. Conclusion: There is limited evidence for the effectiveness of peer mentoring after traumatic brain injury. The available evidence comes from small-scale studies, of variable quality, without detailed information on the content of sessions or the ‘active ingredient’ of the interventions

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

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

The DRESS trial: a feasibility randomized controlled trial of a neuropsychological approach to dressing therapy for stroke inpatients

Objective: To investigate two approaches to treating patients with persistent dressing problems and cognitive difficulties following stroke. Design: Pilot randomized controlled trial. Setting: Inpatient stroke rehabilitation service. Subjects: Seventy consecutive stroke patients with persistent dressing problems and accompanying cognitive difficulties at two weeks after their stroke. Interventions: Patients were randomly allocated to six weeks of either a systematic neuropsychological approach, based on analysis of dressing problems and further cognitive testing, or to the control group who received conventional (functional) dressing practice. Both groups received treatment three times a week in accordance with two separately prepared manuals. Main measures: Nottingham Stroke Dressing Assessment (NSDA), Line Cancellation, 10-hole peg transfer test, Object Decision, Gesture Imitation. Patients were assessed at six weeks after randomization by an independent assessor masked to group allocation. Results: Both neuropsychological and functional groups improved performance on the NSDA over the treatment period (31% and 22%, respectively) but there was no significant difference between groups at six weeks. However, the neuropsychological group showed a significantly greater improvement on a line cancellation test of visual neglect (t(62) = 2.1, P < 0.05) and a planned subanalysis for those with right hemisphere damage showed a trend towards better dressing outcome (P = 0.07, one-tailed). Conclusions: Results demonstrate the potential benefits of a systematic neuropsychological approach to dressing therapy, particularly for patients with right hemisphere damage. This study suggests the need for a phase III study evaluating the efficacy of a systematic neuropsychological approach in treating dressing difficulties, targeting patients with right hemisphere stroke and visuospatial impairments