A randomised controlled trial of occupational therapy for stroke patients not admitted to hospital
Not all stroke patients are admitted to hospital. The literature indicates that between 22% and 60% of stroke patients remain in the community, often with little or no rehabilitation. Occupational therapy is commonly used in the treatment of stroke patients and aims to promote recovery through purposeful activity. Several small trials have suggested that this approach may be effective in reducing disability but none has examined the effect of occupational therapy on stroke patients not admitted to hospital. Therefore the aim of this study was to evaluate the effect of occupational therapy on the disability and handicap experienced by stroke patients who remain in the community. Patients were recruited to the study from a community stroke register. This register covered a geographical area of Nottingham and Southern Derbyshire, incorporating 73 general practitioner practices, covering 494,000 patients. Patients were included in the study if they fulfilled the WHO definition of stroke and had not been admitted to hospital. Patients were excluded if they lived in a nursing or residential home, could not speak or understand English prior to their stroke or had a previous history of dementia. At one month after stroke patients were assessed on a series of physical and cognitive assessments. Patients were then randomly allocated to a treatment group or a control group. Patients allocated to the treatment group received visits from a research occupational therapist for up to five months. The main aim of treatment was independence in personal and extended activities of daily living. Patients were also encouraged to participate in leisure activities. Two hundred and forty patients were notified to the study and of these, 55 patients were excluded. Of the remaining 185 patients, 94 were randomly allocated to the treatment group and 91 to the control group. All baseline assessments and demographic data were well matched between the groups. Twenty-two patients could not be assessed at six months; 13 patients had died during follow up and nine withdrew from the study. Significant differences were found between the groups at six months after stroke on the Barthel Index (p=0.002, 95% CI 0 to 1), Nottingham Extended Activities of Daily Living (p=0.009, 95% CI 1 to 4), Rivermead Gross Function (p=0.004, 95% CI 0 to 2), Caregiver Strain Index (p= 0.02, 95% CI 0 to 2) and the London Handicap Scale (p=0.03, 95% CI 0.3 to 13.5). There were no significant differences between the groups on the Hospital Anxiety and Depression scale. General Health Questionnaire 28 for either the patient or the carer or on the Nottingham Leisure Questionnaire. This study demonstrated that occupational therapy significantly reduced the level of disability and handicap experienced by stroke patients who remained in the community and also significantly reduced the strain of the carer. NB. This ethesis has been created by scanning the typescript original and may contain inaccuracies. In case of difficulty, please refer to the original text.