COTF Outcomes That Matter Final Report

Transcription

1 COTF Outcomes That Matter Final Report Project title: The effectiveness of occupational therapy education and functional training programs for older adults Principal investigator: Seanne Wilkins Address: School of Rehabilitation Science, McMaster University, Institute of Applied Health Sciences, 1400 Main Street West, Hamilton, Ontario L8S 1C7 Phone: ext Fax: Co-investigators: Bonny Jung, Laurie Wishart, Mary Edwards, Shelley Gamble Norton Background: There is a diversity of ways in which aging and chronic illness have an impact on the lives of older adults. This diversity would suggest that occupational therapists must practice in a client-centred way to ascertain what aspects of occupation and occupational performance are important to their older clients. Occupational performance is the result of a dynamic relationship among persons, environment and occupation across the life course (Canadian Association of Occupational Therapists [CAOT], 1997). Once these occupational performance issues are determined, occupational therapists in partnership with their clients must determine what interventions would result in outcomes that would make a difference to the clients= health and occupational performance and thus, improve the quality of their day-to-day lives. Clients expect that interventions will be effective, as do other professionals, care providers and funders. Thus, occupational therapists must provide interventions that are based on research evidence. Enabling occupation with older adults often takes the form of education and functional training in occupational performance (i.e., self-care, productivity and leisure). Programs may include education only, functional training only or a combination of both education and functional training. The education component is usually a didactic approach directed toward knowledge. It includes the dissemination of information through such activities as presentations, written information, demonstrations and counselling (Hammond, 1997). The functional training component is directed towards enabling achievement of the individuals goals in occupational performance. Strategies for enabling change may involve developing, maintaining, restoring, or promoting occupational performance or preventing occupational dysfunction and may involve skill development in activities such as dressing, meal preparation, volunteering and hobbies (CAOT, 1997). It may include a greater use of demonstration than the education component and also includes practice by clients with occupational therapist supervision. The occupational therapist, in collaboration with the client, develops and monitors a home practice program to be used between therapy sessions (Hammond, 1997). To date there has been no critical review of the research literature in this area that determines whether these occupational therapy intervention strategies used separately or in combination are effective in enabling occupation and occupational performance and in enhancing the quality of life (QOL) for older adults. Thus, a critical review of the research literature was undertaken. Objectives: 1

2 A critical review was undertaken to address the following question: What is the effectiveness of occupational therapy education and functional training programs in improving health, occupational performance and quality of life for older adults who may or may not have chronic illnesses? Methods: Original criteria for considering studies for this review (criteria were ultimately revised) Types of studies (qualitative and quantitative) The review selected both qualitative and quantitative studies involving occupational therapy education and functional training programs for older adults with chronic illness. The descriptive critical review (see Table 1) includes all articles which reported a study of the effect of occupational therapy education and functional training programs in developing, maintaining, restoring and/or promoting occupational performance and quality of life of older adults. The quantitative study designs included randomized control trials, cohort, single case, before-after, case control, cross-sectional and case study designs. The qualitative study designs included ethnography, grounded theory, participatory action research, and phenomenology designs. Types of participants Older adults (aged 65 or older) with a diagnosis of a chronic illness (i.e., an illness lasting 6 months or more) involved in education and training programs which may be offered in any setting (in-patient, out-patient, community based). Types of intervention Studies included must be described as occupational therapy education and/or functional training programs. The programs may be offered separately or in combination by occupational therapists. Types of outcome measures Outcomes must include measurement of occupational performance, such as participation in daily activities, and/or in specific areas of self-care, productivity and/or leisure, and/or environmental contexts/conditions. Revised inclusion criteria The original inclusion criteria were pre-tested on a sample of 10 articles to refine and clarify the inclusion criteria, train the research group in applying the criteria, and ensure that the criteria were applied consistently across the research group (Mulrow & Oxman, 1997). Identification of appropriate studies required 75% agreement of the research team. Discussion and consensus of the research group resolved discrepancies. Inclusion criteria were modified after review of 10 articles: sampling included studies with participants 65 and over but not exclusively older adults due to the paucity of studies with only adults 65 and older, sampling included well older adults and/or older adults with chronic illness because there have been important studies utilizing occupational therapy education and functional training programs with well older adults, study design modified to include quasi-experimental and to exclude cross-sectional and case study designs in order to focus on the highest level of evidence, and setting of studies specific to out-patient and community given that there have been critical reviews done of specialized in-patient programs including occupational therapy such as stroke units and that there is a trend toward providing more occupational therapy in the community than in the past. Search strategy for identification of studies Selection of the studies for inclusion in this review was a multiple stage process and followed recommended procedures in the Cochrane Collaboration Handbook (Mulrow & Oxman, 1997). Review included the medical and social sciences literature pertaining to occupational therapy and was conducted 2

3 by an occupational therapist (research associate) who works with older adults in the community. 1. Computer search electronic data bases: Medline, 1966-present CINAHL, 1966-present Health Star, 1985-present Best Evidence,1991-present Ageline, 1978-present Psych Lit, Social Sciences Index, Sociological Abstracts 1980-present Review of Cochrane library 2. Hand searching Review of bibliographies supplied by field experts. Abstracts, specifically Journal of Physical and Occupational Therapy in Geriatrics, The Gerontologist, OT Practice: 1980-present. 3. Citation review Review of all reference lists of retrieved articles. The search involved combining keywords related to education and functional training programs for well and/or older adults with chronic illness. Keywords included: patient/client education; purposeful activity; meaningful activity; occupational therapy,/evaluation; rehabilitation,/evaluation; outcome assessment,/health care; long term care; community health services; quality of life; health promotion; chronic illness; aged/aging; arthritis (rheumatoid & osteoarthritis), osteoporosis, COPD, diabetes, Parkinson s disease, hypertension, stroke, PVD, CHF; falls; driving. Methods of review (a) Article selection: Lists of the articles from the search were reviewed beginning with assessment of each title and abstract by the principal investigator and research associate to determine whether the article met the inclusion criteria. If it was not possible to determine if a particular article met the inclusion criteria, then the full text of the article was reviewed. Each identified article was entered into a reference system (i.e., PAPYRUS). b) Data abstraction: Principal investigator and research associate reviewed the articles against inclusion criteria to ensure that all potentially relevant articles were retrieved. Articles that met the inclusion criteria were reviewed using the Guidelines for Critical Review for quantitative and qualitative studies developed by the McMaster University Occupational Therapy Evidence-Based Practice Research Group (Law et al., 1998a,b). Once a group of articles was retrieved, each of the 5 members of the research group reviewed the articles using aforementioned guidelines. Evaluations of reviews were compared to acquire an assessment of 75% of agreement of the primary rated categories on the review forms. c) Data analysis: The descriptive review is outlined in table format to summarize the important methodological issues and implications of the research findings for occupational therapists (Table 1). Note that groupings (prevention, stroke, and rheumatoid arthritis) emerged during our analysis and articles in Table 1 are listed alphabetically in these groups. Results: 3

4 1.Literature search: The first search using electronic databases found 322 articles pertaining to the applied keywords. Following application of inclusion criteria, a total of 105 articles were identified. Hand searching and citation review identified 10 additional articles. Following the extensive review process, 18 articles were accepted based on the revised criteria. 2. Data extraction and analysis: Descriptive review: Table 1 summarizes the important components and conclusions of the accepted studies and provides an assessment of the methodological issues and implications for occupational therapists. Implications for practice and policy: This critical review suggests that there is evidence to support the effectiveness of occupational therapy education and functional training programs for older adults although there is a need for ongoing, well-controlled and longitudinal research in this area. The evidence varies across the 18 studies described in Table 1. It may be most beneficial to consider the studies reviewed by grouping them into programs provided for the purposes of prevention of functional decline or programs provided to people with different chronic illnesses. Although the search was not designed to focus on specific conditions, these groups emerged as a result of our analysis. It is hoped that this review will be useful to occupational therapists working with older adults in different settings or with different populations as well as influence policy related to occupational therapy practice. Relative to influencing policy, occupational therapists may find this review useful in discussions with policy makers as supporting evidence for programs or program changes. There are some issues regarding the reporting of the studies that are common across most articles. There is generally a lack of detail regarded the actual occupational therapy program that is being provided. This results in an inability to understand the specific intervention or group of interventions and to duplicate the study. Similarly, in studies including both occupational therapy and physiotherapy, there is a lack of clarity as to what is being done uniquely by each professional leading to results that cannot be attributed to one or the other profession. There are many methodological issues across the studies (Table 1). While the ideal design of a randomized control trial has been used in most of the studies included, there is often contamination and co-interventions that may or may not be considered within the limitations of the study description. In many studies the analysis is poor or not clearly described leaving the reader to try to decipher the tables of results. Most of the studies do not include long-term follow-up to enable discussion of the effectiveness of the intervention over time, an important factor in policy decision making. Also in some situations the type of follow-up may not be appropriate for the type of outcomes being measured (e.g., a postal questionnaire rather than direct observation to determine the effectiveness of a program on independence in ADL). While this may be a funding issue, it can weaken the results of the study. Results may not be generalizable to other populations or situations. Although it is encouraging to see studies being conducted in this area, the review emphasized the need for studies that are methodologically more rigorous to help support policy changes related to occupational therapy. We did not include studies of older adults with dementia, developmental delays, or mental illness. Since our focus was on occupational performance, we did not include studies focusing only on performance components (i.e., range, strength, pain), rote exercise, object or imagery based exercise, laboratory-based studies, or health utilization studies (economic analysis). We divided the studies into the following groups: prevention, stroke and rheumatoid arthritis. NOTE that Table 1 has been organized to cluster the articles into these groupings. 4

5 PREVENTION: There are 5 research studies in Table 1 that address this issue (Clark et al., Clemson et al., Close et al., Cummings et al., Liddle et al.). The strongest evidence amongst these studies is provided by the work of Clark et al. This large scale RCT with well older adults living in the community provides statistically significant evidence for a specific occupation based program which offers meaningful choices in an individualized program provided by occupational therapists aware of barriers and supports in the community. This is in contrast to two control groups: a generalized activity (social) group and a group with no intervention. The results are specific to health function and QOL domains but cannot be generalized to people in different living situations and with different SES (socioeconomic status) or to people with disabilities. The remaining 4 studies consider the importance of the environment of older adults relative to falls (Clemson et al., Close et al., Cummings et al.) and loss of independence (Liddle et al.). The qualitative study by Clemson identifies the need for ownership of ideas and exerting control (joint decision-making and negotiation; importance of options and choices) within the context of environment and life experiences strongly influenced acceptance and follow through of environmental changes to reduce falls. The RCT by Close et al. provides evidence of the usefulness of a bi-disciplinary approach (medicine & OT) to decrease the number of falls as well as the rate of recurrent falls at 4 and 12 months. The focus of occupational therapy was on advice and education about home safety as well as recommendations for modifications and equipment. Modifications were made and equipment supplied for the participants. The RCT by Cummings et al. provides evidence that a home visit by an occupational therapist can prevent falls inside and outside the home among people with a history of falls provided there is follow-up and funding for modifications. The RCT by Liddle et al. involved older adults living in the community with no to severe impairment on ADL. There were no statistically significant differences in 3 groups regarding providing equipment, modifying home environments and using community resources to affect independence and quality of life. Easily available services as well as motivation to seek help by participants may have resulted in the lack of difference between groups. Implications for practice: health and QOL can be promoted among well older adults through an occupation based intervention that includes meaningful choices of activities, is individualized and is provided by occupational therapists with well older adults, being engaged through social activity groups is no more effective in promoting health and QOL than no intervention with older adults requiring home modifications, acceptance and follow through of home modifications can be enhanced through ownership of the ideas, the opportunity for exerting control through joint decision-making and negotiation, and through options and choices for change within the actual environment a medical/occupational therapy prevention approach that considers both intrinsic and extrinsic fall risk factors can play a significant role in reducing the number of falls and the rate of recurrent falls in older adults home visits by occupational therapists can reduce the risk of falls both in and outside the home in older adults with a history of falls if there is thorough follow-up as well as funding for modifications Implications for policy: in programs where the goal for well older adults is promoting health and QOL, the type of intervention group must be considered a structured, occupation based group provided by an occupational therapist is more effective than a social activity group run by non-occupational therapists when consideration is being given to the implementation of a home modification program for older adults, consideration must be given to factors such as active participation of the older adult in the decision-making, options and choices for change, funding for the home modifications and thorough follow-up if the focus of the program is the reduction of falls, other professionals in addition to occupational therapists may enhance the success of the program STROKE: There are 11 research studies included in Table 1 (Corr & Bayer; Drummond & Walker; Gilbertson et al.; Jongbloed & Morgan; Logan et al.; Parker et al.; Tangeman et al.; Walker, Drummond et al.; Walker, Gladman et al.; Werner & Kessler; Widen Holmqvist, von Koch et al.). These studies can be further subdivided 5

6 into interventions consisting of: A. occupational therapy, B. occupational therapy focusing on specific skills (i.e., leisure and dressing), and C. rehabilitation (i.e., occupational therapy [OT] and physiotherapy [PT]). A. Occupational therapy: In the RCT by Corr and Bayer, there is little evidence for the provision of ongoing occupational therapy after discharge from a stroke unit due to co-interventions. While there were statistically significant difference in the number of assisted devices used, independence in feeding, use of telephone and a reduction in hospital readmission, the lack of control of co-interventions prevents a positive evaluation of the occupational therapy intervention. In the RCT by Gilbertson et al., there is evidence that a brief community based program of occupational therapy tailored to the individual needs of older adults after discharge from hospital can improve performance in ADL and EADL in the short term (8 weeks) but not at 6 months although the intervention group was more likely to have improved and the change in ADL scores was significantly better than control group. The RCT by Logan et al. supports the provision of enhanced occupational therapy service (early rehabilitation intervention, longer and more visits) compared to usual service (wait list, provision of assisted devices) with statistically significant differences in EADL at 3 months but only on mobility section of EADL at 6 months as well as better moods for caregivers. In the RCT by Walker, Gladman et al., there is evidence of occupational therapy significantly reducing disability and handicap in older adults with stroke who were not admitted to hospital. Focusing on personal care and IADL, there were significant differences in scores in ADL, EADL, caregiver strain and handicap. B. Specific occupational therapy intervention: 1. Leisure: There are mixed results in 3 studies focusing on leisure programs. In a small RCT by Drummond and Walker, there is evidence that leisure rehabilitation maintains and increases leisure participation at 3 and 6 months. In a larger, multi-centred study, Parker et al. attempted to replicate these study results. While all estimates were in the direction of improvement at 6 months, these were not statistically significant. At 12 months, there was no significant difference between the intervention and control group. In a RCT by Jongbloed and Morgan, there was no statistical difference in involvement in leisure activities or satisfaction with involvement in activities between intervention and control groups at 5 or 18 weeks. Methodological issues in the latter 2 studies may have resulted in lack of support for leisure rehabilitation for this population. 2. Dressing: In a randomized cross-over design, Walker, Drummond et al. evaluate an intensive occupational therapy intervention for older adults with persistent dressing problems 6 months after discharge from hospital. They found significant differences between groups on dressing, perceived health and ADL performance. Dressing improvements were maintained at 3 months but did not generalize to other areas of ADL. C. Rehabilitation: A before and after design was used by Tangeman et al. to evaluate the effect of a 1 month intensive outpatient OT/PT rehabilitation program for people 1 year post stroke. Significant improvement was made in weight shift, balance, and ADL with skills retained at 3 month follow-up. In a RCT by Werner and Kessler, there is evidence that functional gains are possible with intensive OT/PT outpatient rehabilitation for older adults who had received inpatient rehabilitation. There was significant increase in functional independence and sickness impact at 3 months but these were not sustained at 9 months. Widen Holmqvist, von Koch et al., in a RCT, evaluated an in-home rehabilitation program with OT, PT and consultant social worker for older adults after early discharge from hospital as compared to rehabilitation in hospital, day care or outpatient care. No significant differences were found at 3 months although there was a reduction of hospitalizations for intervention group. This group was also more satisfied with care especially in their active participation in planning their rehabilitation program. Although not sufficiently to attain statistical significance, at 6 months the difference in outcomes favoured the home rehabilitation group in motor capacity, manual dexterity, walking, EADL, and perceived dysfunction. Follow-up at 12 months has not yet been reported. Implications for practice: there is evidence that community based occupational therapy programs tailored to the individual needs of older adults following discharge from hospital can improve performance in some ADL and EADL in the short-term (8 weeks) although not in the long term (6 months) and help decrease hospital readmission an early, more intensive and comprehensive occupational therapy program provided over a longer period of time as opposed to the provision of assistive devices only may make a difference in EADL at 3 months but not at 6 months 6

7 there is evidence that, amongst people not admitted to hospital following stroke, a home-based occupational therapy program can make a difference in ADL, EADL, caregiver strain and handicap at 6 months evidence for the effectiveness of occupational therapy leisure interventions provides inconclusive results; while a small RCT provided evidence that a leisure rehabilitation program resulted in maintained and increased leisure activities at 3 and 6 months, two other studies showed no evidence of difference; thus, more research is needed in this area specific, intensive occupational therapy intervention (dressing) programs in the home can improve dressing skills, ADL and perceived health the client s home is an optimal environment for occupational therapists to consider dressing in contrast to literature suggesting there is recovery only in the first 3 months following stroke, there is evidence that intensive, short-term rehabilitation programs including both OT and PT for people 1 year poststroke makes a difference in weight shift, balance and ADL at 3 months but not at 9 months with older adults between 6 months and 5 years post stroke, an intensive OT/PT program can improve functional independence and sickness impact at 3 months and dressing and bathing at 9 months early discharge home with interdisciplinary (OT, PT, social work consultation) rehabilitation intervention could be implemented for a selected group of older adults following stroke Implications for policy: in occupational therapy programs for older adults with strokes, there is an ongoing need for program evaluation to ensure that the goals of the programs are being met over time brief, intensive and comprehensive occupational therapy programs that are tailored to the individual needs of older adults as well as offered earlier may be more effective than the provision of assitive devices only brief community based occupational therapy intervention that focus on specific issues of relevance to older adults may be more effective than programs covering all aspects of occupational therapy occupational therapy programs provided to people with strokes who are not admitted to hospital are effective in improving ADL and EADL and in reducing dependency on the social and health care systems the client s home is an optimal environment for occupational therapists to address persistent dressing problems short, intensive OT/PT rehabilitation programs introduced after the time that is usually considered optimal for recovery from stroke may be effective intensive OT/PT rehabilitation provided in the home following early discharge may be as effective as rehabilitation provided in hospital, daycare or outpatient services and may lead to a reduction in hospitalization as well as increase satisfaction of older adults with care and involvement in the planning of their programs RHEUMATOID ARTHRITIS: There are 2 studies included in Table 1 (Helewa et al., Gerber et al.). In the RCT conducted by Helewa et al., a home occupational therapy program was found to be effective in improving daily function (i.e., self-care, productivity and QOL) in people with rheumatoid arthritis even when treatment was delayed for 6 weeks. In a randomized pilot study, Gerber et al. found no significant differences in outcomes for people using a didactic workbook-based occupational therapy program with behavioural and health education strategies than for people involved in a standard occupational therapy program including videotapes, written materials, individualized teaching and review of ADL difficulties. However, the group using the didactic workbook-based occupational therapy program did show some positive change. Implications for practice: there is evidence that a comprehensive, 6 week occupational therapy home program (addressing self-care, productivity and leisure as well as environmental contexts based on the particular needs of the individual) for people with rheumatoid arthritis does improve their functioning in areas of self-care, household management, mobility and QOL a 6 week occupational therapy home program may not be long enough for significant gains in social function, communication, leisure and appearance traditional energy conservation methods used by occupational therapists may not be as effective as a 7

8 systematic workbook-based occupational therapy patient education program but more research needs to be done in this area Implications for policy: a comprehensive, 6 week home occupational therapy program geared to the needs of the individual is effective for people with rheumatoid arthritis especially in improving function in self-care, productivity and QOL for at least 6 additional weeks a longer program may be needed to have an impact on leisure and psychosocial skills a 6 week delay in intervention does not change the effectiveness of the program although the individual may encounter disability during that time a systematic, didactic workbook-based occupational therapy educational program for energy conservation may be more effective than traditional occupational therapy for people with rheumatoid arthritis Summary of key implications across categories: In summary, there were themes across studies which are important to consider in conducting effective occupational therapy education and functional training programs for older adults. These include: client-centred approach individualized and focused on issues relevant to the older adult meaningful choices or options exerting control and taking ownership of ideas partnership and joint decision-making between client and occupational therapist intensive and systematic programs follow-up Dissemination plan: The critical review will be made available to occupational therapists in a variety of ways: on the COTF Web site on the Internet and on the McMaster University School of Rehabilitation Science Web site (Mobility, Aging and Participation Research Group page). An abstract for a paper presentation has been accepted for the annual conference of the Canadian Association of Occupational Therapists in May of An article will be submitted to the Canadian Journal of Occupational Therapy as well as a brief description of the critical literature review findings will be submitted in Occupational Therapy Now (the newsletter of the CAOT) with references made to the complete review on web sites. 8

9 References Canadian Association of Occupational Therapists (CAOT). (1997). Enabling occupation: An occupational therapy perspective. Ottawa, ON: CAOT Publications ACE. Clark, F., Azen, S. P., Zemke, R., Jackson, J., Carlson, M., Mandel, D., Hay, J., Josephson, K., Cherry, B., Hessel, C., Palmer, J., & Lipson, L. (1997). Occupational therapy for independent-living older adults: A randomized controlled trial. JAMA, 278, Clemson, L., Cumming, R. G., & Roland, M. (1999). Managing risk and exerting control: Determining follow through with falls prevention. Disability and Rehabilitation, 21, Close, J., Ellis, M., Hooper, R., Glucksman, E., Jackson, S., & Swift, C. (1999). Prevention of falls in the elderly trial (PROFET): A randomised controlled trial. The Lancet, 353, Corr, S., & Bayer, A. (1995). Occupational therapy for stroke patients after hospital discharge: A RCT. Clinical Rehabilitation, 9, Cummings, R. B., Thomas, M., Szonyi, G., Salkeld, G., O'Neill, E., Westbury, C., & Frampton, G. (1999). Home visits by an occupational therapist for assessment and modification of environmental hazards: A RCT of falls prevention. J AM Geriatr Soc, 47, Drummond, A., & Walker, M. (1995). A RCT of leisure rehabilitation after stroke. Clinical Rehabilitation, 9, Gerber, L., Furst, G., Shulman, B., Thornton, B., Liang, M., Cullen, K., Stevens, M. B., & Gilbert, N. (1987). Patient education program to treat energy conservation to patients with RA. Arch Phys Med Rehabil, 68, Gilbertson, L., Langhorne, P., Walker, A., Allen, A., & Murray, D. (2000). Domiciliary occupational therapy for patients with stroke discharged from hospital. British Medical Journal, 320, Hammond, A. (1997). Joint protection: What are we doing? British Journal of Occupational Therapy, 60, Helewa, A., Goldsmith, C. H., Lee, P., Bombardier, C., Hanes, B., Smythe, H. A., & Tugwell, P. (1991). Effects of occupational therapy home service on patients with rheumatoid arthritis. The Lancet, 337, Jackson, J., Carlson, M., Mandel, D., Zemke, R., & Clark, F. (1998): Occupation in lifestyle redesign: The Well Elderly Study Occupational Therapy Program. AJOT, 52, Jongbloed, L., & Morgan, D. (1991). An investigation of involvement in leisure activities after a stroke. AJOT, 45, Law, M., Stewart, D., Pollock, N., Letts, L., Bosch, J., & Westmorland, M. (1998a). Guidelines for the critical review form-qualitative studies. Hamilton, ON: McMaster Univeristy Occupational Therapy Evidence- Based Practice Research Group. 9

10 Law, M., Stewart, D., Pollock, N., Letts, L., Bosch, J., & Westmorland, M. (1998a). Guidelines for the critical review form-quantitative studies. Hamilton, ON: McMaster Univeristy Occupational Therapy Evidence- Based Practice Research Group. Liddle, J., March, L., Carfrae, B., Finnegan, T., Druce, J., Schwarz, J., & Brooks, P. (1996). Can occupational therapy play a part in maintaining independence and quality of life in older people? A RCT. Australian and New Zealand Journal of Public Health, 20, Logan, P. A., Ahern, J., Gladman, J. R., & Lincoln, N. B, (1997). A RCT of enhanced social service occupational therapy for stroke patients. Clinical Rehabilitation, 11, Mandel, D., Jackson, J., Lemke, R., Nelson, L., & Clark, F. (1999). Lifestyle redesign: Implementing the well elderly program. Bethesda, MD: American Occupational Therapy Association. Parker, C. J., Gladman, J. R. F., Drummond, A. E.R., Dewey, M. E., Lincoln, N. B., Barer, D., Logan, P. A., & Radford, K. A. (in press.). A multi-centre randomised controlled trial of leisure therapy and conventional occupational therapy after stroke. Clinical Rehabilitation Tangeman, P. T., Banaitis, D. A., & Williams, A. K. (1990). Rehabilitation of chronic stroke patients: Change in functional performance. Arch Phys Med Rehabil, 71, von Koch, L., Widen Holmqvist, L., Kostulas, V., Almazan, J., & de Pedro-Cuesta, J. (2000). A randomized controlled trial of rehabilitation at home after stoke in southwest Stockholm: Outcome at six months. Scandinavian Journal Rehabilitation Medicine, 32, Walker, M. F., Drummond, A. E. R., & Lincoln, N. B., (1996). Evaluation of dressing practice for stroke patients after discharge from hospital: A crossover design study. Clinical Rehabilitation, 10, Walker, M. F., Gladman, J. R., Lincoln, N. B., Siemonsma, P., & Whiteley, T. (1999). Occupational therapy for stroke patients not admitted to hospital: A RCT. The Lancet, 354, Werner, R., & Kessler, S. (1996). Effectiveness of an intensive outpatient rehabilitation program for post acute stroke patients. Am J Phys Med Rehabil, 75, Widen Holmqvist, L. F., de Pedro-Cuesta, M. D., Holm, M., & Kostulas, V. (1995). Intervention design for rehabilitation at home after stroke. Scandinavian Journal Rehabilitation Medicine, 27, Widen Holmqvist, L. F., Gladman, J. R., Lincoln, N. B., Siemonsma, P., & Whiteley, T. (1998). Randomized controlled trial of rehabilitation at home after stroke in southwest Stockholm. Stroke, 29,

11 Appendix Table 1: Descriptive Review of the Literature on the Effectiveness of Occupational Therapy Education and Functional Training Programs for Older Adults 11

12 Table 1: DESCRIPTIVE REVIEW OF THE LITERATURE THE EFFECTIVENESS OF OCCUPATIONAL THERAPY EDUCATION AND FUNCTIONAL TRAINING PROGRAMMES FOR OLDER ADULTS Wilkins, S., Jung, B., Wishart, L., Edwards, M., Gamble Norton, S. * See glossary at end of table ** Note all results are significant (p.05) unless stated otherwise PREVENTION Author/ date Clark et al. (1997) Purpose to evaluate the effectiveness of preventative OT services compared to social activity intervention or no intervention on QOL, health & functioning of independent multi-ethnic older adults Design, Sample & Outcomes D: RCT (3 groups) S: N=361; culturally diverse, independent living, community dwelling, older adults with mean age 74 yrs; O: measures at 0 & 9 mths; battery of selfadministered questionnaires: physical & social function; self-rated health; life satisfaction; & depression Research Focus/ Intervention OT group received 2hrs/wk of group intervention (OT facilitated) & 9hrs of individual intervention (i.e., didactic & direct experience) over a 9 mth period; interventions available (Mandal et al., 1999; Jackson et al., 1998) health through occupation focusing on appreciation of importance of meaningful activity and specific knowledge about how to select or perform activities to achieve healthy lifestyle social control group received 2.25 hrs/wk of group intervention (nonprofessional facilitated) & activities designed to encourage social interaction among group members non-treatment control group received no intervention **Results significant benefit for OT group across health function & QOL domains being regularly engaged in activity through social control program was no more effective in promoting health than no intervention Conclusions, Methodology & Implications C: older adults benefit from OT intervention that is occupation based, highly individualized and assists in overcoming barriers + applicable to various ethnicities - some outcome measures may not be useful for well, older adults - can t generalize to different living situations/ses or older adults with disabilities - no follow-up - lack of definitions for some inclusion & exclusion criteria I: health and well-being can be promoted through occupation based intervention administered by OTs 12

13 Author/ date Clemson et al. (1999) Purpose to explore perspectives of older women who did not follow through with OT recommended environmental modifications to reduce risk of falls in the home Design, Sample & Outcomes D: qualitative ethnographic study S: N=9; age 65 yrs; independent, community dwelling older women; referred to OT for home assessment to decrease risk of falls but did not implement recommendations O: in-depth, semistructured home interviews; interviews coded & themes identified Research Focus/ Intervention to gain an understanding of why these older women did not implement home safety recommendations **Results 8 conceptual categories with core concept of exerting control relevant to all categories related to how women manage risk Conclusions, Methodology & Implications C: lack of adherence to implement modifications related to need for ownership of ideas & ability to control within the context of environment - some implications noted may go beyond data - no design limitations noted - did not interview women who implemented suggestions I: importance of ownership of ideas and exerting control within the context of environment and life experiences influences acceptance and follow through of recommendations Close et al. (1999) to determine the effectiveness of a structured medical/ot assessment in decreasing falls of older adults compared to usual care control group who have fallen or at risk of further falls D: RCT (2 groups) S: N=397; mean age of 79 yrs; community dwelling older adults, who had a fall-related visit to hospital emergency O: measures at baseline, 4, 8 & 12 mths; # of falls, ADL, use of health services; follow-up through mailed questionnaires intervention group had 1 outpatient visit for medical assessment & 1 home OT visit to assess falls risk; provide falls education; advise regarding home modifications and referral to relevant services control group had no medical/ot assessment at 12 mths, significantly fewer falls and significantly lower rate of recurrent falling in intervention group C: one medical and one OT visit focused on falls prevention is effective in decreasing falls co-intervention & contamination may have occurred - design limitations not discussed -follow-up completed by postal questionnaire I: medical/ot prevention approach that considers both intrinsic and extrinsic fall risk factors can play a significant role in reducing the risk of falls in older adults 13

14 Author/ date Cummings et al. (1999) Purpose to determine the effectiveness of OT home visits targeted at environmental hazards to reduce the risk of falls in community dwelling older adults who have had a recent hospital visit/ admission compared to no intervention Design, Sample & Outcomes D: RCT (2 groups) S: N=530; mean age of 77 yrs; community dwelling older adults; adults with cognitive impairment were not excluded if they lived with informed caregiver O: follow-up measures at baseline & 12 mths; determining number of falls Research Focus/ Intervention intervention group received OT home safety assessment, recommendations given and follow-up including supervised completion of and funding for modifications 2 wk telephone follow-up control group received no direct OT intervention but 19 of control group received nonstudy OT home visits **Results at 1 yr statistically significant decrease in falls for older adults who had fallen in year prior no benefit for people without history of falls only 50% of home modifications in place after 1 yr therefore OT visit has effect on falls beyond modifications Conclusions, Methodology & Implications C: home visits prevent falls among older people who have a history of falls; this effect suggests that OT intervention may change people s behaviour in conjunction with home modifications + discussed co-interventions +specified recommendations re: home modifications - small sample size - intention-to-treat analysis I: OT home visits can prevent falls in/outside the home in older adults with falls history Liddle et al. (1996) to determine effect on quality of life and independence of older adults receiving OT intervention of home modifications & community services referral as compared to control group who received OT recommendations but not carried out and non intervention group who did not require any intervention D: RCT ( 2 groups) & 3 rd non intervention group S: N=105; age range of yrs; community dwelling older adults living with no to severe impairment in ADL O: measures at 0 & 6 mths; quality of life, sickness impact, morale, life satisfaction and health non intervention group contacted by telephone and postal questionnaire after 6 mths intervention, control, non intervention group assessed in home by OT OT only informed intervention group of recommendations on community services, home modifications and equipment & recommendations carried out or organized by independent research nurse control group recommendations not carried out non intervention group at baseline did not require any intervention no significant difference between groups at baseline significant change from baseline within group but no statistical difference between groups at 6 mths more of intervention than control group used ADL equipment and more had seen their family physician at least once C: experimental group doing no better than control group in enhancing quality of life and independence - no control of prognosis variables for independence & quality of life - contamination: control group was using community service (e.g., MOW, homecare); special equipment and had home modifications - selection bias - special group - high functioning & affluent - no specific details of OT intervention I: consultation model can be effective with certain populations; possible to enable people to follow through on recommendations 14

15 STROKE Author/ date Corr & Bayer (1995) Purpose to evaluate the effectiveness of usual services and OT intervention compared to usual care (control) on ADL & EADL in adults post-stroke and discharged from a stroke unit Design, Sample & Outcomes D:RCT (2 groups) S: N=110; mean age 75 yrs O: follow-up mailed questionnaire at 2, 8, 16 and 24 weeks measuring ADL/EADL, QOL, depression, caregiver QOL, & additional descriptive information (i.e., home circumstances, use of health services, provision of aids and hospital readmissions) Research Focus/ Intervention OT interventions included: learning new skills; facilitation of more independence in ADL & return of function; enabling use of equipment; information given to patient and caregiver and referral to other agencies control group received no special intervention or followup, but could receive any available services as required **Results at 1 yr post-stroke significant number of assisted aids used, independence in feeding, use of telephone and reduction in hospital readmissions in intervention vs control group no significant difference in ADL, EADL & depression Conclusions, Methodology & Implications C: OT interventions are beneficial compared to usual care but cannot conclude that benefits resulted directly from OT intervention due to co-interventions + limitations described - lack of detail re: level of stroke impairment - limited statistical analysis - gender imbalance between groups - contamination & co-interventions not measured - limited amount of OT intervention - missing data I: OT intervention improves some ADL & EADL outcomes and plays a role in decreasing hospital readmissions 1 yr post-stroke Drummond & Walker (1995) to evaluate the effectiveness of leisure rehabilitation program compared to conventional OT and usual care (control group) in older adults who were post-stroke and discharged from a stroke unit D: RCT (3 groups) S: N=65; mean age 64 yrs (29-84); older adults admitted to stroke unit and discharged into community O: measures at baseline on admission to stroke unit, 3 & 6 mths: leisure; frequency/total leisure activity, gross motor function & functional performance OT leisure group had weekly home visits (>30min) for 3mths then biweekly for 3mths focusing on leisure pursuits conventional OT group received home visits for the same amount of time focusing on ADL and perception control group no intervention other than what was received in hospital/ social services in OT leisure rehabilitation group s leisure scores were significantly better at 3 & 6 mths C: OT leisure rehabilitation is an effective way of maintaining & increasing leisure participation in older adults post-stroke + accounted for age variance - co-interventions may have affected outcome - small sample size - SES not adequately collected - no long term follow-up - lack of information regarding level of impairments & disabilities I: OT leisure rehabilitation increases the level of leisure participation of older adults poststroke 15

16 Author/ date Gilbertson et al. (2000) Jongbloed & Morgan (1991) Purpose to establish if a brief program of domicilary OT compared to receiving routine services could improve the recovery of persons poststroke discharged from hospital to determine effect of OT leisure skills intervention compared to OT visits with no leisure specific intervention on activity involvement & satisfaction in stroke survivors Design, Sample & Outcomes D: RCT into 2 groups S: N=138; mean age of 71 yrs ( yrs); with clinical diagnosis of stroke, referred to OT O: measures at baseline and 8 wks addressing: ADL, EADL, client satisfaction, resource use and subjective health D: RCT (2 groups) S: N=40; mean age 69.6yrs (42-86 yrs); post-stroke within 15 mths, community dwelling adults who completed a rehabilitation program O: measures at 0, 5 & 18 wks: involvement and satisfaction with involvement in activity; depression Research Focus/ Intervention intervention was developed through use of focus groups with clients, caregivers and OTs; 6 wk program was client-centred, tailored to needs of each older adult (i.e., self-care, domestic or leisure activities) approximately 10 visits of 30-45min intervention based on goals and liaison with other agencies (advice, equipment, services) control group received routine services intervention group received OT intervention to assist subjects in resuming former leisure activities and to learn to engage in new activities or both control group was visited by OT and asked questions about leisure activity but no leisure intervention provided 1hr visits x5wks for both groups **Results significance at 8 wks after intervention but not at 6mths 8 wks adjusted analysis (based on hemianopia, lower Barthel, longer hospital stay at baseline) significance achieved on EADL, ADL and global outcome of deterioration in ADL overall, no statistical difference between groups pertaining to activity (time) involvement and satisfaction with involvement Conclusions, Methodology & Implications C: a brief program of OT improves the ADL & EADL of clients with stroke in the short term but may not be sustained - cost analysis deducted but measurement not clear - method of follow-up at 6 mths with postal questionnaire vs interviews - small sample size - limited power to detect modest effect on outcomes I: results lend limited support to principle of extending routine stroke rehabilitation from inpatient to community C: no significant differences in leisure noted between stroke survivors in the intervention and control groups; may be explained by intervention too limited, environmental influence on activity + independent evaluator + pre-stroke activity level considered prior to randomization - no pure control group - tests may not be sensitive enough to detect differences in satisfaction - contamination (e.g. unclear if same therapist for both groups; control group asked questions about leisure) - no group comparison or impairment, disability, time post-stroke I: further research must be completed to establish the effectiveness of OT leisure specific intervention 16

17 Author/ date Logan et al. (1997) Purpose to determine the effect on ADL & EADL of social service OT compared to enhanced OT service in older adults post-stroke Design, Sample & Outcomes D: RCT (2 groups) S: N=111; mean age 73 yrs; community dwelling and first time post-stroke O: measures at 3 & 6 mths of functional and psychological outcomes; EADL and ADL & health questionnaire completed at 6mths Research Focus/ Intervention enhanced group were seen more quickly after referral, longer & more visits control group received usual OT service (i.e., prioritized, waiting list and intervention focused on provision of assistive devices) **Results enhanced group at 3 mths demonstrated better EADL at 6 mth, only mobility section of EADL was significant; caregiver lower GHQ (i.e., better moods) at 6 mths more equipment per person but significance for stair rail only Conclusions, Methodology & Implications C: support for use of enhanced OT with older adults post-stroke + independent assessor - OT intervention not clear - no baseline measures - lack of information re interventions received by control at 3, 6 mths - lack of information re: amount of therapy I: benefit of early intervention importance of enhanced OT service vs equipment only service caregivers of enhanced service less distressed than caregivers of usual service Parker et al. (2001) to evaluate the effect of OT leisure therapy or conventional OT compared to control group on mood, leisure participation in independence in ADL of older adults post-stroke 6 to 12 mths after hospital discharge D: multi-centred RCT (3 groups) S: N= 466 at 5 sites; mean age 72 yrs; community dwelling older adults poststroke who were recently discharged from hospital O: measures at baseline, 6 & 12 mths: mood, IADL, leisure, handicap and caregiver burden participants in both treatment groups received OT interventions (i.e., min of 10 sessions 30 minutes in length) at home up to 6 mths after recruitment treatment goals in conventional group focused on improving independence in self-care tasks treatment goals in leisure group focused on leisure activity control group received no occupational therapy intervention all participants were eligible for existing rehab services in the area no significant differences between groups at 6 & 12 mths at 6 mths leisure treatment group was in the direction of improvement but not significant C: no major short or long term beneficial effect of the additional leisure or conventional occupational therapy on the mood, ADL ability or leisure participation of older adults post-stroke living in the community + large sample size - no information on interventions received in hospital - no information on levels/types of impairments - not enough information on standards of therapy and who provided therapy - co-intervention from other community rehab services - inadequate intensity of treatment - insensitivity of outcome measures I: further research is needed to support the effectiveness of OT leisure and ADL intervention 17

18 Author/ date Tangeman et al. (1990) Purpose to investigate the effect of a 1 month intensive outpatient rehabilitation (OT/PT) for individuals who are 1 year post-stroke Design, Sample & Outcomes D: before and after design S: N=40 community dwelling individuals at least 1 year poststroke who ambulate independently; mean age of 66 yrs (27-77yrs) O: measures at 0, 1 & 3 mths: weight shift; balance and ADL Research Focus/ Intervention evaluation in clinic and client s home followed by mutual goal setting during first week intervention group participated in 5 wk rehab program to improve functional skills in a variety of environments with 2hrs of individual OT & PT/day/4 days/wk; group discussion on 5 th day. **Results significant improvement in wt shift, balance, ADL new skills retained for 3 mth follow-up Conclusions, Methodology & Implications C: after 1 mth of intensive rehabilitation, significant improvement on all 3 outcome measures ( wt shift, balance & ADL) at 3 mths functional gains retained - before and after design - need for longer follow-up - volunteer bias - no blinding I: intensive, short-term OT/PT rehabilitation is of benefit for adults one year post-stroke Walker, Drummond et al. (1996) to evaluate intensive OT treatment for older adults with persistent dressing problems at 6 mths after discharge from hospital D: randomized crossover design; where clients received intervention for 3 mths followed by 3 mths of no intervention or the reverse S: N=30; mean age of 68 yrs; clients who experienced a stroke 6 mths prior; living in community following hospital discharge O: measures completed at 3 & 6 mths: dressing; ADL; and client s perceived health clients received regular dressing practice regarding technique, energy conservation, perceptual strategies and advice regarding choice of clothing mean of 6 OT visits completed during treatment phase during no treatment phase clients had no contact with research occupational therapist; all other rehab continued as usual significant differences between groups on dressing, perceived health and ADL performance between the control and treatment phases dressing improvements were not lost over time (i.e., maintained for 3 mths) dressing improvements did not generalize into other areas of ADL dysphasia and poor colour matching ability were negatively associated with improvement in the specific dressing difficulty C: intensive OT dressing practice at 6 mths after discharge from hospital produced a significant impact in the clients dressing ability with a lasting effect +independent assessor at 3, 6 mths - no baseline dressing scores given at time of discharge - no long term follow-up I: intensive OT intervention in the home can have a positive effect on an individual s independence dressing, ADL & perceived health client s home is an optimal environment for OTs to consider the ADL of dressing 18

19 Author/ date Walker, Gladman et al. (1999) Purpose to assess the efficacy of an OT intervention compared to no intervention for older adults with strokes who were not admitted to hospital Design, Sample & Outcomes D: RCT (2 groups) S: N=185; mean age of 74 yrs ; clients < one mth post-stroke; clients were not admitted to hospital and were living in the community O: measures completed at 0 & 6 mths: EADL, ADL, gross motor function, mood, caregiver strain and handicap Research Focus/ Intervention intervention group received OT visits up to 5mths OT encouraged independence in ADL & EADL clients were also encouraged to take part in leisure pursuits specific tasks were set as homework when possible control group received no additional input from research OT but may have received input from existing services **Results significant difference between groups clients with OT intervention demonstrated significant improvement in ADL, EADL, caregiver strain and handicap no significant effect on mood of client or caregiver Conclusions, Methodology & Implications C: OT significantly reduces disability and handicap in individuals with stroke not admitted to hospital and living in the community + blind assessor - no specifics on level of the clients impairment resulting from stroke - co-intervention may have occurred in control group as no specifics given on types of other services received - frequency of intervention not described, actual specifics of intervention not described, OTs providing intervention not described I: need to advocate at the family physician or homecare level for OT referrals for people post-stroke who are not admitted to hospital OT intervention may result in less dependence on social and health care systems and decrease need for institutionalization 19

20 Author/ date Werner & Kessler (1996) Purpose to demonstrate the effectiveness of intensive out patient rehabilitation (OT/ PT) compared to no outpatient rehabilitation to increase functional status of older adults with a stroke Design, Sample & Outcomes D: RCT (2 groups) with 2:1 ratio treated S: N=49; mean age 62.5 yrs; older adults living in the community; experienced stroke between 6 mth & 5 yrs ago O: measures completed at 0, 3 & 9 mths: functional independence, motor recovery, mobility tasks, hand function, motor rating, depression, selfesteem and psychological health Research Focus/ Intervention intervention group received a 12 week intensive outpatient rehab program (i.e., 1hr OT and 1hr PT 4x/wk) initial assessment by physiatrist, OT & PT, followed by a team meeting defining functional interventions (e.g., transfers, walking, self-care & feeding) therapy focused on neuromuscular facilitation and functional tasks control group did not receive any outpatient therapy **Results significant increase in functional independence (i.e., eating, bathing, dressing, shower or tub transfers & stair climbing) & motor recovery during 3mth treatment period largest change in dressing and bathing and gains were maintained at 9 mths no significant change in functional independence at 9mths significant change regarding sickness impact (i.e., fewer functional and emotional complaints) from 0-3mths but not 3-9 mths Conclusions, Methodology & Implications C: functional gains are possible in an outpatient setting for older adults post-stroke who have had inpatient rehabilitation + blind assessor (OT) + accounted for all dropouts - selection bias - analysis poorly reported - lack of equal attention control group - exclusion of dropouts in data analysis I: intensive OT/PT intervention increases functional independence in older adults poststroke 20