An occupational therapy intervention for residents with stroke related disabilities in UK care homes (OTCH): cluster randomised controlled trial
BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h468 (Published 05 February 2015) Cite this as: BMJ 2015;350:h468
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The paper by Sackley et al [1] on occupational therapy for patients with stroke in UK care homes had great potential to improve the quality of life of many older people at the end of their life. It is a welcome change to see such effective discipline of occupational therapy presenting in this journal.
Unfortunately this study did not realise the expected outcomes for improved function and activities of daily living. A number of problems arise in this study where 71% of patients were cognitively impaired and were unlikely to participate in any new learning. Another reason is that independent therapy does not reflect comprehensive rehabilitation unless delivered as part of a multidisciplinary team [2]. It would also have been interesting to see the outcome of goal setting using another more useful outcome measure such as the goal attainment scale [3]. Perhaps the goal should have been to preserve the current level of function considering the severe impairment of function and mobility in 50% of the participants.
The growth of the aging population will require intervention in the care home sector. The intervention of occupational therapy should be supported but in addition the input of a variety of other disciplines of the multidisciplinary team including medical leadership. The black box of rehabilitation has been found to be effective when it includes a range of health professionals [4].
1. Sackley C M et al. An occupational therapy intervention for residents with stroke related disabilities in UK care homes (OTCH): cluster randomised controlled trial. BMJ 2015;350:h246
2. Young J. Review of Stroke Rehabilitation. BMJ 2007;334:86
3. Khan F, Pallant J and Turner-Stokes L. Use of Goal Attainment Scaling in Inpatient Rehabilitation for Persons with Multiple Sclerosis. J.apmr.2007.09.049
4. Wade, D T. Editorial, Research into the black box of rehabilitation: the risks of a Type III error. Clin Rehabil, 15.1 (Jan 2001): 1-
Competing interests: No competing interests
Re: An occupational therapy intervention for residents with stroke related disabilities in UK care homes (OTCH): cluster randomised controlled trial
We thank Alex and Wilson for their interest.
In UK care homes, the provision of a qualified occupational service, either as a standalone service or as part of a team, is unusual [1]. We wanted to evaluate whether there was robust clinical and economic evidence to address this, using a treatment model which has been successful in others settings [2, 3] and has shown promise in this setting [4].
We agree that that the observed prevalence of cognitive impairment (71%) may have prevented new learning; however, we disagree that this was a reason not to deliver an OT intervention. OT interventions have shown their efficacy for populations with cognitive impairment [5]. We felt it was important to take a pragmatic approach that included all residents with a history of stroke regardless of levels of cognitive, language and physical impairment. The selection of a high functioning sub-sample would have limited the scope to generalise evidence.
Measurement is an issue in this population, however we wonder if using goal attainment scaling in a population unable to set goals, who are not receiving therapy (the control group) or being assessed by a therapist will introduce bias. Indeed, this further emphasises our point that this theoretical approach is presumed to be effective without robust evidence.
Clearly, we agree that the care of older people in care homes is extremely important. However, we have demonstrated that an intervention with evidence of clinical efficacy and cost effectiveness in other populations and settings [1, 2] cannot be directly transferred to a care home population. This is an important finding and will focus future research and practice so that we do discover effective interventions.
1. Sackley C.M., Gatt J. & Walker M.F. 2001. The use of rehabilitation services by private nursing homes in Nottingham. Age and Ageing, 30(6): 532-3
2. Legg L, Drummond A, Leonardi-Bee J, et al. Occupational therapy for patients with problems in personal activities of daily living after stroke: systematic review of randomised trials. BMJ 2007;335(7626):922.
3. Walker MF, Leonardi-Bee J, Bath P, et al. Individual patient data meta-analysis of randomized controlled trials of community occupational therapy for stroke patients. Stroke. 2004;35(9):2226-32
4. Sackley C, Wade D, Mant D, et al. Cluster randomized pilot controlled trial of an occupational therapy intervention for residents with stroke in UK care homes. Stroke 2006;37(9):2336-41.
5. Graff MJ, Vernooij-Dassen MJ, Thijssen M, et al. Community based occupational therapy for patients with dementia and their care givers: randomised controlled trial. BMJ 2006;333:1196
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Competing interests: No competing interests