Occupational Therapy After Stroke Helps Prevent Further Loss

GLASGOW, Scotland, Sept. 28 -- Putting stroke patients to work keeps them from deteriorating, found investigators in a meta-analysis.

Occupational therapy for stroke patients with problems managing every-day personal activities helped prevent a long downhill slide with a risk of serious deterioration and even death, according to a meta-analysis by research therapist Lynn Legg of the Glasgow Royal Infirmary University, and colleagues.

In addition, patients who received therapy to help with tasks, such as eating, dressing, grooming, and getting about, achieved a 5% improvement in handling these activities, they reported in BMJ OnLine First. Focused occupational therapy should be available to everyone who has had a stroke, they added.

"We believe that these finding 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 investigators concluded.

Previous reviews that have assessed the role of occupational therapy have not specifically focused on stroke, which is the leading cause of serious, long-term disability. Six months after a stroke approximately half of survivors are dependent on others to help them carry out everyday tasks, the researchers said.

They undertook a meta-analysis of nine randomized controlled trials with a total of 1,258 patients (mean age ranging from 55 to 87.5 years). The proportion of men ranged from 19% to 66%.

Most studies had parallel groups with occupational therapy by a qualified therapist focused on activities of daily living compared with usual care or no routine intervention.

Primary outcomes in the meta-analysis were independent of personal activities at the end of a scheduled follow-up. Secondary outcomes were death, institutionalization, extended activities necessary for maintaining a home (preparing meals, doing light housework, managing money), and quality of life for the patient and care-giver.

Occupational therapy delivered to patients after a stroke and targeted toward personal activities of daily living increased performance scores (standardized mean difference 0.18, 95% confidence interval 0.04 to 0.32, P=0.01). This amounted to a 5% difference in the Barthel index for personal activities for the group receiving occupational therapy.

However, Legg noted that the Barthel index had a ceiling effect so that once a patient reached a maximum score, there was no way to record further improvement.

Data on poor outcomes were available for 1,065 participants from seven trials and showed that for participants who received therapy the odds of a poor outcome were significantly lower.

Therapy reduced the risk of a poor outcome (death, institutionalization, deterioration, or increased dependency in managing everyday tasks) by 33% (odds ratio 0.67, confidence interval 0.51 to 0.87), the researchers reported.

The overall rate of a poor outcome for controls was 42%, which combined with an odds ratio of 0.67 for a poor outcome among treated individuals showed that for every 100 patients who received occupational therapy, 11 would be spared a poor outcome (95% CI, 7 to 30).

However, the researchers pointed out that this calculation is a relatively crude measure of outcome and does not capture potential benefits in other domains of health.

This figure also suggests that not all patients treated by an occupational therapist will benefit. Further work is required to define those individuals who are most likely to benefit, and economic studies are required to examine the cost-effectiveness of occupational therapy.

Additional analysis for death and deterioration included information on 407 participants from four trials and produced similar results (odds ratio of 0.60, CI, 0.39- 0.91, P=0.02), with no significant heterogeneity in the trials.

The study had limitations, the researcher wrote. First, the masking of therapies from patient and therapist was difficult, thus permitting the introduction of bias, particularly when the person providing the intervention was also the person doing the research, as was the case with many of these studies.

Secondly, while usual or standard care is recognized as an appropriate control, this may have included interventions that promoted activities that potentially reduced the estimate of the intervention effect.

Finally, intervention trials typically have lengthy follow-up periods with a risk of study dropout. This made doing a true intention-to-treat analysis with complex scores, such as the Barthel Index, problematic as it was difficult to score for missing participants.

Despite these potential concerns, however, the quality of the included trials was generally good, and the results were consistent among the trials, the researchers said.