Self-care

National Clinical Guideline Centre (UK)

14Self-care

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?

Table

Nottingham Extended Activities of Daily Living (NEADL) Extended Activities of Daily Living (EADL)

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 contact^t 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

Table

Provide occupational therapy for people after stroke who are likely to benefit, to address difficulties with personal activities of daily living. Therapy may consist of restorative or compensatory strategies. Restorative strategies may include:

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).

Publication Details

Copyright

Publisher

Royal College of Physicians (UK), London

NLM Citation

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, Self-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:	Nottingham Extended Activities of Daily Living (NEADL) Extended Activities of Daily Living (EADL) Functional Independence Measure (FIM) Barthel Index Nottingham Stroke Dressing Assessment Northwick Park Nursing Dependency Scale Rivermead Mobility Index

Table 119Summary of studies included in the clinical evidence review

For full details of the extraction please see Appendix H.

STUDY	POPULATION	INTERVENTION	COMPARISON	OUTCOME
Chiu, 2004⁴³	Patients with a stroke who are able to follow instructions and verbally communicate and who are living at home with family support.	An additional home-based training programme on bathing devices including at least 2 visits but not more than 3 (mean 2.74) 1^st visit : explanation of device and safety; 2^nd visit: opportunity to discuss problems using devices and devices checked for fit and safety; 3^rd visit: optional, depending on patient’s proficiency using device. (N=30)	Pre-discharge home visit (mean 1.39 visits) but no treatment post-discharge. (N=23)	Functional Independence Measure (FIM)
Corr, 1995 ⁴⁸	First and second stroke patients. (Median number of days since stroke = 50).	Teaching new skills, facilitating independence in activities of daily living, facilitating return of function, enabling patients to use equipment, giving information to patient/carer; referring to or liaising with other agencies. Home visits by an OT after discharge and offered further rehabilitation and reviewed at 2, 8, 16 and 24 weeks. (N=55)	Usual care. (N=55)	Barthel Index Nottingham Extended Activities of Daily Living
Gilbertson, 2000 ⁹¹	Patients with a clinical diagnosis of stroke (excluding subarachnoid haemorrhage) without severe cognitive or communication problems.	Domiciliary occupational therapy (OT): 6 week programme (around 10 sessions lasting 30–45 minutes) tailored to recovery goals set by patient (for example regaining self-care or domestic or leisure activities). (N=67)	Inpatient multidisciplinary rehabilitation, pre-discharge home visit for selected patients, support services and equipment, regular review in multidisciplinary stroke clinic and selected patients referred to day hospital. (N=71)	Barthel Index Nottingham Extended Activities Daily Living
Logan, 1997 ¹⁵⁸	First time stroke patients discharged from hospital and referred to occupational therapy department.	Enhanced occupational therapy (OT): equal access to aids and budgets for adaptations. Patients seen and treated by a single research OT (sooner than possible with routine service) for a duration of 240 mean minutes per therapy for mean number of 6 visits. (N=53)	Usual care; 85 mean minutes per therapy for a mean number of 2.5 visits (N=58).	Extended Activities of Daily Living(EADL) Barthel Index
Parker, 2001 ¹⁹⁹	Patients with stroke not more than 6 months without severe illness and no documented history of dementia	Treatment goals: improving independence in self-care tasks such as washing, dressing or bathing. Home occupational therapy (total 10 sessions) lasting not less than 30 minutes each session for up to 6 months (N=156).	No care (N=157).	Nottingham Extended ADL Barthel Index
Sackley, 2006 ²²⁶	Participants in residential homes with moderate to severe stroke related disability (BI score 4 to 15) were included.	Aimed at improving independence in personal activities of daily living, such as feeding, dressing, toileting, bathing, transferring and mobilizing. Frequency and duration of therapies was dependent on resident and therapists agreed goals (over 3 months). Median visits per resident per month: 2.7 (range 1–25); time spent with therapist per resident per month 4.5 hours (range 1–10); most sessions lasted around 30 minutes. (N=63)	Usual care (occupational therapist not involved (N=55).	Barthel Index Rivermead Mobility Index
Walker, 1999 ²⁷⁸	Patients with stroke less than 1 month; not been admitted to the hospital; not living in a nursing or residential home.	Aimed at improving independence in personal and instrumental activities of daily living. Visits from the occupational therapist for up to 5 months (frequency of visits was agreed between the therapist, patient, and carer). Mean number of visits: 5.8 (SD 3.3, range 1–15). Mean length of each visit was 52 min (11.8, 24–90). (N=94)	No care (N=91).	Extended Activities of Daily Living (EADL) Barthel Index

Table 120Intensive occupational therapy versus usual care/no care - Clinical study characteristics and clinical summary of findings

Quality assessment						Summary of findings
Quality assessment						Intensive occupational therapy Median (IQR)/Mean (SD)/Frequency (%)	Usual care/no care Median (IQR)/Mean (SD)/ Frequency (%)	Effect		Confidence (in effect)
Authors	Design	Limitations	Inconsistency	Indirectness	Imprecision		Usual care/no care Median (IQR)/Mean (SD)/ Frequency (%)	Relative Risk/Mean difference (95% CI)	Absolute effect / Mean Difference (MD) (95% CI) or P value	Confidence (in effect)
Functional Independence Measure (3 months follow-up) (Better indicated by higher values)
Chiu, 2004⁴³	RCT- Single blinded	Serious limitations^(a)	No serious inconsistency	No serious indirectness	Very serious imprecision ^(b)	78.6 (7.4)	73.5 (10.9)	5.1 (−0.08 to 10.28)	MD 5.1 higher (0.08 lower to 10.28 higher)	Very low
Barthel Index (2 months follow-up) (Better indicated by higher values)
Gilbertson, 2000⁹¹	RCT- single blinded	Serious limitations^(c)	No serious inconsistency	No serious indirectness	Serious imprecision ^(k^d)	1 (0–2)	0 (−3–1)	1 (0.42 to 1.58)	MD 1 higher (0.42 to 1.58 higher)	Low
Barthel Index (3 months follow-up) (Better indicated by higher values)
Sackley, 2006 ²²⁶	Cluster RCT- Single blinded	Serious limitations^(e)	No serious inconsistency	No serious indirectness	No serious imprecision	10.8 (5.5)	8.2 (5.2)	2.6 (0.54 to 4.66)	MD 2.6 higher (0.54 to 4.66 higher)	Moderate
Barthel Index (6 months follow-up) (Better indicated by higher values)
3 Gilbertson, 2000⁹¹; Walker, 1999²⁷⁸ Sackley, 2006 ²²⁶	RCTs- 3 single- blinded, 1 Cluster RCT	Serious limitations^(c)	No serious inconsistency	No serious indirectness	Serious imprecision ^(d)	Gilbertson: 17 (15–19) Walker: 20 (18–20) Sackley (changes): −0.3 (4.2)	Gilbertson: 17 (13–18) Walker: 18 (16–20) Sackley (changes): −2.1 (3.7)	0.59 (−0.55, 1.73)	MD 0.59 higher (0.55 lower to 1.73 higher)	Low
Barthel Index (6 months follow-up) (Better indicated by higher values)
Logan, 1997 ¹⁵⁸	RCT- Single blinded	Serious limitations^(a)	No serious inconsistency	No serious indirectness	^(f)	16 (1–20)	16 (2–20)	^(g)	^(g)	Moderate ^(f)
Barthel Index (6 months follow-up) (Better indicated by higher values)
Parker, 2001 ¹⁹⁹	RCT- Single blinded	Serious limitations^(c)	No serious inconsistency	No serious indirectness	^(f)	18 (15–20)	17 (15–20)	^(g)	^(g)	Moderate ^(f)
Barthel Index (score <12) (1 year follow-up) (Better indicated by higher values)
Corr, 1995⁴⁸	RCT- Single blinded	Serious limitations^(a)	No serious inconsistency	No serious indirectness	Very serious imprecision ^(m)	22/55 (40%)	22/55 (40%)	1 (0.63 to 1.58)	0 fewer per 1000 (from 148 fewer to 232 more)	Very low
Barthel Index (1 year follow-up) (Better indicated by higher values)
Parker, 2001 ¹⁹⁹	RCT- Single blinded	Serious limitations^(c)	No serious inconsistency	No serious indirectness	^(f)	17 (14–19)	17 (14–20)	^(g)	^(g)	Moderate ^(f)
Nottingham Extended Activities of Daily Living (total) (2 months follow-up) (Better indicated by higher values)
Gilbertson, 2000 ⁹¹	RCT	Serious limitations^(c)	No serious inconsistency	No serious indirectness	Serious imprecision ⁽ⁱ⁾	27 (19–43)	23 (11–35)	4 (−0.43 to 8.43)	MD 4 higher (0.44 lower to 8.44 higher)	Low
Nottingham Extended Activities of Daily Living (total) (6 months follow-up) (Better indicated by higher values)
2 Parker, 2001 ¹⁹⁹ Gilbertson, 2000 ⁹¹	RCTs- Single blinded	Serious limitations^(c)	No serious inconsistency	No serious indirectness	Serious imprecision ⁽ⁱ⁾	Parker: 28 (15–38) Gilbertson: 34.7 (18.4)	Parker: 21 (14–38) Gilbertson: 33.1 (18.9)	3.41 (0.00, 6.82)	MD 7 higher (12.37 lower to 26.37 higher)	Low
Nottingham Extended Activities of Daily Living (total) (1 year follow-up) (Better indicated by higher values)
Parker, 2001 ¹⁹⁹	RCT- Single blinded	Serious limitations^(c)	No serious inconsistency	No serious indirectness	Serious imprecision ⁽ⁱ⁾	34.1 (19.1)	33.3 (19.5)	0.8 (−4.32 to 5.92)	MD 0.8 higher (4.32 lower to 5.92 higher)	Low
Nottingham Extended Activities of Daily Living (not able to feed) (1 year follow-up) (Better indicated by higher values)
Corr, 1995⁴⁸	RCT- Single blinded	Serious limitations^(a)	No serious inconsistency	No serious indirectness	Serious imprecision ^(j)	11/55 (20%)	19/55 (34.5%)	0.58 (0.3 to 1.1)	145 fewer per 1000 (from 242 fewer to 35 more)	Low
Nottingham Extended Activities of Daily Living (Not able to use the telephone) (1 year follow-up) (Better indicated by higher values)
Corr, 1995⁴⁸	RCT- Single blinded	Serious limitations^(a)	No serious inconsistency	No serious indirectness	Serious imprecision ^(j)	16/55 (29.1%)	29/55 (52.7%)	0.55 (0.34 to 0.89)	237 fewer per 1000 (from 58 fewer to 348 fewer)	Low
Nottingham Extended Activities of Daily Living (total) (1 year follow-up) (Better indicated by higher values)
Corr, 1995⁴⁸	RCT- Single blinded	Serious limitations^(a)	No serious inconsistency	No serious indirectness	^(f)	3 (0–20)	2 (0–21)	^(g)	^(g)	Low ^(f)
Extended Activities of Daily Living (total) (3 months follow-up) (Better indicated by higher values)
Logan, 1997 ¹⁵⁸	RCT- Single blinded	Serious limitations^(a)	No serious inconsistency	No serious indirectness	^(f)	8 (0–19)	3 (0–18)	^(g)	P<0.01^(g) ^(h)	Moderate ^(f)
Rivermead Mobility Index (3 months follow-up) (Better indicated by higher values)
Sackley, 2006 ²²⁶	Cluster Randomised Trial- Single blinded	Serious limitations^(e)	No serious inconsistency	No serious indirectness	No serious imprecision	5.2 (3.7)	3.5 (3.1)	1.7 (0.40 to 3.00)	MD 1.7 higher (0.4 to 3 higher)	Moderate
Rivermead Mobility Index (6 months follow-up) (Better indicated by higher values)
Sackley, 2006 ²²⁶	Cluster Randomised Trial- Single blinded	Serious limitations^(e)	No serious inconsistency	No serious indirectness	Very serious imprecision ^(l)	4.5 (3.5)	3.4 (2.7)	1.1 (−0.20 to 2.4)	MD 1.1 higher (0.2 lower to 2.4 higher)	Very low
Extended Activities of Daily living (6 months follow-up) (Better indicated by higher values)
Walker, 1999 ²⁷⁸	RCT- Single blinded	Serious limitations^(c)	No serious inconsistency	No serious indirectness	No serious imprecision	16 (11–18.75)	12 (6–17)	3 (0.78 to 5.22)	MD 3 higher (0.78 to 5.22 higher)	Moderate
Extended Activities of Daily Living (total) (6 months follow-up) (Better indicated by higher values)
Logan, 1997 ¹⁵⁸	RCT- Single blinded	Serious limitations^(a)	No serious inconsistency	No serious indirectness	^(f)	8 (0–21)	6 (0–18)	^(g)	^(g) ^(k)	Moderate ^(f)

a: Unclear randomisation and allocation concealment.

b: Mean difference did not reach the agreed MID of 17 points.

c: Unclear blinding

d: Mean difference did not reach the agreed MID of 1.85 points.

e: Unclear allocation concealment

f: Imprecision could not be assessed because only median and interquartile ranges of data reported

g: Relative/Absolute effect could not be estimated because only median and interquartile ranges of data reported

h: P value as reported by the authors.

i: Confidence interval crosses the lower limit of specified MID (−0.9)

j: Confidence interval crosses one end of the default MID (0.75).

k: Authors reported no significant difference between the intensive occupational therapy group and usual care group.

l: Confidence interval crossed both ends of default MID.

m: Confidence interval crosses both ends of default MID (0.75 to 1.25)

	108. Provide occupational therapy for people after stroke who are likely to benefit, to address difficulties with personal activities of daily living. Therapy may consist of restorative or compensatory strategies. Restorative strategies may include: - encouraging people with neglect to attend to the neglected side - encouraging people with arm weakness to incorporate both arms - establishing a dressing routine for people with difficulties such as poor concentration, neglect or dyspraxia which make dressing problematic. Compensatory strategies may include: - teaching people to dress one-handed - teaching people to use devices such as bathing and dressing aids. 109. People who have difficulties in activities of daily living after stroke should have regular monitoring and treatment by occupational therapists with core skills and training in the analysis and management of activities of daily living. Treatment should continue until the person is stable or able to progress independently. 110. Assess people after stroke for their equipment needs and whether their family or carers need training to use the equipment. This assessment should be carried out by an appropriately qualified professional. Equipment may include hoists, chair raisers and small aids such as long-handled sponges. 111. Ensure that appropriate equipment is provided and available for use by people after stroke when they are transferred from hospital, whatever the setting (including care homes).
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.