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National Clinical Guideline Centre (UK). Stroke Rehabilitation: Long Term Rehabilitation After Stroke [Internet]. London: Royal College of Physicians (UK); 2013 May 23. (NICE Clinical Guidelines, No. 162.)
14.1. Intensity of occupational therapy for personal activities of daily living
Personal Activities of Daily Living (PADLs) are ‘those tasks which all of us undertake every day of our lives in order to maintain our level of care’ (Hopson, 1981) for example, eating, washing, brushing teeth, and dressing.
A core aspect of Occupational Therapy is the skilled analysis of performance and the impact of physical, sensory, psychological and emotional domains on function. Specific therapeutic goals are then set, and treatment delivered which targets functional performance for example, dressing in the context of the physical, sensory or cognitive impairments. Grading of activities is often a feature of the intervention so that activities increase in complexity as patients develop necessary skills. The theoretical perspective of occupational therapy is twofold, using restorative and compensatory approaches to intervention.
14.1.1. Evidence review: In people after stroke what is the clinical and cost-effectiveness of intensive occupational therapy focused specifically on personal activities of daily living (dressing / others) versus usual care?
| Clinical Methodological Introduction | |
|---|---|
| Population: | Adults and young people 16 or older who have had a stroke |
| Intervention: | Intensive occupational therapy (OT) - dressing, grooming, bathing, feeding/eating, washing, toileting |
| Comparison: | Usual care (OT once a week)/no care |
| Outcomes: |
|
14.1.1.1. Clinical evidence
Searches were conducted for systematic reviews and RCTs comparing the clinical and cost effectiveness of intensive occupational therapy focused on personal activities of daily living with usual care or no care in adults or young people of 16 years old or older after stroke. Only studies with a minimum sample size of 20 participants (10 in each arm) were selected. We included seven (7) RCTs.
Table 119 summarises the population, intervention, comparison and outcomes for each of the studies.
Table 119
Summary of studies included in the clinical evidence review. For full details of the extraction please see Appendix H.
14.1.1.2. Comparison: Intensive occupational therapy focussed on personal activities of daily living versus usual care/no care
Table 120
Intensive occupational therapy versus usual care/no care - Clinical study characteristics and clinical summary of findings.
14.1.1.3. Economic evidence
Literature review
No relevant economic evaluations comparing intensive occupational therapy with usual care were identified.
Intervention costs
In the absence of cost-effectiveness analysis for this review question, the GDG considered the expected differences in resource use between the comparators and relevant UK NHS unit costs. Consideration of this alongside the clinical review of effectiveness evidence was used to inform their qualitative judgement about cost effectiveness.
The GDG noted that the main difference in terms of resources between intensive therapy and usual care was the time occupational therapists would spend with patients.
The estimated cost per hour of client contactt for a band 6 occupational therapist is £45 (hospital-based) or £48 (community-based). The GDG also noted that to these costs it may be necessary to add the cost of additional specific aids (such as bars used to facilitate the use of bathrooms) that can be used in these interventions.
14.1.1.4. Evidence statements
Clinical evidence statements
One study43 comprising 53 participants found no significant difference in Functional Independence Measure at 3 months after stroke between the group that received intensive occupational therapy and the usual care group (VERY LOW CONFIDENCE IN EFFECT).
One study91 comprising 138 participants found a significant difference in the Barthel Index at 2 months in favour of the group that received intensive occupational therapy compared to the usual care group, although this difference was not of clinical importance (LOW CONFIDENCE IN EFFECT).
One study226 comprising 118 participants found a significant difference in the Barthel scores at 3 months after stroke in favour of the group that received intensive occupational therapy compared to the usual care group (MODERATE CONFIDENCE IN EFFECT).
Three studies91,226,278 comprising 441 participants found no significant difference in the Barthel Index at 6 months follow-up by the group receiving intensive occupational therapy compared to the usual care group (LOW CONFIDENCE IN EFFECT).
One study48 comprising 110 participants found no significant difference in the proportion of participants achieving less than 12 in Barthel scores at 1 year after stroke between the group that received intensive occupational therapy and the usual care group (VERY LOW CONFIDENCE IN EFFECT).
One study91 comprising 138 participants found no significant difference in the Nottingham Extended ADL scores at 2 months between the group that received intensive occupational therapy and the usual care group (LOW CONFIDENCE IN EFFECT).
Two studies 91,199 comprising 451 participants found no significant difference in the Nottingham Extended ADL scores at 6 months after stroke between the group that received intensive occupational therapy and the usual care group (LOW CONFIDENCE IN EFFECT).
One study199 comprising 313 participants found no significant difference in the Nottingham Extended ADL scores at 12 months after stroke between the group that received intensive occupational therapy and the usual care group (LOW CONFIDENCE IN EFFECT).
One study48 comprising 110 participants found no significant difference in the proportion of participants able to feed themselves as measured by the Nottingham Extended Activities of Daily Living scale at 1 year after stroke in the intensive occupational therapy group compared to the usual care group (LOW CONFIDENCE IN EFFECT).
One study48 comprising 110 participants showed that a significantly higher proportion of participants in the intensive occupational therapy group were able to use the telephone as measured by the Nottingham Extended Activities of Daily Living scale at 1 year after stroke compared to the usual care group (LOW CONFIDENCE IN EFFECT).
One study226 comprising 118 participants found a significant difference in the Rivermead mobility scores at 3 months follow-up in favour of the group that received intensive occupational therapy compared to the usual care group (MODERATE CONFIDENCE IN EFFECT).
One study226 comprising 118 participants found no significant difference in the Rivermead mobility scores at 6 months follow-up between the group that received intensive occupational therapy and the usual care group (VERY LOW CONFIDENCE IN EFFECT).
One study278 comprising 185 participants found a significant difference in the Extended Activities of Daily Living scores at 6 months follow-up in favour of the group that received intensive occupational therapy compared to the usual care group (MODERATE CONFIDENCE IN EFFECT).
Economic evidence statements
No cost-effectiveness evidence was identified.
14.1.2. Recommendations and Link to Evidence
| |
|---|---|
| Relative values of different outcomes | The outcomes included in the review were: Functional Independence Measure, Barthel Index, Nottingham Extended ADL Index, Extended Activities of Daily Living Scale and Rivermead Mobility Index, The GDG considered the studies that reported FIM (Motor subscale) and Barthel outcomes to be the most useful for assessing functional outcomes. |
| Trade-off between clinical benefits and harms | Provided the intervention is delivered by an appropriately trained Occupational Therapist the GDG did not consider there to be any significant harms associated with this type of intervention and that the benefits gained by being able to participate in activities of daily living were significant in terms of patients’ quality of life. The GDG agreed that therapies should include both a restorative approach (aiming to regain function) and a compensatory (use of aids and equipment) approach to help an individual compensate for residual impairments. Appropriate equipment needs to be provided to stroke patients once discharged from hospital, whatever the setting they are discharged to, including nursing homes. This provision would ideally be following assessment by an Occupational Therapist and may include practice and training with equipment. |
| Economic considerations | No cost-effectiveness studies were found for this question. Occupational therapy is currently routinely provided to stroke patients. Delivering more intensive intervention would require higher personnel input, and possibly more equipment, hence more resources would be needed. However, these may be offset by a reduction in social and health-funded care packages and improvements in patients’ quality of life. |
| Quality of evidence | The GDG recognised that most of the studies were community based and therefore have applicability to early supported discharge and to the long-term management of stroke. It was noted that the patient population in the Sackley study, 2006 was different from the other studies as they were older and in residential nursing homes (these patients were seen to maintain performance in comparison with control group, who deteriorated). The GDG also considered that management of patients had changed since the publication of the Walker study 278 as these patients had not been admitted to hospital, however it was useful and it may reflect a population who would now receive early supported discharge as they scored higher on the Barthel index at baseline. The GDG considered the studies included in the review to be feasibility studies. Confidence in the effect shown in most of the outcomes were low to moderate due to limitations in study design (unclear randomisation and allocation concealment) and imprecision around the effect estimate. Although it was found that there was a clinically significant effect of intensive OT in Barthel Index at 3 months compared to usual care group (Sackley 2006 226) and the confidence on this effect was moderate, this effect was not preserved at six months follow-up. The Parker study 199 was the only large multi-centred, RCT, however this produced equivocal results. The inclusion of this data in a meta-analysis 151 (which included studies with smaller numbers than included in this clinical review) has shown that there was significant benefit shown in the intensive arm of occupational therapy. Overall the GDG agreed studies showed short-term functional gain at 3 months but not over a longer term. Some limited evidence showed that functional gains are maintained at 6 months and 1 year in the intensive OT groups (Gilbertson 2000, Sackley 2006, Walker 1999 91,226,278) The GDG agreed that from the evidence available for those patients with stroke who are managed within the community, occupational therapy provides some benefit, but there is currently no evidence for those patients with moderate stroke who are managed in the acute (hospital) setting and further research is required. The GDG considered that the patients included in the studies tended to be those with moderate stroke and physically fitter, therefore treatment within the community rather than in hospital would be appropriate for this particular population, but would not be applicable for all stroke patients. |
| Other considerations | The GDG recognised that defining intensity is challenging and can be defined in terms of frequency of treatment, total amount of treatment, duration of treatment, or mode of delivery. The amount of occupational therapy mentioned in the reviewed studies varied but was typically less than the current (5 session × 45 minutes per week) recommended in the current NICE Quality standards. The studies identified gave little indication how much occupational therapy is needed but did indicate that occupational therapy is effective. The GDG noted that the description of occupational therapy interventions was limited within the studies reviewed, but they did employ a range of restorative and compensatory strategies. Consensus recommendations were made to reflect this and examples of the types of interventions delivered were indicated. |
Footnotes
- t
Estimated based on data and methods from the Personal Social Services Research Unit ‘Unit costs of health and social care’ report and Agenda for Change salary band 651 (typical salary band identified by clinical GDG members).
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