This meta analysis of the referenced studies aim to evaluate efficacy of occupational therapy: whether it focused specifically on personal activities of daily living improves recovery for patients following stroke and to know does .Occupational therapy aims to help people reach their maximum level of function and independence in all aspects of daily living.
Reviewing 07 studies with 1178 participants, people who had a stroke were more independent in personal activities of daily living like feeding, dressing, bathing, toileting and moving about and more likely to maintain these abilities if they received treatment from an occupational therapist after stroke.
Abstract (around 200-250 words)
Aims A systematic review of studies testing the effectiveness of occupational therapy in post stroke patient, focused specifically on personal activities of daily living improves recovery for patients following stroke.
Data sources We searched EBSCOMEDLINE, EMBASE, CINAHL and the Cochrane Library (2000- 2010). AMED:
Selection criteria Selection criteria included studies that used randomized controlled trials of an occupational therapy intervention compared to usual care or no care, where stroke patients practiced personal activities of daily living, or performance in activities of daily living was the focus of the occupational therapy intervention.
Review methods A meta-analysis, using a random effects model, of 24 programmes identified in 19 trials. Effect sizes were adjusted by inverse variance weights to control for studies’ sample sizes.
We identified 64 potentially eligible trials and included nine studies (1258 participants). Occupational therapy interventions reduced the odds of a poor outcome (Peto odds ratio 0.67 (95% confidence interval (CI) 0.51 to 0.87; P = 0.003). and increased personal activity of daily living scores (standardised mean difference 0.18 (95% CI 0.04 to 0.32; P = 0.01). For every 11 (95% CI 7 to 30) patients receiving an occupational therapy intervention to facilitate personal activities of daily living, one patient was spared a poor outcome.
Patients who receive occupational therapy interventions are less likely to deteriorate and are more likely to be independent in their ability to perform personal activities of daily living. However, the exact nature of the occupational therapy intervention to achieve maximum benefit needs to be defined.
Chapter 1: Introduction:
The overall aim of this meta analysis was to evaluate the effectiveness of OT in post stroke patient. Extensive literature search was done by locating published stroke rehabilitation management intervention studies that measured personal activities of daily living outcomes among stroke patient. Data were extracted from study reports which included interventions designed to improve post stroke activities of patient.
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From WHO’s report of global burden of stroke it was found that Worldwide 15 millions people suffer a stroke annually. 5milloin of these die and another 5 million are left permanently disabled, causing burden on family and community. High blood pressure and tobacco use are considered as a major risk factor for stroke (WHO, 2010). The World Health Organisation (WHO) defines Stroke as “a clinical syndrome of resumed vascular origin, typified by rapidly developing signs of focal or global disturbance of cerebral function lasting more then 24 hours or leading to death” (WHO, 1978).
The causes of stroke can be classified as:
Ischaemic cause: blood supply to brain stopped due to formation of blood clot. It causes 70% of all cases.
Haemorrhagic: brain damage caused due to bursting of blood vessel which supply blood to brain
There is also a related condition known as a transient ischaemic attack (TIA), which affect 35 people per 100,000 of population each year and is associated with a very high risk of stroke in the first month of event upto one year (Coull, et al., 2004 ). In transient ischemic attack the blood supply to the brain is temporarily interrupted due to inadequate cerebral or ocular blood supply which is due to low blood flow, thrombosis or embolism. Symptoms last for less than 24hours causing a sort of ‘mini-stroke’ (Hankey and Warlow, 1994).
The risk of death due to stroke depends on its type like TIA has the best outcome whereas blockage of an artery is more dangerous, with rupture of blood vessels. It has found that even if country is having advance technology and facilities 60% people die or become dependent causing high cost of treatment (WHO, 2010).
Those of Afro-Caribbean origin are at increased risk of having a stroke, and the number of people affected by the condition is higher among this ethnic group than any other. This is because people of Afro-Caribbean origin have a genetic predisposition (a natural tendency) to developing diabetes and heart disease, which are two conditions that can cause strokes.
Ischaemic strokes occur when blood clots block the flow of blood to the brain. Blood clots typically form in areas where the arteries have been narrowed or blocked by fatty cholesterol-containing deposits known as plaques. This narrowing of the arteries is known as atherosclerosis.
As the age advances, our arteries become narrower, but certain risk factors can dangerously accelerate the process. Risk factors include:
high blood pressure (hypertension),
high cholesterol levels (often caused by a high-fat diet), and
a family history of heart disease or diabetes.
Diabetes is also a risk factor, particularly if it is poorly controlled, because the excess glucose in the blood can damage the arteries.
Haemorrhagic strokes occur when a blood vessel in the brain bursts. The main cause of this is high blood pressure (hypertension), which can weaken the arteries in the brain and make them prone to split or rupture.
The risk factors for high blood pressure include:
drinking excessive amounts of alcohol,
a lack of exercise, and
stress, which may cause a temporary rise in blood pressure.
A person’s ethnic group can also be a risk factor for high blood pressure. Half of all people of black-African or Caribbean origin who are over 40 years of age are likely to have high blood pressure. Research has suggested this is because people of African origin have an increased sensitivity to the effects of salt, which can cause their blood pressure to rise. A haemorrhagic stroke can also sometimes occur as a result of a traumatic head injury (NHS Choices, 2008).
Every year, an estimated 150,000 people in the UK have a stroke. That is one person every five minutes (Office of National Statistics, 2001).The brain damage caused by strokes means that they are the largest cause of adult disability in the UK.
People who are over 65 years of age are most at risk from having strokes, although 25% of strokes occur in people who are under 65 years of age. It is also possible for children to have strokes (NHS Choices, 2008).
Around 1000 people under 30 have a stroke each year. Stroke can result in many different disabilities ranging from motor control and urinary incontinence to depression and memory loss. Disablement has been conceptualized by the world health organization in terms organ dysfunction (impairments), disability (difficulty with task), and handicap (social disadvantage) (Post stroke rehabilitation, 1995).
The analysis of cost of illness of stroke by Saka et al (2009) has found that stroke has greater impact on economy of UK, as treatment of and productivity loss arising due to stroke cost £8.9 billion a year. In which treatment cost is nearly 5% of total UK NHS costs. Direct care including diagnosis, inpatient care and outpatient care accounts for approximately 50% of the total, informal care costs 27% and the indirect costs that is cost resulting from premature death due to stroke is 24%. This study concluded that chronic phase of stroke is most costly and therefore suggested better understanding of long-term care in terms of its effectiveness and cost-effectiveness is necessary.
Due to stroke one side of the body may be paralyzed or the muscles on the affected side may weaken. After stroke treatment is comprise of care and rehabilitation (Post stroke rehabilitation, 1995). During the period of acute inpatient care, patient will receive rehabilitation and care input from a variety of qualified and unqualified nursing and allied health staff. It is therefore important that all staff should be familiar with the consequences of stroke, and able to effectively manage problems relating to stroke appropriately within their roles. The consequences of stroke are manifold; as well as the more visible physical problems; stroke survivors will likely have a number of emotional, cognitive, and communication problems (Ross et al, 2009) Research shows that patients benefit from treatment in stroke units in the acute and rehabilitation phases (Indredavik, 2008).
Rehabilitation is the process of overcoming or learning to cope with the damage the stroke has caused. It is about getting back to normal life and achieving the best level of independence by: relearning skills and abilities; learning new skills; adapting to some of the limitations caused by a stroke; and finding social, emotional and practical support at home and in the community. The benefits of stroke rehabilitation packages are well documented (SUTC, 2000) but little is known about the efficacy of the various components of such interventions.
Rehabilitation requires multidisciplinary approach involving therapist (physical therapist, speech therapist, and occupational therapist), doctors, psychologist and social workers. Occupational therapist teaches the patient daily living skills and how to use living aids such as walkers or bathroom grab bars (stroke rehabilitation, 2010).
After stroke life become difficult due to disability caused by it. stroke have high morbidity rates which means that patient with stroke suffer from both mental and physical disability following stroke. It is the leading cause of lower quality of life in adults. Rehabilitation offers a chance to restore quality of life after stroke. Brain damaged caused due to stroke cannot be healed but rehabilitation helps a patient in maintaining existing abilities and provide strategy for handling disabilities cause by stroke. Stroke treatment depends on time duration after stroke, risk factor that may affect treatment. Depending on these factors stroke treatment include blood thinner medication which can dissolve a blood clot, or brain surgery for rupture blood vessel. Rehabilitation after stroke begins after acute treatment. It helps in relearning the skills lost due to stroke and compensating for disability caused by stroke. It stroke includes memory rehabilitation, language rehabilitation and emotional rehabilitation, motor and sensory control rehabilitation (Healthtree, 2010).
Functional impairment following acute illnesses -such as stroke – frequently have severe physical consequences for adult and older patients (Desrosiers, 2003). Occupational therapy is an essential component for the rehabilitation of disabled patients, having a wide range of interventions available to assist persons towards independence (cup, 2003).
The goal of occupational therapy is to restore functional independence when possible and to facilitate psychosocial adjustment to residual disability (Landi, 2006).
The philosophy of occupational therapy is founded on the concept of occupation as a key element of health and well-being. Practice in social care services embraces the social model of disability and is based on holistic and person-centered care, emphasizing the promotion of self-reliance and resourcefulness (College of Occupational Therapists, 2008).
The Occupational therapy is commonly used in the post stroke patients by an occupational therapist with the specific aim of facilitating personal activities of daily living to improve the outcomes for patients following stroke. Different trials have been conducted in different countries to prove the effectiveness of occupational therapy but there is lack of evidence suggesting that occupational therapy interventions can reduce the likelihood of such deterioration and improve patients’ ability to perform personal activities of daily living. Therefore the aim of this Meta analysis is to evaluate the efficacy of occupational therapy on stroke rehabilitation.
The main aim of occupational therapy (OT) is to maintain, restore or create a match beneficial to the individual between the abilities of the person, the demands of his or her occupations and the demands of the environment (Creek, 2003) Activity and participation limitations in stroke typically diminish health and wellbeing As a result, improvement of functional abilities, improvement of participation in society and an increased quality of life are important outcomes of OT treatment (Steultjens, 2005).
Historically, several treatment approaches have been introduced and adopted by physical and occupational therapists. The stroke rehabilitation methods adopted by therapists vary widely depending on their background knowledge, clinical experience, clinical skills, and personal preferences [6-9]. The availability of a plethora of treatment methods shows that stroke rehabilitation practices are continually evolving. Previous studies conducted
in the United Kingdom used surveys to determine common treatment practices in stroke rehabilitation among physical therapists [10-11].
The result of the study by Landi et al. (2006) shows that patients with stroke who received the combined program of physical and occupational therapy had a greater level of independence in activities of daily living over a period of 8 weeks than patients who did not.
It has been found from the Cochrane review of benefits of stroke rehabilitation that it reduces approximately 22% in death or dependency and these benefits are more prominent under and over 75 years of age, in both sexes. Length of hospital stay is also reduced due to early rehabilitation (Scottish intercollegiate guidelines network, 2002). Stroke is a complex condition where knowledge base is continuously increasing. There is constant advance in understanding of the condition, assessment and intervention techniques. Occupational therapists are a vital component in the rehabilitation of patient with this condition (Edmans, 2000).
Occupational therapist work with individuals who have conditions that are physically, mentally, developmentally, or emotionally disabling. They help them develop, recover, maintain daily living and work skills. The goal of occupational therapist is to help their client have independent, satisfying and productive lives (Weeks and Zona, 2000).
Chapter 2: The Literature Search
Selection criteria – brief description of the main elements of the question under consideration. This is subdivided into:
Types of studies – eg: RCT’s
Types of participants – the population of interest. This section may include details of diagnostic criteria, if desired or appropriate.
Types of interventions – the main intervention under consideration and any comparison treatments.
Types of outcome measures – any outcome measures/endpoints (for example, reduction in symptoms) that are considered important by the reviewer, defined in advance; not only outcome measures actually used in trials.
Definition of Occupational therapy
World federation of occupational therapist (2004) define Occupational therapy as a profession concerned with promoting health and well being through occupation. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. Occupational therapists achieve this outcome by enabling people to do things that will enhance their ability to participate or by modifying the environment to better support participation.
The search strategy for systematic reviews of the efficacy of OT has identifies randomised trial comparing occupational therapy with other intervention or no intervention. It has been done by searching EBSCO host research database from 2000-2010. The other sources are Google Scholar and The Occupational Therapy Research Index and Dissertation Abstracts register, scanned reference lists of relevant articles, relevant journals. (1999-2010).
Fifty-three studies were identified and abstracted. Four studies reported total
hemorrhagic stroke as the outcome, which includes intracerebral and subarachnoid hemorrhage.4,7,10,11 None of the studies reported information on subdural hemorrhagic strokes. We have used the term hemorrhagic stroke throughout the article. Two reports consisted of the same case patients but different controls and were treated as 2 separate studies. 23,24 From the 53 studies, 18 were further excluded for various reasons. Two studies were excluded because combined risk estimates were reported for men and women but levels of alcohol consumption were not the same for men as for women.49,50 We excluded 5 studies that examined only the effect of binge drinking or acute alcohol consumption (within 24 hours before stroke)51-55 because our study assessed habitual alcohol consumption and relative risk of stroke. Five studies that lacked sufficient data for calculation of relative risk estimates were excluded.56-60 The remaining 6 excluded reports did not use abstainers as the reference group.61-66 We included 19 cohort studies and 16 case control studies in our final analysis
Types of studies
This study included randomized controlled trials of stroke patients receiving an occupational therapy intervention provided by an occupational therapist. All of the selected studies intend to improve personal activities of daily living compared to usual care or no care in post stroke patient.
If large randomized trials are impractical, we have to draw the most reliable conclusions from smaller trials. Unfortunately, the conventional approach, the narrative review is unreliable. Conventional review usually fails to define the review question, to ensure that all relevant trials are explicitly based on the evidence. Systematic reviews set out to improve upon narrative reviews by applying scientific methods to the review of the research evidence (Langhorne, et al., 2008).
Types of participants:
This study included the trial if the participant of the study met the clinical definition of stroke as defined by WHO “a clinical syndrome of resumed vascular origin, typified by rapidly developing signs of focal or global disturbance of cerebral function lasting more then 24 hours or leading to death” . All of the included studies have given clear inclusion criteria. They include participant on the basis of clinical diagnosis, except Sackley et al (2006) included residents with moderate to severe stroke-related disability by using Barthel Activity of Daily Living Index score (BI score 4 to 15 inclusive). Participants with other acute illness are excluded from the studies.
Types of intervention:
In this study trials are include if they have following features:
â€¢ Occupational therapy intervention which specially focused on activities of daily living and tried to improve their personal activities of daily living.
â€¢ The trials are included in which control group receives normal care or no intervention.
â€¢ Interventions are provided under the supervision of qualified occupational therapist.
The study by Sackley et al (2006) has developed an intervention by using existing evidence with the help of a group of expert occupational therapists delivered on individual level. The period of intervention was three month which include occupational therapy and carer education, wheras
Researcher included studies that used randomized or controlled clinical designs, of an occupational therapy intervention, compared to usual care or no care. In which stroke patient’s performance in terms of activities of daily living was the focus of the occupational therapy intervention
Selected database is EBSCO host web research database this collection of databases provide access to key journals, many having links to full text journal articles.
It contains various databases as follow:
British Nursing Index
CINHAL plus with full text
MEDLINE with full text
SocINDEX with full text
The other sources are Google Scholar and The Occupational Therapy Research Index and Dissertation Abstracts register, scanned reference lists of relevant articles, relevant journals. (1999-2010) (See Appendix 1).
Key words or term used in literature search
KW: Stroke in Title
Rehabilitation in Abstract
Randomised controlled trail in Abstract
Time frame: 2000-2010
Randomized controlled trial
Language or national context: English language only
Main focus of paper: Stroke rehabilitation
Peer reviewed journal only
National and international studies.
Types of outcome measure
The out come measure are that reflected the change in personal activities of daily living in stroke patient after receiving occupational therapy
(1) Performance in personal activities of daily living (pADL including:
feeding, dressing, bathing, toileting, simple mobility and
transfers) at the end of scheduled follow up.
(2) Death or a poor outcome. Death or a poor outcome is defined
as the combined outcome of being dead or:
â€¢ having deteriorated, characterised by experiencing a
deterioration in ability to perform personal activities of daily
living (that is, experiencing a drop in pADL score); or
â€¢ being dependent, characterised by lying above or below a
pre-defined cut-off point on a given pADL scale; or
â€¢ requiring institutional care at the end of scheduled follow
Secondary outcomes of interest
(1) Death at the end of scheduled follow up
(2) Number of patients dead or physically dependent at the end
of scheduled follow up
(3) Number of patients dead or requiring institutional care at the
end of scheduled follow up
(4) Performance in extended activities of daily living (community
and domestic activities) at the end of scheduled follow up
(5) Patient mood at the end of scheduled follow up
(6) Patient subjective health status or quality of life at the end of
scheduled follow up
(7) Carer mood at the end of scheduled follow up
(8) Carer subjective health status or quality of life at the end of
scheduled follow up
(9) Patient and carer satisfaction with services
We aimed to record outcomes that reflected resource use (that is the
number of admissions to hospital, number of days in hospital, aids
and appliances provided, number of staff required per caseload).
Search methods for identification of studies
See: ‘Specialized register’ section in Cochrane Stroke Group
Papers excluded from the review were works that focused predominantly upon:
Stroke rehabilitation studies before 2000.
Which are not published studies
Which are other than English language
A meta-analysis, by using quantitative methods such as a random effects model, of 7 randomized controlled trial identified literature search.
Analysis of Data
Researcher will analyse binary outcomes with a fixed-effect model, as odds ratios (OR) with 95% confidence intervals (CI). For continuous outcomes, a random-effects model will be used to take account of statistical heterogeneity. As there is some heterogeneity between the trials in terms of their design, duration of follow up and selection criteria for patients.
Researcher will performed an intention to treat analysis to reduce potential biases in terms of follow-up, publication, and reporting bias associated with extracting data from published reports. Publication bias will be assessed with a rank correlation test and a funnel plot.
Systematic reviews show that occupational therapy increases functional ability and/or social participation in elderly people and in patients with stroke or rheumatoid arthritis. For patients with progressive neurological diseases, cerebral palsy or mental illnesses the efficacy of occupational therapy is still unclear because high-quality studies are lacking.
Chapter 3 – Methodology
Justification of methodological approach – qualitative or quantitative
Methods of the review – description of how studies eligible for inclusion in the review were selected, how their quality was assessed, how data were extracted from the studies (evaluated), how data were analysed, whether any subgroups were studied or whether any sensitivity analyses were carried out,
A major challenge with stroke rehabilitation is that the intervention itself is likely to be very complex and non uniform. Any intervention developed by therapist or multidisciplinary team will involve many components which may interact in different ways. It is likely that these interventions may a mixture of both effective and ineffective elements so it is important that we are aware of variability between the different trials and we explore this variability when analyzing the result (Langhorne, et al., 2008).
Chapter 4 – The Studies
Description of studies – how many studies were found, what were their inclusion criteria, how big were they, etc.?
Methodological quality of included studies – were there any reasons to doubt the conclusions of any studies because of concerns about the study quality?
4.1 Characteristics of included studies:
Characteristics of included studies
Pretest and posttest randomized control trial
-Age: 55 years or older.
-Mean age: 72.1
-With primary diagnosis of stroke
-Living at home
Intervention group received additional home-based intervention in the use of devices
immediately after discharge, but the control group did not.
Subjects were assessed by
1.Functional Independence Measure and
2. The Quebec User Evaluation of Satisfaction with Assistive Technology.
Single blind randomised controlled trial.
-Mean age: 71
-with clinical diagnosis of stroke
-were admitted to
Glasgow royal infirmary NHS trust were
Intervention group received 6wk domiciliary programme and control group received included inpatient multidisciplinary
Subjects were assessed by
1.Nottingham extended activities of daily living scale
2. Barthel activities of daily living index.
-Mean age: 78.3
– With primary diagnosis of ischemic stroke
Intervention group received received 8 weeks of a combined rehabilitation program based on occupational therapy and physiotherapy
received no input from the occupational therapists
Subjects were assessed by
– ADL scale
Randomised controlled trial.
-Mean age: 74
diagnosis of stroke in previous 36 months
Intervention group received leaflets with assessment
and up to seven intervention sessions by an occupational
therapist. Control group received leaflets describing local transport services for
– Nottingham extended
activities of daily living scale, Nottingham leisure questionnaire,
and general health questionnaire.
Multicentre randomized controlled trial.
-Mean age: 72
.Randomization was done in three groups.
groups received occupational therapy interventions at home for up to six months after recruitment.
The General Health Questionnaire (12 item), the
Nottingham Extended ADL Scale and the Nottingham Leisure Questionnaire
Randomised controlled trial with concealed
allocation and blinded assessment.
-patients with a clinical diagnosis of stroke in the
previous 36 months
Control group received one session consisting of advice, encouragement, and the provision of leaflets describing local mobility services. intervention group received
the leaflets plus occupational therapy assessment and
up to seven intervention sessions for up to 3 months.
Primary outcome was self-report, Secondary outcomes were 1-self-report of the number of journeys outdoors in the past month, 2-Nottingham extended activities of daily living scale, 3-Nottingham leisure questionnaire. 4-general health questionnaire.
cluster randomized controlled trial
-Residents with moderate to severe
– Residents with acute illness and those admitted for end-of-life care.
Occupational therapy was provided to intervention group but included carer education.
control group received usual care
1-Barthel Activity of Daily Living Index (BI) scores
2-Rivermead Mobility Index.
Characteristics of intervention included in study
Chapter 5 Findings / Results
What do the data show? The synthesis of results – thematic analysis or statistical analysis. Accompanied by a graph to show a meta-analysis, if this was carried out.
Chapter 6 – Discussion
Interpretation and assessment of results.
Chapter 7 – Conclusion
Subdivided into Implications for practice and Im
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