COTF Outcomes That Matter Final Report Canadian Occupational by MikeJenny

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									COTF Outcomes That Matter Final Report

Project title: The effectiveness of occupational therapy education and functional training programs
for older adults

Principal investigator: Seanne Wilkins

Address: School of Rehabilitation Science, McMaster University, Institute of Applied Health
Sciences, 1400 Main Street West, Hamilton, Ontario L8S 1C7

E-mail: swilkins@mcmaster.ca                 Phone: 905-525-9140 ext 27839                Fax: 905-524-0069

Co-investigators: Bonny Jung, Laurie Wishart, Mary Edwards, Shelley Gamble Norton



Background:

There is a diversity of ways in which aging and chronic illness have an impact on the lives of older adults. This
diversity would suggest that occupational therapists must practice in a client-centred way to ascertain what
aspects of occupation and occupational performance are important to their older clients. Occupational
performance is the result of a dynamic relationship among persons, environment and occupation across the life
course (Canadian Association of Occupational Therapists [CAOT], 1997). Once these occupational performance
issues are determined, occupational therapists in partnership with their clients must determine what interventions
would result in outcomes that would make a difference to the clients= health and occupational performance and
thus, improve the quality of their day-to-day lives. Clients expect that interventions will be effective, as do other
professionals, care providers and funders. Thus, occupational therapists must provide interventions that are based
on research evidence.

Enabling occupation with older adults often takes the form of education and functional training in occupational
performance (i.e., self-care, productivity and leisure). Programs may include education only, functional training
only or a combination of both education and functional training. The education component is usually a didactic
approach directed toward knowledge. It includes the dissemination of information through such activities as
presentations, written information, demonstrations and counselling (Hammond, 1997). The functional training
component is directed towards enabling achievement of the individuals’ goals in occupational performance.
Strategies for enabling change may involve developing, maintaining, restoring, or promoting occupational
performance or preventing occupational dysfunction and may involve skill development in activities such as
dressing, meal preparation, volunteering and hobbies (CAOT, 1997). It may include a greater use of
demonstration than the education component and also includes practice by clients with occupational therapist
supervision. The occupational therapist, in collaboration with the client, develops and monitors a home practice
program to be used between therapy sessions (Hammond, 1997).

To date there has been no critical review of the research literature in this area that determines whether these
occupational therapy intervention strategies used separately or in combination are effective in enabling occupation
and occupational performance and in enhancing the quality of life (QOL) for older adults. Thus, a critical review
of the research literature was undertaken.

Objectives:



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A critical review was undertaken to address the following question:
What is the effectiveness of occupational therapy education and functional training programs in improving health,
occupational performance and quality of life for older adults who may or may not have chronic illnesses?

Methods:

Original criteria for considering studies for this review (criteria were ultimately revised)

Types of studies (qualitative and quantitative)
The review selected both qualitative and quantitative studies involving occupational therapy education and
functional training programs for older adults with chronic illness. The descriptive critical review (see Table 1)
includes all articles which reported a study of the effect of occupational therapy education and functional training
programs in developing, maintaining, restoring and/or promoting occupational performance and quality of life of
older adults. The quantitative study designs included randomized control trials, cohort, single case, before-after,
case control, cross-sectional and case study designs. The qualitative study designs included ethnography,
grounded theory, participatory action research, and phenomenology designs.

Types of participants
Older adults (aged 65 or older) with a diagnosis of a chronic illness (i.e., an illness lasting 6 months or more)
involved in education and training programs which may be offered in any setting (in-patient, out-patient,
community based).

Types of intervention
Studies included must be described as occupational therapy education and/or functional training programs. The
programs may be offered separately or in combination by occupational therapists.

Types of outcome measures
Outcomes must include measurement of occupational performance, such as participation in daily activities, and/or
in specific areas of self-care, productivity and/or leisure, and/or environmental contexts/conditions.

Revised inclusion criteria
The original inclusion criteria were pre-tested on a sample of 10 articles to refine and clarify the inclusion criteria,
train the research group in applying the criteria, and ensure that the criteria were applied consistently across the
research group (Mulrow & Oxman, 1997). Identification of appropriate studies required 75% agreement of the
research team. Discussion and consensus of the research group resolved discrepancies.
Inclusion criteria were modified after review of 10 articles:
 • sampling included studies with participants 65 and over but not exclusively older adults due to the paucity of
    studies with only adults 65 and older,
 • sampling included well older adults and/or older adults with chronic illness because there have been important
    studies utilizing occupational therapy education and functional training programs with well older adults,
 • study design modified to include quasi-experimental and to exclude cross-sectional and case study designs in
    order to focus on the highest level of evidence, and
 • setting of studies specific to out-patient and community given that there have been critical reviews done of
    specialized in-patient programs including occupational therapy such as stroke units and that there is a trend
    toward providing more occupational therapy in the community than in the past.

Search strategy for identification of studies
Selection of the studies for inclusion in this review was a multiple stage process and followed recommended
procedures in the Cochrane Collaboration Handbook (Mulrow & Oxman, 1997).
Review included the medical and social sciences literature pertaining to occupational therapy and was conducted


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by an occupational therapist (research associate) who works with older adults in the community.

1. Computer search – electronic data bases:
Medline, 1966-present
CINAHL, 1966-present
Health Star, 1985-present
Best Evidence,1991-present
Ageline, 1978-present
Psych Lit, Social Sciences Index , Sociological Abstracts 1980-present
Review of Cochrane library

2. Hand searching
Review of bibliographies supplied by field experts.
Abstracts, specifically Journal of Physical and Occupational Therapy in Geriatrics, The Gerontologist, OT
Practice: 1980-present.

3. Citation review
Review of all reference lists of retrieved articles.

The search involved combining keywords related to education and functional training programs for well and/or
older adults with chronic illness.
Keywords included:
patient/client education; purposeful activity; meaningful activity; occupational therapy,/evaluation;
rehabilitation,/evaluation; outcome assessment,/health care; long term care; community health services;
quality of life; health promotion; chronic illness; aged/aging; arthritis (rheumatoid & osteoarthritis), osteoporosis,
COPD, diabetes, Parkinson’s disease, hypertension, stroke, PVD, CHF; falls; driving.

Methods of review
(a) Article selection:
Lists of the articles from the search were reviewed beginning with assessment of each title and abstract by the
principal investigator and research associate to determine whether the article met the inclusion criteria. If it was
not possible to determine if a particular article met the inclusion criteria, then the full text of the article was
reviewed. Each identified article was entered into a reference system (i.e., PAPYRUS).

b) Data abstraction:
Principal investigator and research associate reviewed the articles against inclusion criteria to ensure that all
potentially relevant articles were retrieved. Articles that met the inclusion criteria were reviewed using the
Guidelines for Critical Review for quantitative and qualitative studies developed by the McMaster University
Occupational Therapy Evidence-Based Practice Research Group (Law et al., 1998a,b). Once a group of articles
was retrieved, each of the 5 members of the research group reviewed the articles using aforementioned
guidelines. Evaluations of reviews were compared to acquire an assessment of 75% of agreement of the primary
rated categories on the review forms.

c) Data analysis:
The descriptive review is outlined in table format to summarize the important methodological issues and
implications of the research findings for occupational therapists (Table 1). Note that groupings (prevention, stroke,
and rheumatoid arthritis) emerged during our analysis and articles in Table 1 are listed alphabetically in these
groups.

Results:


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1.Literature search:
The first search using electronic databases found 322 articles pertaining to the applied keywords. Following
application of inclusion criteria, a total of 105 articles were identified. Hand searching and citation review
identified 10 additional articles. Following the extensive review process, 18 articles were accepted based on the
revised criteria.

2. Data extraction and analysis:
Descriptive review: Table 1 summarizes the important components and conclusions of the accepted studies and
provides an assessment of the methodological issues and implications for occupational therapists.

Implications for practice and policy:

This critical review suggests that there is evidence to support the effectiveness of occupational therapy education
and functional training programs for older adults although there is a need for ongoing, well-controlled and
longitudinal research in this area. The evidence varies across the 18 studies described in Table 1. It may be most
beneficial to consider the studies reviewed by grouping them into programs provided for the purposes of
prevention of functional decline or programs provided to people with different chronic illnesses. Although the
search was not designed to focus on specific conditions, these groups emerged as a result of our analysis.

It is hoped that this review will be useful to occupational therapists working with older adults in different settings
or with different populations as well as influence policy related to occupational therapy practice. Relative to
influencing policy, occupational therapists may find this review useful in discussions with policy makers as
supporting evidence for programs or program changes.

There are some issues regarding the reporting of the studies that are common across most articles. There is
generally a lack of detail regarded the actual occupational therapy program that is being provided. This results in
an inability to understand the specific intervention or group of interventions and to duplicate the study. Similarly, in
studies including both occupational therapy and physiotherapy, there is a lack of clarity as to what is being done
uniquely by each professional leading to results that cannot be attributed to one or the other profession.

There are many methodological issues across the studies (Table 1). While the ideal design of a randomized
control trial has been used in most of the studies included, there is often contamination and co-interventions that
may or may not be considered within the limitations of the study description. In many studies the analysis is poor
or not clearly described leaving the reader to try to decipher the tables of results. Most of the studies do not
include long-term follow-up to enable discussion of the effectiveness of the intervention over time, an important
factor in policy decision making. Also in some situations the type of follow-up may not be appropriate for the type
of outcomes being measured (e.g., a postal questionnaire rather than direct observation to determine the
effectiveness of a program on independence in ADL). While this may be a funding issue, it can weaken the
results of the study. Results may not be generalizable to other populations or situations. Although it is encouraging
to see studies being conducted in this area, the review emphasized the need for studies that are methodologically
more rigorous to help support policy changes related to occupational therapy.

We did not include studies of older adults with dementia, developmental delays, or mental illness. Since our focus
was on occupational performance, we did not include studies focusing only on performance components (i.e.,
range, strength, pain), rote exercise, object or imagery based exercise, laboratory-based studies, or health
utilization studies (economic analysis).

We divided the studies into the following groups: prevention, stroke and rheumatoid arthritis.
NOTE that Table 1 has been organized to cluster the articles into these groupings.


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PREVENTION: There are 5 research studies in Table 1 that address this issue (Clark et al., Clemson et al.,
Close et al., Cummings et al., Liddle et al.). The strongest evidence amongst these studies is provided by the
work of Clark et al. This large scale RCT with well older adults living in the community provides statistically
significant evidence for a specific occupation based program which offers meaningful choices in an individualized
program provided by occupational therapists aware of barriers and supports in the community. This is in contrast
to two control groups: a generalized activity (social) group and a group with no intervention. The results are
specific to health function and QOL domains but cannot be generalized to people in different living situations and
with different SES (socioeconomic status) or to people with disabilities. The remaining 4 studies consider the
importance of the environment of older adults relative to falls (Clemson et al., Close et al., Cummings et al.) and
loss of independence (Liddle et al.). The qualitative study by Clemson identifies the need for ownership of ideas
and exerting control (joint decision-making and negotiation; importance of options and choices) within the context
of environment and life experiences strongly influenced acceptance and follow through of environmental changes
to reduce falls. The RCT by Close et al. provides evidence of the usefulness of a bi-disciplinary approach
(medicine & OT) to decrease the number of falls as well as the rate of recurrent falls at 4 and 12 months. The
focus of occupational therapy was on advice and education about home safety as well as recommendations for
modifications and equipment. Modifications were made and equipment supplied for the participants. The RCT by
Cummings et al. provides evidence that a home visit by an occupational therapist can prevent falls inside and
outside the home among people with a history of falls provided there is follow-up and funding for modifications.
The RCT by Liddle et al. involved older adults living in the community with no to severe impairment on ADL.
There were no statistically significant differences in 3 groups regarding providing equipment, modifying home
environments and using community resources to affect independence and quality of life. Easily available services
as well as motivation to seek help by participants may have resulted in the lack of difference between groups.
Implications for practice:
• health and QOL can be promoted among well older adults through an occupation based intervention that
     includes meaningful choices of activities, is individualized and is provided by occupational therapists
• with well older adults, being engaged through social activity groups is no more effective in promoting health
     and QOL than no intervention
• with older adults requiring home modifications, acceptance and follow through of home modifications can be
     enhanced through ownership of the ideas, the opportunity for exerting control through joint decision-making
     and negotiation, and through options and choices for change within the actual environment
• a medical/occupational therapy prevention approach that considers both intrinsic and extrinsic fall risk factors
     can play a significant role in reducing the number of falls and the rate of recurrent falls in older adults
• home visits by occupational therapists can reduce the risk of falls both in and outside the home in older adults
     with a history of falls if there is thorough follow-up as well as funding for modifications
Implications for policy:
• in programs where the goal for well older adults is promoting health and QOL, the type of intervention group
     must be considered
• a structured, occupation based group provided by an occupational therapist is more effective than a social
     activity group run by non-occupational therapists
• when consideration is being given to the implementation of a home modification program for older adults,
     consideration must be given to factors such as active participation of the older adult in the decision-making,
     options and choices for change, funding for the home modifications and thorough follow-up
• if the focus of the program is the reduction of falls, other professionals in addition to occupational therapists
     may enhance the success of the program

STROKE: There are 11 research studies included in Table 1 (Corr & Bayer; Drummond & Walker; Gilbertson
et al.; Jongbloed & Morgan; Logan et al.; Parker et al.; Tangeman et al.; Walker, Drummond et al.; Walker,
Gladman et al.; Werner & Kessler; Widen Holmqvist, von Koch et al.). These studies can be further subdivided



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into interventions consisting of: A. occupational therapy, B. occupational therapy focusing on specific skills (i.e.,
leisure and dressing), and C. rehabilitation (i.e., occupational therapy [OT] and physiotherapy [PT]).
A. Occupational therapy: In the RCT by Corr and Bayer, there is little evidence for the provision of ongoing
occupational therapy after discharge from a stroke unit due to co-interventions. While there were statistically
significant difference in the number of assisted devices used, independence in feeding, use of telephone and a
reduction in hospital readmission, the lack of control of co-interventions prevents a positive evaluation of the
occupational therapy intervention. In the RCT by Gilbertson et al., there is evidence that a brief community based
program of occupational therapy tailored to the individual needs of older adults after discharge from hospital can
improve performance in ADL and EADL in the short term (8 weeks) but not at 6 months although the
intervention group was more likely to have improved and the change in ADL scores was significantly better than
control group. The RCT by Logan et al. supports the provision of enhanced occupational therapy service (early
rehabilitation intervention, longer and more visits) compared to usual service (wait list, provision of assisted
devices) with statistically significant differences in EADL at 3 months but only on mobility section of EADL at 6
months as well as better moods for caregivers. In the RCT by Walker, Gladman et al., there is evidence of
occupational therapy significantly reducing disability and handicap in older adults with stroke who were not
admitted to hospital. Focusing on personal care and IADL, there were significant differences in scores in ADL,
EADL, caregiver strain and handicap.
B. Specific occupational therapy intervention: 1. Leisure: There are mixed results in 3 studies focusing on
leisure programs. In a small RCT by Drummond and Walker, there is evidence that leisure rehabilitation
maintains and increases leisure participation at 3 and 6 months. In a larger, multi-centred study, Parker et al.
attempted to replicate these study results. While all estimates were in the direction of improvement at 6 months,
these were not statistically significant. At 12 months, there was no significant difference between the intervention
and control group. In a RCT by Jongbloed and Morgan, there was no statistical difference in involvement in
leisure activities or satisfaction with involvement in activities between intervention and control groups at 5 or 18
weeks. Methodological issues in the latter 2 studies may have resulted in lack of support for leisure rehabilitation
for this population.
2. Dressing: In a randomized cross-over design, Walker, Drummond et al. evaluate an intensive occupational
therapy intervention for older adults with persistent dressing problems 6 months after discharge from hospital.
They found significant differences between groups on dressing, perceived health and ADL performance.
Dressing improvements were maintained at 3 months but did not generalize to other areas of ADL.
C. Rehabilitation: A before and after design was used by Tangeman et al. to evaluate the effect of a 1 month
intensive outpatient OT/PT rehabilitation program for people 1 year post stroke. Significant improvement was
made in weight shift, balance, and ADL with skills retained at 3 month follow-up. In a RCT by Werner and
Kessler, there is evidence that functional gains are possible with intensive OT/PT outpatient rehabilitation for
older adults who had received inpatient rehabilitation. There was significant increase in functional independence
and sickness impact at 3 months but these were not sustained at 9 months. Widen Holmqvist, von Koch et al., in
a RCT, evaluated an in-home rehabilitation program with OT, PT and consultant social worker for older adults
after early discharge from hospital as compared to rehabilitation in hospital, day care or outpatient care. No
significant differences were found at 3 months although there was a reduction of hospitalizations for intervention
group. This group was also more satisfied with care especially in their active participation in planning their
rehabilitation program. Although not sufficiently to attain statistical significance, at 6 months the difference in
outcomes favoured the home rehabilitation group in motor capacity, manual dexterity, walking, EADL, and
perceived dysfunction. Follow-up at 12 months has not yet been reported.
Implications for practice:
• there is evidence that community based occupational therapy programs tailored to the individual needs of
     older adults following discharge from hospital can improve performance in some ADL and EADL in the
     short-term (8 weeks) although not in the long term (6 months) and help decrease hospital readmission
• an early, more intensive and comprehensive occupational therapy program provided over a longer period of
     time as opposed to the provision of assistive devices only may make a difference in EADL at 3 months but
     not at 6 months


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•  there is evidence that, amongst people not admitted to hospital following stroke, a home-based occupational
   therapy program can make a difference in ADL, EADL, caregiver strain and handicap at 6 months
• evidence for the effectiveness of occupational therapy leisure interventions provides inconclusive results;
   while a small RCT provided evidence that a leisure rehabilitation program resulted in maintained and
   increased leisure activities at 3 and 6 months, two other studies showed no evidence of difference; thus, more
   research is needed in this area
• specific, intensive occupational therapy intervention (dressing) programs in the home can improve dressing
   skills, ADL and perceived health
• the client’s home is an optimal environment for occupational therapists to consider dressing
• in contrast to literature suggesting there is recovery only in the first 3 months following stroke, there is
   evidence that intensive, short-term rehabilitation programs including both OT and PT for people 1 year post-
   stroke makes a difference in weight shift, balance and ADL at 3 months but not at 9 months
• with older adults between 6 months and 5 years post stroke, an intensive OT/PT program can improve
   functional independence and sickness impact at 3 months and dressing and bathing at 9 months
• early discharge home with interdisciplinary (OT, PT, social work consultation) rehabilitation intervention could
   be implemented for a selected group of older adults following stroke
Implications for policy:
• in occupational therapy programs for older adults with strokes, there is an ongoing need for program
   evaluation to ensure that the goals of the programs are being met over time
• brief, intensive and comprehensive occupational therapy programs that are tailored to the individual needs of
   older adults as well as offered earlier may be more effective than the provision of assitive devices only
• brief community based occupational therapy intervention that focus on specific issues of relevance to older
   adults may be more effective than programs covering all aspects of occupational therapy
• occupational therapy programs provided to people with strokes who are not admitted to hospital are effective
   in improving ADL and EADL and in reducing dependency on the social and health care systems
• the client’s home is an optimal environment for occupational therapists to address persistent dressing
   problems
• short, intensive OT/PT rehabilitation programs introduced after the time that is usually considered optimal for
   recovery from stroke may be effective
• intensive OT/PT rehabilitation provided in the home following early discharge may be as effective as
   rehabilitation provided in hospital, daycare or outpatient services and may lead to a reduction in hospitalization
   as well as increase satisfaction of older adults with care and involvement in the planning of their programs

RHEUMATOID ARTHRITIS: There are 2 studies included in Table 1 (Helewa et al., Gerber et al.). In the
RCT conducted by Helewa et al., a home occupational therapy program was found to be effective in improving
daily function (i.e., self-care, productivity and QOL) in people with rheumatoid arthritis even when treatment was
delayed for 6 weeks. In a randomized pilot study, Gerber et al. found no significant differences in outcomes for
people using a didactic workbook-based occupational therapy program with behavioural and health education
strategies than for people involved in a standard occupational therapy program including videotapes, written
materials, individualized teaching and review of ADL difficulties. However, the group using the didactic
workbook-based occupational therapy program did show some positive change.
Implications for practice:
• there is evidence that a comprehensive, 6 week occupational therapy home program (addressing self-care,
     productivity and leisure as well as environmental contexts based on the particular needs of the individual) for
     people with rheumatoid arthritis does improve their functioning in areas of self-care, household management,
     mobility and QOL
• a 6 week occupational therapy home program may not be long enough for significant gains in social function,
     communication, leisure and appearance
• traditional energy conservation methods used by occupational therapists may not be as effective as a


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   systematic workbook-based occupational therapy patient education program but more research needs to be
   done in this area
Implications for policy:
• a comprehensive, 6 week home occupational therapy program geared to the needs of the individual is
   effective for people with rheumatoid arthritis especially in improving function in self-care, productivity and
   QOL for at least 6 additional weeks
• a longer program may be needed to have an impact on leisure and psychosocial skills
• a 6 week delay in intervention does not change the effectiveness of the program although the individual may
   encounter disability during that time
• a systematic, didactic workbook-based occupational therapy educational program for energy conservation
   may be more effective than traditional occupational therapy for people with rheumatoid arthritis

Summary of key implications across categories: In summary, there were themes across studies which are
important to consider in conducting effective occupational therapy education and functional training programs for
older adults. These include:
ü client-centred approach individualized and focused on issues relevant to the older adult
ü meaningful choices or options
ü exerting control and taking ownership of ideas
ü partnership and joint decision-making between client and occupational therapist
ü intensive and systematic programs
ü follow-up

Dissemination plan:

The critical review will be made available to occupational therapists in a variety of ways: on the COTF Web site
on the Internet and on the McMaster University School of Rehabilitation Science Web site (Mobility, Aging and
Participation Research Group page). An abstract for a paper presentation has been accepted for the annual
conference of the Canadian Association of Occupational Therapists in May of 2001. An article will be submitted
to the Canadian Journal of Occupational Therapy as well as a brief description of the critical literature review
findings will be submitted in Occupational Therapy Now (the newsletter of the CAOT) with references made to
the complete review on web sites.




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References

        Canadian Association of Occupational Therapists (CAOT). (1997). Enabling occupation: An occupational
therapy perspective. Ottawa, ON: CAOT Publications ACE.

        Clark, F., Azen, S. P., Zemke, R., Jackson, J., Carlson, M., Mandel, D., Hay, J., Josephson, K., Cherry, B.,
Hessel, C., Palmer, J., & Lipson, L. (1997). Occupational therapy for independent-living older adults: A
randomized controlled trial. JAMA, 278, 1321-1326.

        Clemson, L., Cumming, R. G., & Roland, M. (1999). Managing risk and exerting control: Determining
follow through with falls prevention. Disability and Rehabilitation, 21, 531-541.

         Close, J., Ellis, M., Hooper, R., Glucksman, E., Jackson, S., & Swift, C. (1999). Prevention of falls in the
elderly trial (PROFET): A randomised controlled trial. The Lancet, 353, 93-96.

         Corr, S., & Bayer, A. (1995). Occupational therapy for stroke patients after hospital discharge: A RCT.
Clinical Rehabilitation, 9, 291-296.

         Cummings, R. B., Thomas, M., Szonyi, G., Salkeld, G., O'Neill, E., Westbury, C., & Frampton, G. (1999).
Home visits by an occupational therapist for assessment and modification of environmental hazards: A RCT of
falls prevention. J AM Geriatr Soc, 47, 1397-1402.

        Drummond, A., & Walker, M. (1995). A RCT of leisure rehabilitation after stroke. Clinical Rehabilitation,
9, 283-290.

        Gerber, L., Furst, G., Shulman, B., Thornton, B., Liang, M., Cullen, K., Stevens, M. B., & Gilbert, N.
(1987). Patient education program to treat energy conservation to patients with RA. Arch Phys Med Rehabil, 68,
442-445.

        Gilbertson, L., Langhorne, P., Walker, A., Allen, A., & Murray, D. (2000). Domiciliary occupational
therapy for patients with stroke discharged from hospital. British Medical Journal, 320, 603-606.

       Hammond, A. (1997). Joint protection: What are we doing? British Journal of Occupational Therapy, 60,
401-406.

        Helewa, A., Goldsmith, C. H., Lee, P., Bombardier, C., Hanes, B., Smythe, H. A., & Tugwell, P. (1991).
Effects of occupational therapy home service on patients with rheumatoid arthritis. The Lancet, 337, 1453-1456.

       Jackson, J., Carlson, M., Mandel, D., Zemke, R., & Clark, F. (1998): Occupation in lifestyle redesign: The
Well Elderly Study Occupational Therapy Program. AJOT, 52, 326-36

       Jongbloed, L., & Morgan, D. (1991). An investigation of involvement in leisure activities after a stroke.
AJOT, 45, 420-427.

          Law, M., Stewart, D., Pollock, N., Letts, L., Bosch, J., & Westmorland, M. (1998a). Guidelines for the
critical review form-qualitative studies. Hamilton, ON: McMaster Univeristy Occupational Therapy Evidence-
Based Practice Research Group.




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          Law, M., Stewart, D., Pollock, N., Letts, L., Bosch, J., & Westmorland, M. (1998a). Guidelines for the
critical review form-quantitative studies. Hamilton, ON: McMaster Univeristy Occupational Therapy Evidence-
Based Practice Research Group.


        Liddle, J., March, L., Carfrae, B., Finnegan, T., Druce, J., Schwarz, J., & Brooks, P. (1996). Can
occupational therapy play a part in maintaining independence and quality of life in older people? A RCT.
Australian and New Zealand Journal of Public Health, 20, 574-578.

        Logan, P. A., Ahern, J., Gladman, J. R., & Lincoln, N. B, (1997). A RCT of enhanced social service
occupational therapy for stroke patients. Clinical Rehabilitation, 11, 107-113.

        Mandel, D., Jackson, J., Lemke, R., Nelson, L., & Clark, F. (1999). Lifestyle redesign: Implementing the
well elderly program. Bethesda, MD: American Occupational Therapy Association.

        Parker, C. J., Gladman, J. R. F., Drummond, A. E .R., Dewey, M. E., Lincoln, N. B., Barer, D., Logan, P.
A., & Radford, K. A. (in press.). A multi-centre randomised controlled trial of leisure therapy and conventional
occupational therapy after stroke. Clinical Rehabilitation

       Tangeman, P. T., Banaitis, D. A., & Williams, A. K. (1990). Rehabilitation of chronic stroke patients:
Change in functional performance. Arch Phys Med Rehabil, 71, 876-80.

       von Koch, L., Widen Holmqvist, L., Kostulas, V., Almazan, J., & de Pedro-Cuesta, J. (2000). A
randomized controlled trial of rehabilitation at home after stoke in southwest Stockholm: Outcome at six months.
Scandinavian Journal Rehabilitation Medicine, 32, 80-86.

         Walker, M. F., Drummond, A. E. R., & Lincoln, N. B., (1996). Evaluation of dressing practice for stroke
patients after discharge from hospital: A crossover design study. Clinical Rehabilitation, 10, 23-.31

        Walker, M. F., Gladman, J. R., Lincoln, N. B., Siemonsma, P., & Whiteley, T. (1999). Occupational
therapy for stroke patients not admitted to hospital: A RCT. The Lancet, 354, 278-280.

         Werner, R., & Kessler, S. (1996). Effectiveness of an intensive outpatient rehabilitation program for post
acute stroke patients. Am J Phys Med Rehabil, 75, 114-120.

        Widen Holmqvist, L. F., de Pedro-Cuesta, M. D., Holm, M., & Kostulas, V. (1995). Intervention design
for rehabilitation at home after stroke. Scandinavian Journal Rehabilitation Medicine, 27, 43-50.

      Widen Holmqvist, L. F., Gladman, J. R., Lincoln, N. B., Siemonsma, P., & Whiteley, T. (1998).
Randomized controlled trial of rehabilitation at home after stroke in southwest Stockholm. Stroke, 29, 591-597.




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Appendix

Table 1: Descriptive Review of the Literature on the Effectiveness of Occupational Therapy
Education and Functional Training Programs for Older Adults




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                                                Table 1: DESCRIPTIVE REVIEW OF THE LITERATURE
               THE EFFECTIVENESS OF OCCUPATIONAL THERAPY EDUCATION AND FUNCTIONAL TRAINING PROGRAMMES FOR OLDER ADULTS
                                            Wilkins, S., Jung, B., Wishart, L., Edwards, M., Gamble Norton, S.

* See glossary at end of table        ** Note all results are significant (p ≤.05) unless stated otherwise


PREVENTION

  Author/            Purpose              Design, Sample &                 Research Focus/                   **Results            Conclusions, Methodology & Implications
    date                                      Outcomes                       Intervention
Clark et al.   • to evaluate the        D: RCT (3 groups)        •OT group received 2hrs/wk of        • significant benefit for   C: older adults benefit from OT intervention
(1997)         effectiveness of         S: N=361; culturally     group intervention (OT               OT group across             that is occupation based, highly individualized
               preventative OT          diverse, independent     facilitated) & 9hrs of individual    health function & QOL       and assists in overcoming barriers
               services compared to     living, community        intervention (i.e., didactic &       domains                     M:
               social activity          dwelling, older adults   direct experience) over a 9 mth       • being regularly          + applicable to various ethnicities
               intervention or no       with mean age 74         period; interventions available      engaged in activity         - some outcome measures may not be useful
               intervention on QOL,     yrs;                     (Mandal et al., 1999; Jackson et     through social control      for well, older adults
               health & functioning     O: measures at 0 & 9     al., 1998)                           program was no more         - can’t generalize to different living
               of independent           mths; battery of self-   • health through occupation          effective in promoting      situations/SES or older adults with disabilities
               multi-ethnic older       administered             focusing on appreciation of          health than no              - no follow-up
               adults                   questionnaires:          importance of meaningful             intervention                - lack of definitions for some inclusion &
                                        physical & social        activity and specific knowledge                                  exclusion criteria
                                        function; self-rated     about how to select or perform                                   I: health and well-being can be promoted
                                        health; life             activities to achieve healthy                                    through occupation based intervention
                                        satisfaction; &          lifestyle                                                        administered by OTs
                                        depression               • social control group received
                                                                 2.25 hrs/wk of group
                                                                 intervention (nonprofessional
                                                                 facilitated) & activities designed
                                                                 to encourage social interaction
                                                                 among group members
                                                                 • non-treatment control group
                                                                 received no intervention




                                                                                                                                                                               12
   Author/            Purpose              Design, Sample &                Research Focus/                     **Results            Conclusions, Methodology & Implications
     date                                      Outcomes                      Intervention
Clemson et     • to explore              D: qualitative           • to gain an understanding of         • 8 conceptual              C: lack of adherence to implement
al. (1999)     perspectives of           ethnographic study       why these older women did not         categories with core        modifications related to need for ownership of
               older women who did       S: N=9; age ≥ 65 yrs;    implement home safety                 concept of “exerting        ideas & ability to control within the context of
               not follow through        independent,             recommendations                       control” relevant to all    environment
               with OT                   community dwelling                                             categories related to       M:
               recommended               older women;                                                   how women manage            - some implications noted may go beyond data
               environmental             referred to OT for                                             risk                        - no design limitations noted
               modifications to          home assessment to                                                                         - did not interview women who implemented
               reduce risk of falls in   decrease risk of falls                                                                     suggestions
               the home                  but did not                                                                                I: importance of ownership of ideas and
                                         implement                                                                                  exerting control within the context of
                                         recommendations                                                                            environment and life experiences influences
                                         O: in-depth, semi-                                                                         acceptance and follow through of
                                         structured home                                                                            recommendations
                                         interviews;
                                         interviews coded &
                                         themes identified

Close et al.   • to determine the        D: RCT (2 groups)        • intervention group had 1            • at 12 mths,                C: one medical and one OT visit focused on
(1999)         effectiveness of a        S: N=397; mean age       outpatient visit for medical          significantly fewer falls    falls prevention is effective in decreasing falls
               structured                of 79 yrs; community     assessment & 1 home OT visit          and significantly lower      M:
               medical/OT                dwelling older adults,   to assess falls risk; provide falls   rate of recurrent falling   – co-intervention & contamination may have
               assessment in             who had a fall-related   education; advise regarding           in intervention group        occurred
               decreasing falls of       visit to hospital        home modifications and referral                                   - design limitations not discussed
               older adults              emergency                to relevant services                                               -follow-up completed by postal questionnaire
               compared to usual         O: measures at           •control group had no                                              I: medical/OT prevention approach that
               care control group        baseline, 4, 8 & 12      medical/OT assessment                                              considers both intrinsic and extrinsic fall risk
               who have fallen or at     mths; # of falls, ADL,                                                                      factors can play a significant role in reducing
               risk of further falls     use of health                                                                               the risk of falls in older adults
                                         services; follow-up
                                         through mailed
                                         questionnaires




                                                                                                                                                                                    13
   Author/            Purpose              Design, Sample &               Research Focus/                   **Results            Conclusions, Methodology & Implications
     date                                       Outcomes                     Intervention
Cummings        • to determine the       D: RCT (2 groups)        • intervention group received      • at 1 yr statistically     C: home visits prevent falls among older
et al. (1999)   effectiveness of OT      S: N=530; mean age       OT home safety assessment,         significant decrease in     people who have a history of falls; this effect
                home visits targeted     of 77 yrs;               recommendations given and          falls for older adults      suggests that OT intervention may change
                at environmental         community dwelling       follow-up including supervised     who had fallen in year      people’s behaviour in conjunction with home
                hazards to reduce the    older adults; adults     completion of and funding for      prior                       modifications
                risk of falls in         with cognitive           modifications                      • no benefit for people     M:
                community dwelling       impairment were not      • 2 wk telephone follow-up         without history of falls    + discussed co-interventions
                older adults who         excluded if they lived   • control group received no        •only 50% of home           +specified recommendations re: home
                have had a recent        with informed            direct OT intervention but 19 of   modifications in place      modifications
                hospital visit/          caregiver                control group received non-        after 1 yr therefore OT     - small sample size
                admission compared       O: follow-up             study OT home visits               visit has effect on falls   - intention-to-treat analysis
                to no intervention       measures at baseline                                        beyond modifications        I: OT home visits can prevent falls in/outside
                                         & 12 mths;                                                                              the home in older adults with falls history
                                         determining number
                                         of falls

Liddle et al.   • to determine effect    D: RCT ( 2 groups) &     • intervention, control, non       • no significant            C: experimental group doing no better than
(1996)          on quality of life and   3rd non intervention     intervention group assessed in     difference between          control group in enhancing quality of life and
                independence of          group                    home by OT                         groups at baseline          independence
                older adults             S: N=105; age range       • OT only informed intervention   • significant change        M:
                receiving OT             of 69-94 yrs;             group of recommendations on       from baseline within        - no control of prognosis variables for
                intervention of home     community dwelling        community services, home          group but no statistical    independence & quality of life
                modifications &          older adults living       modifications and equipment &     difference between          - contamination: control group was using
                community services       with no to severe         recommendations carried out or    groups                      community service (e.g., MOW, homecare);
                referral as compared     impairment in ADL         organized by independent          • at 6 mths more of         special equipment and had home modifications
                to control group who     O:                        research nurse                    intervention than            - selection bias - “special group”- high
                received OT              • measures at 0 & 6      • control group                    control group used          functioning & affluent
                recommendations          mths; quality of life,   recommendations not carried out    ADL equipment and           - no specific details of OT intervention
                but not carried out      sickness impact,         • non intervention group at        more had seen their         I: consultation model can be effective with
                and non intervention     morale, life             baseline did not require any       family physician at         certain populations; possible to enable people
                group who did not        satisfaction and         intervention                       least once                  to follow through on recommendations
                require any              health
                intervention             • non intervention
                                         group contacted by
                                         telephone and postal
                                         questionnaire after 6
                                         mths




                                                                                                                                                                               14
STROKE

  Author/         Purpose              Design, Sample &                 Research Focus/                      **Results            Conclusions, Methodology & Implications
    date                                   Outcomes                        Intervention
Corr &      • to evaluate the        D:RCT (2 groups)          • OT interventions included:           • at 1 yr post-stroke       C: OT interventions are beneficial compared to
Bayer       effectiveness of         S: N=110; mean age        learning new skills; facilitation of   significant number of       usual care but cannot conclude that benefits
(1995)      usual services and       75 yrs                    more independence in ADL &             assisted aids used,         resulted directly from OT intervention due to
            OT intervention          O: follow-up mailed       return of function; enabling use       independence in             co-interventions
            compared to “usual       questionnaire at 2, 8,    of equipment; information given        feeding, use of             M:
            care” (control) on       16 and 24 weeks           to patient and caregiver and           telephone and               + limitations described
            ADL & EADL in            measuring                 referral to other agencies             reduction in hospital        - lack of detail re: level of stroke impairment
            adults post-stroke       ADL/EADL, QOL,            • control group received no            readmissions in              - limited statistical analysis
            and discharged from      depression, caregiver     special intervention or follow-        intervention vs control      - gender imbalance between groups
            a stroke unit            QOL, & additional         up, but could receive any              group                        - contamination & co-interventions not
                                     descriptive               available services as required         • no significant            measured
                                     information (i.e.,                                               difference in ADL,           - limited amount of OT intervention
                                     home circumstances,                                              EADL & depression            - missing data
                                     use of health                                                                                I: OT intervention improves some ADL &
                                     services, provision                                                                          EADL outcomes and plays a role in decreasing
                                     of aids and hospital                                                                         hospital readmissions 1 yr post-stroke
                                     readmissions)

Drummond    • to evaluate the        D: RCT (3 groups)         • OT leisure group had weekly          • in OT leisure             C: OT leisure rehabilitation is an effective way
& Walker    effectiveness of         S: N=65; mean age         home visits (>30min) for 3mths         rehabilitation group’s      of maintaining & increasing leisure
(1995)      leisure rehabilitation   64 yrs (29-84); older     then biweekly for 3mths                leisure scores were         participation in older adults post-stroke
            program compared to      adults admitted to        focusing on leisure pursuits           significantly better at 3    M:
            conventional OT and      stroke unit and           • conventional OT group                & 6 mths                    + accounted for age variance
            usual care (control      discharged into           received home visits for the                                       - co-interventions may have affected outcome
            group) in older          community                 same amount of time focusing                                       - small sample size
            adults who were          O: measures at            on ADL and perception                                              - SES not adequately collected
            post-stroke and          baseline on               • control group no intervention                                    - no long term follow-up
            discharged from a        admission to stroke       other than what was received in                                    - lack of information regarding level of
            stroke unit              unit, 3 & 6 mths:         hospital/ social services                                          impairments & disabilities
                                     leisure;                                                                                     I: OT leisure rehabilitation increases the level
                                     frequency/total                                                                              of leisure participation of older adults post-
                                     leisure activity, gross                                                                      stroke
                                     motor function &
                                     functional
                                     performance




                                                                                                                                                                               15
   Author/             Purpose             Design, Sample &                 Research Focus/                     **Results            Conclusions, Methodology & Implications
     date                                      Outcomes                        Intervention
Gilbertson      • to establish if a      D: RCT into 2 groups      • intervention was developed          • significance at 8 wks     C: a brief program of OT improves the ADL &
et al. (2000)   brief program of         S: N=138; mean age        through use of focus groups           after intervention but      EADL of clients with stroke in the short term
                domicilary OT            of 71 yrs ( 28-89 yrs);   with clients, caregivers and OTs;     not at 6mths                but may not be sustained
                compared to              with clinical             6 wk program was client-centred,      • 8 wks adjusted            M:
                receiving routine        diagnosis of stroke,      tailored to needs of each older       analysis (based on          - cost analysis deducted but measurement not
                services could           referred to OT            adult (i.e., self-care, domestic or   hemianopia, lower           clear
                improve the recovery     O: measures at            leisure activities)                   Barthel, longer hospital     - method of follow-up at 6 mths with postal
                of persons post-         baseline and 8 wks        • approximately 10 visits of 30-      stay at baseline)           questionnaire vs interviews
                stroke discharged        addressing: ADL,          45min                                 significance achieved        - small sample size
                from hospital            EADL, client              • intervention based on goals         on EADL, ADL and             - limited power to detect modest effect on
                                         satisfaction, resource    and liaison with other agencies       global outcome of            outcomes
                                         use and subjective        (advice, equipment, services)         deterioration in ADL        I: results lend limited support to principle of
                                         health                    • control group received routine                                  extending routine stroke rehabilitation from
                                                                   services                                                          inpatient to community
Jongbloed       • to determine effect    D: RCT (2 groups)         • intervention group received OT      • overall, no statistical   C: no significant differences in leisure noted
& Morgan        of OT leisure skills     S: N=40; mean age         intervention to assist subjects in    difference between          between stroke survivors in the intervention and
(1991)          intervention             69.6yrs (42-86 yrs);      resuming former leisure activities    groups pertaining to        control groups; may be explained by
                compared to OT           post-stroke within 15     and to learn to engage in new         activity (time)             intervention too limited, environmental influence
                visits with no leisure   mths, community           activities or both                    involvement and             on activity
                specific intervention    dwelling adults who       • control group was visited by        satisfaction with           M:
                on activity              completed a               OT and asked questions about          involvement                 + independent evaluator
                involvement &            rehabilitation            leisure activity but no leisure                                   + pre-stroke activity level considered prior to
                satisfaction in stroke   program                   intervention provided                                             randomization
                survivors                O: measures at 0, 5       • 1hr visits x5wks for both                                       - no pure control group
                                         & 18 wks:                 groups                                                            - tests may not be sensitive enough to detect
                                         involvement and                                                                             differences in satisfaction
                                         satisfaction with                                                                           - contamination (e.g. unclear if same therapist
                                         involvement in                                                                              for both groups; control group asked
                                         activity; depression                                                                        questions about leisure)
                                                                                                                                     - no group comparison or impairment,
                                                                                                                                     disability, time post-stroke
                                                                                                                                     I: further research must be completed to
                                                                                                                                     establish the effectiveness of OT leisure
                                                                                                                                     specific intervention




                                                                                                                                                                                 16
  Author/             Purpose             Design, Sample &              Research Focus/                      **Results            Conclusions, Methodology & Implications
    date                                      Outcomes                     Intervention
Logan et al.    • to determine the      D: RCT (2 groups)       • enhanced group were seen            • enhanced group at 3       C: support for use of enhanced OT with older
(1997)          effect on ADL &         S: N=111; mean age      more quickly after referral, longer   mths demonstrated           adults post-stroke
                EADL of social          73 yrs; community       & more visits                         better EADL                 M:
                service OT compared     dwelling and first      • control group received usual        • at 6 mth, only            + independent assessor
                to enhanced OT          time post-stroke        OT service (i.e., prioritized,        mobility section of         - OT intervention not clear
                service in older        O: measures at 3 & 6    waiting list and intervention         EADL was significant;       - no baseline measures
                adults post-stroke      mths of functional      focused on provision of               caregiver lower GHQ         - lack of information re interventions received
                                        and psychological       assistive devices)                    (i.e., better moods) at 6   by control at 3, 6 mths
                                        outcomes; EADL                                                mths                        - lack of information re: amount of therapy
                                        and ADL & health                                              • more equipment per        I:
                                        questionnaire                                                 person but significance     • benefit of early intervention
                                        completed at 6mths                                            for stair rail only         • importance of enhanced OT service vs
                                                                                                                                  equipment only service
                                                                                                                                  • caregivers of enhanced service less
                                                                                                                                  distressed than caregivers of usual service

Parker et al.   • to evaluate the       D: multi-centred RCT     • participants in both treatment     • no significant            C: no major short or long term beneficial effect
(2001)          effect of OT leisure    (3 groups)               groups received OT                   differences between         of the additional leisure or conventional
                therapy or              S: N= 466 at 5 sites;    interventions (i.e., min of 10       groups at 6 & 12 mths       occupational therapy on the mood, ADL
                conventional OT         mean age 72 yrs;         sessions ≥30 minutes in length)      • at 6 mths leisure         ability or leisure participation of older adults
                compared to control     community dwelling       at home up to 6 mths after           treatment group was in      post-stroke living in the community
                group on mood,          older adults post-       recruitment                          the direction of            M:
                leisure participation   stroke who were          • treatment goals in                 improvement but not         + large sample size
                in independence in      recently discharged      conventional group focused on        significant                 - no information on interventions received in
                ADL of older adults     from hospital            improving independence in                                        hospital
                post-stroke 6 to 12     O: measures at           self-care tasks                                                  - no information on levels/types of
                mths after hospital     baseline, 6 & 12         • treatment goals in leisure                                     impairments
                discharge               mths: mood, IADL,        group focused on leisure                                         - not enough information on standards of
                                        leisure, handicap and    activity                                                         therapy and who provided therapy
                                        caregiver burden         • control group received no                                      - co-intervention from other community rehab
                                                                 occupational therapy                                             services
                                                                 intervention                                                     - inadequate intensity of treatment
                                                                 • all participants were eligible                                 - insensitivity of outcome measures
                                                                 for existing rehab services in                                   I: further research is needed to support the
                                                                 the area                                                         effectiveness of OT leisure and ADL
                                                                                                                                  intervention




                                                                                                                                                                               17
   Author/            Purpose             Design, Sample &                 Research Focus/                    **Results             Conclusions, Methodology & Implications
     date                                     Outcomes                       Intervention
Tangeman        • to investigate the    D: before and after       • evaluation in clinic and client’s   • significant               C: after 1 mth of intensive rehabilitation,
et al. (1990)   effect of a 1 month     design                    home followed by mutual goal          improvement in wt           significant improvement on all 3 outcome
                intensive outpatient    S: N=40 community         setting during first week             shift, balance, ADL         measures ( wt shift, balance & ADL)
                rehabilitation          dwelling individuals      • intervention group participated     • new skills retained for   • at 3 mths functional gains retained
                (OT/PT) for             at least 1 year post-     in 5 wk rehab program to              3 mth follow-up             M:
                individuals who are 1   stroke who ambulate       improve functional skills in a                                    - before and after design
                year post-stroke        independently; mean       variety of environments with                                      - need for longer follow-up
                                        age of 66 yrs (27-        2hrs of individual OT &                                           - volunteer bias
                                        77yrs)                    PT/day/4 days/wk; group                                           - no blinding
                                        O: measures at 0, 1 &     discussion on 5th day.                                            I: intensive, short-term OT/PT rehabilitation is
                                        3 mths: weight shift;                                                                       of benefit for adults one year post-stroke
                                        balance and ADL

Walker,         • to evaluate           D: randomized cross-      • clients received regular            • significant               C: intensive OT dressing practice at 6 mths
Drummond        intensive OT            over design; where        dressing practice regarding           differences between         after discharge from hospital produced a
et al. (1996)   treatment for older     clients received          technique, energy conservation,       groups on dressing,         significant impact in the clients’ dressing
                adults with             intervention for 3        perceptual strategies and advice      perceived health and        ability with a lasting effect
                persistent dressing     mths followed by 3        regarding choice of clothing          ADL performance             M:
                problems at 6 mths      mths of no                • mean of 6 OT visits completed       between the control         +independent assessor at 3, 6 mths
                after discharge from    intervention or the       during treatment phase                and treatment phases        - no baseline dressing scores given at time of
                hospital                reverse                   • during no treatment phase           • dressing                  discharge
                                        S: N=30; mean age of      clients had no contact with           improvements were not       - no long term follow-up
                                        68 yrs; clients who       research occupational therapist;      lost over time (i.e.,       I:
                                        experienced a stroke      all other rehab continued as          maintained for 3 mths)      • intensive OT intervention in the home can
                                        6 mths prior; living in   usual                                 • dressing                  have a positive effect on an individual’s
                                        community following                                             improvements did not        independence dressing, ADL & perceived
                                        hospital discharge                                              generalize into other       health
                                        O: measures                                                     areas of ADL                • client’s home is an optimal environment for
                                        completed at 3 & 6                                              • dysphasia and poor        OTs to consider the ADL of dressing
                                        mths: dressing;                                                 colour matching ability
                                        ADL; and client’s                                               were negatively
                                        perceived health                                                associated with
                                                                                                        improvement in the
                                                                                                        specific dressing
                                                                                                        difficulty




                                                                                                                                                                                  18
   Author/         Purpose              Design, Sample &                Research Focus/                 **Results           Conclusions, Methodology & Implications
     date                                   Outcomes                      Intervention
Walker,      • to assess the          D: RCT (2 groups)        • intervention group received      •significant difference   C: OT significantly reduces disability and
Gladman et   efficacy of an OT        S: N=185; mean age       OT visits up to 5mths              between groups            handicap in individuals with stroke not
al. (1999)   intervention             of 74 yrs ; clients <    • OT encouraged independence       • clients with OT         admitted to hospital and living in the
             compared to no           one mth post-stroke;     in ADL & EADL                      intervention              community
             intervention for older   clients were not         • clients were also encouraged     demonstrated               M:
             adults with strokes      admitted to hospital     to take part in leisure pursuits   significant               + blind assessor
             who were not             and were living in the   • specific tasks were set as       improvement in ADL,        - no specifics on level of the clients’
             admitted to hospital     community                homework when possible             EADL, caregiver strain    impairment resulting from stroke
                                      O: measures              • control group received no        and handicap              - co-intervention may have occurred in control
                                      completed at 0 & 6       additional input from research     • no significant effect   group as no specifics given on types of
                                      mths: EADL, ADL,         OT but may have received input     on mood of client or      “other” services received
                                      gross motor              from existing services             caregiver                 - frequency of intervention not described,
                                      function, mood,                                                                       actual specifics of intervention not described,
                                      caregiver strain and                                                                  OTs providing intervention not described
                                      handicap                                                                              I:
                                                                                                                            • need to advocate at the family physician or
                                                                                                                            homecare level for OT referrals for people
                                                                                                                            post-stroke who are not admitted to hospital
                                                                                                                            • OT intervention may result in less
                                                                                                                            dependence on social and health care systems
                                                                                                                            and decrease need for institutionalization




                                                                                                                                                                        19
  Author/         Purpose              Design, Sample &                 Research Focus/                **Results            Conclusions, Methodology & Implications
    date                                   Outcomes                       Intervention
Werner &    • to demonstrate the     D: RCT (2 groups)        • intervention group received a   • significant increase in   C: functional gains are possible in an
Kessler     effectiveness of         with 2:1 ratio treated   12 week intensive outpatient      functional                  outpatient setting for older adults post-stroke
(1996)      intensive out patient    S: N=49; mean age        rehab program (i.e., 1hr OT and   independence (i.e.,         who have had inpatient rehabilitation
            rehabilitation (OT/      62.5 yrs; older adults   1hr PT 4x/wk)                     eating, bathing,            M:
            PT) compared to no       living in the            • initial assessment by           dressing, shower or         + blind assessor (OT)
            outpatient               community;               physiatrist, OT & PT, followed    tub transfers & stair       + accounted for all dropouts
            rehabilitation to        experienced stroke       by a team meeting defining        climbing) & motor           - selection bias
            increase functional      between 6 mth & 5        functional interventions (e.g.,   recovery during 3mth        - analysis poorly reported
            status of older adults   yrs ago                  transfers, walking, self-care &   treatment period            - lack of equal attention control group
            with a stroke            O: measures              feeding)                          • largest change in         - exclusion of dropouts in data analysis
                                     completed at 0, 3 & 9    • therapy focused on              dressing and bathing        I: intensive OT/PT intervention increases
                                     mths: functional         neuromuscular facilitation and    and gains were              functional independence in older adults post-
                                     independence, motor      functional tasks                  maintained at 9 mths        stroke
                                     recovery, mobility       • control group did not receive   • no significant change
                                     tasks, hand function,    any outpatient therapy            in functional
                                     motor rating,                                              independence at 9mths
                                     depression, self-                                          • significant change
                                     esteem and                                                 regarding sickness
                                     psychological health                                       impact (i.e., fewer
                                                                                                functional and
                                                                                                emotional complaints)
                                                                                                from 0-3mths but not 3-
                                                                                                9 mths




                                                                                                                                                                         20
   Author/           Purpose             Design, Sample &             Research Focus/                     **Results            Conclusions, Methodology & Implications
     date                                     Outcomes                   Intervention
Widen          • to evaluate           D: RCT (2 groups)      • intervention group received a 3     • no significant           C: no difference between 2 groups
Holmqvist      rehabilitation of       S: N=81; mean age      to 4 month rehab program [i.e.,       differences at 3 & 6       • no worse off with early discharge and home
et al., 1998   moderately disabled     72 yrs; adults with    mean of 12 visits (range of 3-31)]    mths                       rehabilitation
(3mth          older adults with       moderate               at home [OT, PT, SW                   • home rehabilitation      M:
outcomes);     strokes at home after   neurological           (consultation)]                       is equally beneficial to   + documented other interventions
von Koch       early supported         impairment,            • rehab program emphasized a          other rehab services       + assessor blinded (PT)
et al., 2000   discharge from          continent and          task and context oriented             • home rehabilitation      + interventions described in previous article
(6 mth         hospital as compared    independent in         approach                              group 52% reduction        (Widen Holmqvist et al., 1995)
outcome)       to older adults         feeding 1 week after   • control group received routine      in length of stay in       - frequency of visits not well documented
               receiving               first or recurrent     rehab service which included a        hospital                   - potential for contamination because of
               rehabilitation in       acute strokes and      heterogeneous set of                  • overall intervention     introduction of home based rehabilitation for
               hospital, daycare or    had an average of      interventions (i.e., rehabilitation   group was more             control group
               through outpatient      4wks hospitalization   in hospital, day care &               satisfied with care,       - limited information on type of stroke, co-
               care                    in routine care        outpatient)                           especially with active     morbidities
                                       O: measures:                                                 participation in           - reported results descriptive and difficult to
                                       baseline, 3, 6 & 12                                          planning their rehab       follow
                                       mths addressing                                              program                    I: early home discharge could be implemented
                                       social activity,                                             • 12 month outcomes        for a selected group of older adults post-
                                       dysphasia, ADL &                                             not yet reported           stroke
                                       IADL, motor
                                       capacity, falls,
                                       walking ability,
                                       coordination,
                                       subjective
                                       dysfunction, manual
                                       dexterity, client
                                       satisfaction




                                                                                                                                                                           21
RHEUMATOID ARTHRITIS

   Author/         Purpose           Design, Sample &                 Research Focus/                   **Results            Conclusions, Methodology & Implications
     date                                Outcomes                       Intervention
Helewa et    • to assess the       D: RCT (2 groups)         • intervention group received       • at 6 wks intervention     C: OT improves function in adults with RA; a
al. (1991)   effectiveness of a    S: N=105; mean age        intensive occupational therapy      group had significantly     6 wk delay did not change efficacy of
             home OT program in    54yrs (18-70yrs);         treatment (i.e.: hand & foot        improved in daily           intervention
             improving function    community dwelling        management; ADL education &         function (i.e., dressing,   M:
             for adults with RA    adults with RA            functional intervention;            eating, grooming,           + improved QOL assumed with adequate
             compared to control   having limitations        vocational assessment &             hygiene, household          measurement
             group                 with physical             education, leisure activities and   management, light           - unclear inclusion criteria regarding functional
                                   functioning, no other     psychosocial counselling) at        housekeeping, heavy         limitations
                                   sources of disability,    home for first 6 wks followed by    cleaning, & mobility)       - 6 week time frame may not be long enough to
                                   stable clinically, on     less intensive follow-up            but no change in social     show change in social function
                                   stable drug therapy,      • control group received no OT      function,                   - no follow-up
                                   no surgery in last        intervention for first 6 weeks      communication and           - co-intervention not discussed
                                   3mths & not               followed by 6 weeks of intensive    leisure                     - not enough information on reliability and
                                   pregnant                  OT                                  • at 12 wks no              validity of primary outcome measure
                                   O: measures at 0, 6,                                          significant difference      - lack of information on amount of intervention
                                   12 wks: global                                                between groups              - not a true RCT as control group received
                                   functional capacity                                                                       intervention during 6-12 wks
                                   score (i.e., self-care,                                                                   I: occupational therapy can have positive
                                   productivity and                                                                          short-term effects on improving the
                                   leisure areas)                                                                            functioning of adults with RA




                                                                                                                                                                           22
  Author/             Purpose             Design, Sample &               Research Focus/                 **Results           Conclusions, Methodology & Implications
    date                                       Outcomes                    Intervention
Gerber et al.   • to compare            D: randomized pilot     • intervention group had           • OT workbook group       C: workbook-based occupational therapy
(1987)          effectiveness of an     study                   standardized group sessions        showed positive but       education intervention did not appear to be
                OT workbook for         S: N=25; mean age       1.5/wk hrs for 6wks and            not significant           more effective than standard OT techniques in
                teaching energy         54 yrs (33-84); >18     provided with didactic workbook    differences in rest       changing behaviours and functioning of
                conservation            yrs; adults with        with behaviour modification and    during physical           adults with RA
                behaviours with         rheumatoid arthritis;   health education strategies        activity, time spent      M:
                standard OT             excluding adults        • goals to decrease the amount     being physically active   + defined the 2 interventions clearly
                techniques to           using w/c’s & those     or intensity of pain and fatigue   • no significant          - pilot study therefore results should be
                change behaviours,      who had surgery         and increase participation in      difference between        interpreted with caution
                influence level of      within 30 days of       activities                         groups at pre-            - larger study needed
                physical activity and   entry                   • control group with two 1.5 hr    intervention & 3 mths     - more sensitive measures required
                modify disease          O: measures at 0 & 3    traditional OT treatment           post-intervention in      - longer study duration
                activity and function   mths: grip strength,    sessions (i.e., energy             disease activity,         - unequal attention between groups
                of adults with          joint tenderness,       conservation, adaptive aids and    walking and group         I: further research required to determine best
                rheumatoid arthritis    joint swelling,         splints)                           strength                  OT intervention method to promote
                                        walking time,                                                                        behavioural/ functional change in adults with
                                        psychosocial                                                                         rheumatoid arthritis
                                        adjustment, health
                                        status, ADL, pain,
                                        fatigue




                                                                                                                                                                        23
           Glossary of Short Forms
ADL               Activities of Daily Living
C                 Conclusions
D                 Design
EADL              Extended Activities of Daily Living
GHQ               General Health Questionnaire
hrs               hours
I                 Implications
IADL              Instrumental Activities of Daily
                  Living
M                 Methodology
MOW               Meals on wheels
mth/mths          month/months
O                 Outcomes measured
OT                Occupational Therapy
PT                Physical Therapy
QOL               Quality of Life
RA                Rheumatoid Arthritis
S                 Sample
SES               Socioeconomic status ( occupation,
                  income & education)
vs                versus
w/c               wheelchair
wk/wks            week/weeks
wt                weight
yr/yrs            year/years




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