Research suggests that occupational therapy alone may not be effective in improving the function of care home residents who have had a stroke
Citation: Jacques H (2016) Occupational therapy for older people with disability post stroke. Nursing Times [online]; 112: 16, 21.
Author: Helen Jacques is medical writer, Evidence Information Services, National Institute for Health and Care Excellence.
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In the UK, around one in 10 people who survive a stroke cannot return home and are discharged to a care home (Royal College of Physicians, Clinical Effectiveness and Evaluation Unit on behalf of the Intercollegiate Stroke Working Party, 2015). Many people who enter a care home become inactive and experience deterioration in their ability to carry out activities of daily living. Little evidence is available to support occupational therapy for people with stroke-related disabilities who live in care homes.
A randomised controlled trial by Sackley et al (2015) investigated individualised OT for older people who had stroke-related disabilities and lived in care homes. A random selection of UK care homes with more than 10 beds was invited to participate in the study and those that agreed were randomly allocated to the OT intervention or control group. Eligible care home residents were those with a history of ischaemic/haemorrhagic stroke or transient ischaemic attack.
The intervention comprised a three-month programme of individualised OT designed to improve or maintain participants’ functional capacity. Occupational therapists trained participants in techniques to help with personal activities of daily living and mobility. Therapists also changed participants’ environments where necessary, such as offering walking aids and raised toilet seats, and provided education to care home staff. The primary outcome was score on the Barthel Index, a measure of dependence in self-care activities, at three months after randomisation.
A total of 228 care homes were recruited (intervention: 114 homes, 568 residents; control: 114 homes, 474 residents). Participants were 83 years old on average and most (64%) lived in a home with nursing care. Over 70% had severe or very severe dependency at baseline. Those in the intervention arm had a mean of 5.1 sessions (median session duration: 30 minutes).
At a three-month follow-up, dependence did not differ between the OT group and controls. They also did not differ significantly at six or 12 months.
Strengths of this study include its size, the geographical diversity of participating care homes, and the inclusion of people who had cognitive or communication impairments after stroke. However, many participants were classified as having severe or very severe dependency levels at baseline, which may have limited their ability to participate in the intervention. Participants had also experienced stroke several years before taking part in the study.
- Reproduced with permission. Adapted from National Institute for Health and Care Excellence (2016) Occupational therapy for older people with stroke-related disabilities who live in care homes. Eyes on Evidence; January. Study sponsorship: National Institute for Health Research.
Box 1. Commentary
Occupational therapy has an important role to play in the rehabilitation and management of stroke survivors living with complex disabilities. Sackley et al (2015) found OT had no effect on older people with stroke-related disabilities who lived in care homes, but a number of factors may have contributed to this finding.
OT needs to be delivered in sufficient doses to effect change. This study intervention falls well below the input specified in the National Institute for Health and Care Excellence’s stroke rehabilitation guidance. Furthermore, rehabilitation is a multidisciplinary intervention best delivered by a team of health professionals who are able to assess, negotiate person-centred goals, and deliver evidenced-based treatment.
The intervention for the residents was provided, on average, three years after the onset of stroke and most improvements would have already occurred. It is also uncertain to what extent depression may have contributed to their lack of improvement. Stroke survivors with substantial physical and cognitive impairments, depression and comorbidities who live in care homes do not benefit from brief, unidisciplinary interventions. With the limited resources available to community-based rehabilitation teams, interventions should be focused on those who are most likely to benefit.
Rory J O’Connor, associate clinical professor of rehabilitation medicine, University of Leeds, and lead clinician, National Demonstration Centre in Rehabilitation, Leeds
Royal College of Physicians, Clinical Effectiveness and Evaluation Unit on behalf of the Intercollegiate Stroke Working Party (2015) Sentinel Stroke National Audit Programme Clinical Audit January–March 2015: Public Report.
Sackley CM et al (2015) An occupational therapy intervention for residents with stroke related disabilities in UK care homes (OTCH): cluster randomised controlled trial. British Medical Journal; 350: h468.