BMJ  2004;329:1372 (11 December), doi:10.1136/bmj.38264.679560.8F (published 25 November 2004)

Paper

Randomised controlled trial of an occupational therapy intervention to increase outdoor mobility after stroke

¹ University of Nottingham, School of Community Health Sciences, University of Nottingham, Nottingham NG7 2RD, ² Research and Development Office, Broxtowe and Hucknall Primary Care Trust, Hucknall Health Centre, Hucknall, Nottingham NG15 7JE

Abstract

Objective To evaluate an occupational therapy intervention to improve outdoor mobility after stroke.

Design Randomised controlled trial.

Setting General practice registers, social services departments, a primary care rehabilitation service, and a geriatric day hospital.

Participants 168 community dwelling people with a clinical diagnosis of stroke in previous 36 months: 86 were allocated to the intervention group and 82 to the control group.

Interventions Leaflets describing local transport services for disabled people (control group) and leaflets with assessment and up to seven intervention sessions by an occupational therapist (intervention group).

Main outcome measures Responses to postal questionnaires at four and 10 months: primary outcome measure was response to whether participant got out of the house as much as he or she would like, and secondary outcome measures were response to how many journeys outdoors had been made in the past month and scores on the Nottingham extended activities of daily living scale, Nottingham leisure questionnaire, and general health questionnaire.

Results Participants in the treatment group were more likely to get out of the house as often as they wanted at both four months (relative risk 1.72, 95% confidence interval 1.25 to 2.37) and 10 months (1.74, 1.24 to 2.44). The treatment group reported more journeys outdoors in the month before assessment at both four months (median 37 in intervention group, 14 in control group: P < 0.01) and 10 months (median 42 in intervention group, 14 in control group: P < 0.01). At four months the mobility scores on the Nottingham extended activities of daily living scale were significantly higher in the intervention group, but there were no significant differences in the other secondary outcomes. No significant differences were observed in these measures at 10 months.

Conclusion A targeted occupational therapy intervention at home increases outdoor mobility in people after stroke.

Introduction

Many people after stroke do not get out of the house as much as they would like, and this has deleterious effects on quality of life.^{1 2} Some reasons for poor outdoor mobility are potentially remediable, including lack of confidence and inadequate information on transport options, aids, appliances, or adaptations to the home.³ On the basis of findings of a qualitative interview study, we developed an occupational therapy intervention programme to overcome these barriers.³

Methods

We identified patients with a clinical diagnosis of stroke in the previous 36 months from general practice registers and other sources in the community. We included people in care homes.

A research occupational therapist (PAL) collected baseline data, which included personal details, mobility status, personal activities of daily living ability (Barthel activities of daily living index),⁴ instrumental activities of daily living ability (Nottingham extended activities of daily living),⁵ and psychological wellbeing (12 item version of the general health questionnaire).⁶ At this visit PAL provided one session of occupational therapy. This included advice, encouragement, and the provision of leaflets describing local mobility services. This session reflected a routine occupational therapy session and also served as the intervention for those who were later allocated to the control group.

Participants were then randomly allocated to either the control intervention or the outdoor mobility intervention.

PAL made a clinical assessment of the barriers to outdoor mobility in the participants allocated to the occupational therapy intervention, negotiated mobility goals with them, and then delivered interventions to achieve those goals, using up to seven treatment sessions at home for up to three months. The treatment programme included the provision of information (for example, resuming driving, alternatives to cars and buses); the use of minor aids or adaptations, such as walking aids; and overcoming fear and apprehension by, for example, accompanying participants until confidence was restored. Aids and appliances were obtained from usual sources.

Outcome measures
We measured outcomes by post at four and 10 months after randomisation. Our main outcome measure was the response to the query "do you get out of the house as much as you would like?" Our secondary measures were response to the query "how many journeys outdoors have you taken in the last month?" and scores on the Nottingham extended activities of daily living scale,⁵ Nottingham leisure questionnaire,⁷ and the 12 item version of the general health questionnaire.⁶ Partners or carers were also invited to complete the general health questionnaire.

Results

Between June 2001 and December 2002, we invited 262 people to take part in our study (see bmj.com). Overall, 178 of the 262 people responded of whom 10 were excluded, leaving 168 participants. The groups were comparable at baseline (table 1).

View this table: [in this window] [in a new window]   Table 1 Baseline characteristics of people with clinical diagnosis of stroke allocated to outdoor mobility intervention or leaflet describing local transport services for disabled people (control group). Values are numbers (percentages) of participants unless stated otherwise

 

Intervention and outcomes
Participants in the intervention group had a mean number of 4.7 visits (median 6, interquartile range 4-6), giving a mean (SD) total of contact time of 230 (113) minutes.

At both four and 10 months, participants in the intervention group were more likely to get out of the house as often as wanted and to undertake more journeys in the month before assessment (table 2).

View this table: [in this window] [in a new window]   Table 2 Outcomes at four and 10 months for people receiving outdoor mobility intervention or leaflets describing local transport services for disabled people. Values are medians (interquartile ranges) unless stated otherwise

 

At four months, mobility scores on the Nottingham extended activities of daily living scale were significantly higher in the intervention group than in the control group, but the differences in the scores on the total and other subscores of the Nottingham extended activities of daily living scale, Nottingham leisure questionnaire, and general health questionnaire did not reach significance (figure). By 10 months we found no significant differences in the scores (see bmj.com).

View larger version (29K): [in this window] [in a new window]   Multivariate linear regression analysis of self reported mobility scores at four months, adjusted for sex, ethnic origin, age, and prior use of transport at baseline. Centre of diamonds represents estimated treatment effect when expressed as percentage of scale range for each scale, and ends of diamonds are 95% confidence intervals for effects

 

Discussion

A simple and feasible occupational therapy intervention in people after stroke was successful in increasing outdoor mobility in both the short and the longer term. The benefits of treatment were not lost within the observational period.

This targeted intervention was specially prepared for this study and was expected to overcome many of the barriers to outdoor mobility in patients after stroke. We propose that a cause and effect relation exists between our intervention and the improvement in outcome, and also that our findings are clinically meaningful.

Our recruitment rate indicates that there is likely to be a sufficient number of people in other health districts to make it worth while setting up services to deliver the intervention elsewhere. The high adherence to the trial protocol and the relatively small number of visits for occupational therapy suggests that the intervention is feasible within a NHS or similar healthcare setting (for example, community rehabilitation teams).

Our findings are likely to apply to the delivery of the intervention by other motivated occupational therapists who have been trained to provide the sorts of interventions used in this study. Our findings may not, however, apply to services delivered by untrained staff, to treatments that are considerably shorter than in our study, or to where one or more elements of the intervention cannot be provided, such as access to aids and equipment.

Our findings that occupational therapy can improve outdoor mobility are novel, but they are compatible with existing evidence that supports the use of community rehabilitation services after stroke⁸ and targeted interventions from an occupational therapist.⁹

What is already known on this topic The quality of life of many people after stroke is poor because they are housebound What this study adds A brief intervention by an occupational therapist improves outdoor mobility in community dwelling people after stroke The intervention includes the provision of information, aids, and appliances, and approaches to overcoming fear The intervention is likely to be feasible in many healthcare settings

---

This is the abridged version of an article that was posted on bmj.com on 25 November 2004: http://bmj.com/cgi/doi/10.1136/bmj.38264.679560.8F

We thank the participants, the primary care services who searched their records for people with stroke and sent letters on our behalf, Carol Coupland (lecturer in statistics) who provided statistical assistance, and Trent Focus, Primary Care Research network for promoting the research in the primary care setting.

Contributors: See bmj.com

Funding: The NHS research and development department funded the study through a National Primary Care Researcher Development Award to PAL.

Competing interests: None declared.

Ethical approval: Ethical approval was obtained from the Nottingham Queen's Medical Centre ethics committee (HC060001).

References

1. Logan PA, Gladman JRF, Radford KA. The use of transport by stroke patients. Br J Occup Ther 2001;64: 261-4.
2. Pound P, Gompertz P, Ebrahim S. A patient-centred study of the consequences of stroke. Clin Rehabil 1998;12: 338-47.[Abstract/Free Full Text]
3. Logan PA, Gladman JRF, Dyas J. An interview study of the use of transport by people who have had a stroke. Clin Rehabil 2004;18: 703-8.[Abstract/Free Full Text]
4. Collin C, Wade DT, Davies S, Horne V. The Barthel ADL index: a reliability study. Int Disability Stud 1988;10: 61-3.[Medline]
5. Nouri FM, Lincoln NB. An extended activities of daily living scale for stroke patients. Clin Rehabil 1987;1: 301-5.
6. Goldberg D. General health questionnaire (GHQ-12). Windsor: Nfer-Nelson, 1992.
7. Drummond AER, Parker CJ, Gladman JRF, Logan PA on behalf of the TOTAL study group. Development and validation of the Nottingham leisure questionnaire. Clin Rehabil 2001;15: 647-56.[Abstract/Free Full Text]
8. Outpatient Therapy Trialists. Rehabilitation therapy services for stroke patients living at home: a systematic review of the randomised trials. Lancet 2004;363: 352-6.[CrossRef][Web of Science][Medline]
9. Steultjens EMJ, Dekker J, Bouter LM, van de Nes JCM, Cup EHC, van den Ende CHM. Occupational therapy for stroke patients. A systematic review. Stroke 2002;34: 676-87.

(Accepted 27 September 2004)

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    StumbleUpon    Technorati    What's this?

Relevant Articles

Occupational therapy gets stroke patients out of the house
BMJ 2004 329: 0. [Full Text]

Public health's Holy Grail

Kamran Abbasi
BMJ 2004 329: 0. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

• Chen, H.-M., Hsieh, C.-L., Sing Kai Lo, , Liaw, L.-J., Chen, S.-M., Lin, J.-H. (2007). The Test-Retest Reliability of 2 Mobility Performance Tests in Patients With Chronic Stroke. Neurorehabil Neural Repair 21: 347-352 [Abstract]  
• Dawes, H, Korpershoek, N, Freebody, J, Elsworth, C, van Tintelen, N, Wade, D T, Izadi, H, Jones, D H (2006). A pilot randomised controlled trial of a home-based exercise programme aimed at improving endurance and function in adults with neuromuscular disorders. J. Neurol. Neurosurg. Psychiatry 77: 959-962 [Abstract] [Full text]  

Rapid Responses:

Read all Rapid Responses

Occupational therapy intervention after stroke

Elliot F Epstein
bmj.com, 14 Dec 2004 [Full text]

Author's reply to Dr Epstein and a correction

John R Gladman
bmj.com, 16 Dec 2004 [Full text]

Online poll

Find out more here>> and here>>