Domiciliary occupational therapy for patients with stroke discharged from hospital: randomised controlled trial

British Medical Journal, March 4, 2000 by Louise Gilbertson, Peter Langhorne, Andrew Walker, Ann Allen, Gordon D Murray

Abstract

Objective To establish if a brief programme of domiciliary occupational therapy could improve the recovery of patients with stroke discharged from hospital.

Design Single blind randomised controlled trial.

Setting Two hospital sites within a UK teaching hospital.

Subjects 138 patients with stroke with a definite plan for discharge home from hospital.

Intervention Six week domiciliary occupational therapy or routine follow up.

Main outcome measures Nottingham extended activities of daily living score and "global outcome" (deterioration according to the Barthel activities of daily living index, or death).

Results By eight weeks the mean Nottingham extended activities of daily living score in the intervention group was 4.8 points (95% confidence interval -0.5 to 10.0, P = 0.08) greater than that of the control group. Overall, 16 (24%) intervention patients had a poor global outcome compared with 30 (42%) control patients (odds ratio 0.43, 0.21 to 0.89, P = 0.02). These patterns persisted at six months but were not statistically significant. Patients in the intervention group were more likely to report satisfaction with a range of aspects of services.

Conclusion The functional outcome and satisfaction of patients with stroke can be improved by a brief occupational therapy programme carried out in the patient's home immediately after discharge. Major benefits may not, however, be sustained.

Introduction

Discharge home from hospital can be a critical stage in the rehabilitation of patients with stroke. The early recovery and new skills achieved in hospital may be difficult to transfer to the home environment.[1,2] Poor coordination of planning of discharge, lack of access to services, psychosocial problems, and reduced quality of life are also common experiences at this time.[1,3] Home based rehabilitation has been proposed to address these needs, and recent trials indicate that interventions for occupational therapy at home are feasible and possibly effective.[4,5] We therefore aimed to establish a brief outreach service for occupational therapy and to evaluate whether it could improve the recovery of patients with stroke discharged home from hospital.

Participants and methods

Study population

Patients with a clinical diagnosis of stroke (excluding subarachnoid haemorrhage) who were admitted to a Glasgow royal infirmary NHS trust were eligible if they had been referred to the occupational therapy department and if a discharge date had been set. We excluded only patients for whom the service might be inappropriate (full recovery, discharge to institutional care, terminal illness), those living outside the hospital area, and those unable to take part in the trial (severe cognitive or communication problems preventing consent, completion of outcome measures, or the agreement of simple goals for recovery).

Assignment

Eligible patients were contacted by the study therapist (LG) who obtained baseline data and informed consent. Patients were told the study would compare two types of follow up; routine services (control group) or routine services plus domiciliary occupational therapy (intervention). The therapist telephoned an independent central office where baseline data were logged before allocation. Patients were randomly allocated to either intervention by a computer generated schedule stratified by sex and attendance at a clay hospital contained in sequentially numbered opaque sealed envelopes. The study was approved by the local ethics committee.

Interventions

Routine services

Routine services included inpatient multidisciplinary rehabilitation, a predischarge home visit for selected patients, the provision of support services and equipment, regular multidisciplinary review at a stroke clinic, and selected patients referred to a medical day hospital.

Intervention service

The intervention service was designed to be client centred and was developed through focus group sessions with patients, carers, and local occupational therapy staff.[3] From these sessions a six week domiciliary programme was developed (comprising around 10 visits lasting 30-45 minutes) tailored to recovery goals identified by the patient such as regaining self care or domestic or leisure activities. The therapist worked with the patient to achieve these goals and also liaised with other agencies for advice, services, and equipment.

Outcomes

Baseline data were collected before randomisation, with follow up by interview after the intervention period (eight weeks) and postal outcome questionnaire at six months. The primary outcomes were the Nottingham extended activities of daily living scale and the "global outcome" of deterioration according to the Barthel activities of daily living index, or death.[6] Secondary outcomes included the Barthel index, satisfaction with outpatient services,[7] resource use (staff time, hospital readmission, provision of equipment and services), and measures of subjective health.[3]

We aimed to recruit a minimum of 128 patients to achieve an 80% power at 5% significance to detect a nine point difference in the Nottingham scores (66 point version) or a halving of the risk of poor global outcome. The outcome assessor (AA), who was blinded to treatment allocation, was based in a separate department from the research therapist.