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Improves personal activities of daily living, but evidence remains sparse on other potential effects
In this week's BMJ, Legg and colleagues present a systematic review of randomised trials assessing the effect of occupational therapy on personal activities of daily life in people who have had a stroke.1
Stroke is a leading cause of death and disability2 and sadly, despite medical advances and public health initiatives, its incidence is not declining.3 The sequelae are often devastating and can affect the full range of human life and functioning.4 The impact of stroke extends beyond the individual to the people closest to them—carers experience high rates of distress, depression, and social isolation; reduced health status; and even premature death.5 6 7 8 Prevention and acute medical management are a fundamental part of the response to the problem, but improving life after stroke is also important and, as increasing evidence indicates, possible.9
Occupational therapists have for many years been identified as key contributors to the rehabilitation of people with stroke. The 2004 national clinical guidelines for stroke 10 stated that “a specialist stroke team should include staff with specialist knowledge of stroke including an occupational therapist.” Despite the fact that their input has long been seen as important, the level of evidence for this recommendation was limited to expert committee reports, opinions, or experience of respected authorities, with an indication that directly applicable clinical studies of good quality were absent.10
The review by Legg and colleagues1 synthesises data collected over the past decade and finds that occupational therapy targeted towards activities of daily living significantly increased performance on scores of personal activities of daily living (standardised mean difference 0.18, P=0.01) and reduced the risk of poor outcome (deterioration or dependency in personal activities of daily living: odds ratio 0.67, 95% confidence interval 0.51 to 0.87). The review, which includes a wide range of studies, provides strong evidence that occupational therapy after stroke improves outcome and prevents deterioration in functional performance. As many people struggle with the consequences of a stroke for years, policies should ensure a satisfactory level of service provision and appropriate staff capacity, and should optimise appropriate referral and management from health professionals.
Legg and colleagues1 focused on the effect of occupational therapy targeted at enhancing activities of daily living. Although this is a key intervention, it is just one aspect of occupational therapy after stroke. Other activities undertaken by therapists aim to enhance participation in domestic and leisure activities and facilitate engagement in activities that people find meaningful—occupation in the widest sense of the word. As a result, assessing occupational therapy along with other aspects of rehabilitation is complex, and the evidence from Legg and colleagues focuses on an aspect that is perhaps the easiest to capture. The challenge ahead is to build on and maintain this evidence base.
As Legg and colleagues note,1 key questions remain about which occupational therapy interventions are most beneficial and for whom. In the meantime, occupational therapists, medical practitioners, and others involved in the care of people with stroke should be heartened by these findings. For therapists, the evidence clearly shows that occupational therapy does make a difference. For general practitioners and community service providers, referral to occupational therapy may make a real difference for stroke survivors and their families. Not everyone will benefit from occupational therapy, however, and challenges include identifying those who will benefit and deciding exactly how to provide services.
So what needs to happen next? Undoubtedly, more people who have had a stroke should be referred to occupational therapy for help with activities of daily life. We still don't know which people are most likely to benefit (age, type of stroke, location of insult, duration of time since stroke); whether occupational therapy makes a difference to outcomes such as participation in meaningful activities like work and other life roles; and which outcomes are most important to people who have had a stroke and whether they are accounted for in rehabilitation interventions.11
Rehabilitation has often been labelled as comprising “black box” interventions12 and being a “Cinderella” discipline.9 The promising results from Legg and colleagues' trial should stimulate research into other areas of occupational therapy practice and encourage better provision of such services for people who have had a stroke.
Competing interests: None declared.
Provenance and peer review: Commissioned, not externally peer reviewed