Randomised controlled trial of an occupational therapy intervention to increase outdoor mobility after stroke
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《英国医生杂志》
1 University of Nottingham, School of Community Health Sciences, University of Nottingham, Nottingham NG7 2RD, 2 Research and Development Office, Broxtowe and Hucknall Primary Care Trust, Hucknall Health Centre, Hucknall, Nottingham NG15 7JE
Correspondence to: J R F Gladman john.gladman@nottingham.ac.uk
Abstract
Many people after stroke do not get out of the house as much as they would like, and this has deleterious effects on quality of life.1 2 Some reasons for poor outdoor mobility are potentially remediable, including lack of confidence and inadequate information on transport options, aids, appliances, or adaptations to the home.3 On the basis of findings of a qualitative interview study, we developed an occupational therapy intervention programme to overcome these barriers.3
Our primary objective was to establish whether people who received the intervention were more likely to get out of the house as much as they wanted. Our secondary objectives were to examine whether the intervention increased the number of journeys taken outdoors, affected the performance of activities of daily living, leisure activity, or psychological wellbeing, and affected the psychological wellbeing of partners or carers.
Methods
Between June 2001 and December 2002, we invited 262 people to take part in our study (fig 1). We identified eligible participants with a clinical diagnosis of stroke in the previous 36 months from social services departments, a primary care rehabilitation service, a geriatric day hospital, and general practice registers. Overall, 178 of the 262 people responded of whom 10 were excluded, leaving 168 participants. Table 1 shows the characteristics of the groups at baseline.
Fig 1 Flow of participants through trial
Table 1 Baseline characteristics of people with clinical diagnosis of stroke allocated to outdoor mobility intervention of leaflet describing local transport services for disabled people (control group). Values are numbers (percentages) of participants unless stated otherwise
Intervention and outcomes
Participants in the intervention group had a mean number of 4.7 visits (median 6, interquartile range 4-6), giving a mean (SD) total of contact time of 230 (113) minutes.
Seven participants in the control group and nine participants in the intervention group required visits at four months to obtain outcome data. At 10 months this applied to eight participants in the control group and 10 participants in the intervention group.
At both four and 10 months, participants in the intervention group were more likely to get out of the house as often as wanted and to undertake more journeys in the month before assessment (table 2).
Table 2 Outcomes at four and 10 months for people receiving outdoor mobility intervention or leaflets describing local transport services for disabled people. Values are medians (interquartile ranges) unless stated otherwise
At four months, mobility scores on the Nottingham extended activities of daily living scale were significantly higher in the intervention group than in the control group, but the differences in the scores on the total and other subscores of the Nottingham extended activities of daily living scale, Nottingham leisure questionnaire, and general health questionnaire (for participants or carers) did not reach significance (fig 2). By 10 months we found no significant differences in the scores (fig 3).
Fig 2 Multivariate linear regression analysis of self reported mobility scores at four months, adjusted for sex, ethnic origin, age, and prior use of transport at baseline. Centre of diamonds represent estimated treatment effect when expressed as percentage of scale range for each scale, and ends of diamonds are 95% confidence intervals for effects
Fig 3 Multivariate linear regression analysis of self reported mobility scores at 10 months, adjusted for sex, ethnic origin, age, and prior use of transport at baseline. Centre of diamonds represent estimated treatment effect when expressed as percentage of scale range for each scale, and ends of diamonds are 95% confidence intervals for effects
Ancillary analyses
The effect of the intervention at four months was non-significantly greater in those (112 participants) who did not get out of the house as much as they wanted at baseline (relative risk 2.1, 95% confidence interval 1.32 to 3.34) compared with those (56 participants) who got out of the house as much as they wanted at baseline (1.42, 0.92 to 2.18); test for interaction, P = 0.21. Twenty three of the participants (41%) who got out of the house as much as they wanted at baseline did not get out of the house as much as they wanted at four months (seven in intervention group, 16 in control group).
Twenty seven participants who got out of the house as much as they wanted at four months reported that they did not do so at 10 months (17 in intervention group, 10 in control group). Twenty two participants who did not get out of the house as much as they wanted at four months reported that they did at 10 months (14 in intervention group, eight in control group). These differences were not statistically significant (P > 0.1).
The intervention group made a median of 16 more outside journeys at four months than at baseline, compared with a median change of 0 in the control group (P < 0.01). Both groups had a median 0 change in the number of journeys between four and 10 months (P < 0.01).
Discussion
Logan PA, Gladman JRF, Radford KA. The use of transport by stroke patients. Br J Occup Ther 2001;64: 261-4.
Pound P, Gompertz P, Ebrahim S. A patient-centred study of the consequences of stroke. Clin Rehabil 1998;12: 338-47.
Logan PA, Gladman JRF, Dyas J. An interview study of the use of transport by people who have had a stroke. Clin Rehabil 2004;18: 703-8.
Collin C, Wade DT, Davies S, Horne V. The Barthel ADL index: a reliability study. Int Disability Stud 1988;10: 61-3.
Nouri FM, Lincoln NB. An extended activities of daily living scale for stroke patients. Clin Rehabil 1987;1: 301-5.
Goldberg D. General health questionnaire (GHQ-12). Windsor: Nfer-Nelson, 1992.
Drummond AER, Parker CJ, Gladman JRF, Logan PA on behalf of the TOTAL study group. Development and validation of the Nottingham leisure questionnaire. Clin Rehabil 2001;15: 647-56.
Walker MF, Gladman JRF, Lincoln NB, Siemonsma P, Whiteley T. A randomised controlled trial of occupational therapy for stroke patients not admitted to hospital. Lancet 1999;354: 278-80.
Parker CJ, Gladman JRF, Drummond AER, Dewey ME, Lincoln NB, Barer BH, et al. A multi-centre randomised controlled trial of leisure therapy and conventional occupational therapy after stroke. Clin Rehabil 2001;15: 42-52.
Parker CJ, Dewey ME on behalf of the TOTAL study group. Assessing research outcomes by postal questionnaire with telephone follow up. Int J Epidemiol 2000;29: 1065-9.
Outpatient Therapy Trialists. Rehabilitation therapy services for stroke patients living at home: a systematic review of the randomised trials. Lancet 2004;363: 352-6.
Steultjens EMJ, Dekker J, Bouter LM, van de Nes JCM, Cup EHC, van den Ende CHM. Occupational therapy for stroke patients. A systematic review. Stroke 2002;34: 676-87.(P A Logan, research fello)
Correspondence to: J R F Gladman john.gladman@nottingham.ac.uk
Abstract
Many people after stroke do not get out of the house as much as they would like, and this has deleterious effects on quality of life.1 2 Some reasons for poor outdoor mobility are potentially remediable, including lack of confidence and inadequate information on transport options, aids, appliances, or adaptations to the home.3 On the basis of findings of a qualitative interview study, we developed an occupational therapy intervention programme to overcome these barriers.3
Our primary objective was to establish whether people who received the intervention were more likely to get out of the house as much as they wanted. Our secondary objectives were to examine whether the intervention increased the number of journeys taken outdoors, affected the performance of activities of daily living, leisure activity, or psychological wellbeing, and affected the psychological wellbeing of partners or carers.
Methods
Between June 2001 and December 2002, we invited 262 people to take part in our study (fig 1). We identified eligible participants with a clinical diagnosis of stroke in the previous 36 months from social services departments, a primary care rehabilitation service, a geriatric day hospital, and general practice registers. Overall, 178 of the 262 people responded of whom 10 were excluded, leaving 168 participants. Table 1 shows the characteristics of the groups at baseline.
Fig 1 Flow of participants through trial
Table 1 Baseline characteristics of people with clinical diagnosis of stroke allocated to outdoor mobility intervention of leaflet describing local transport services for disabled people (control group). Values are numbers (percentages) of participants unless stated otherwise
Intervention and outcomes
Participants in the intervention group had a mean number of 4.7 visits (median 6, interquartile range 4-6), giving a mean (SD) total of contact time of 230 (113) minutes.
Seven participants in the control group and nine participants in the intervention group required visits at four months to obtain outcome data. At 10 months this applied to eight participants in the control group and 10 participants in the intervention group.
At both four and 10 months, participants in the intervention group were more likely to get out of the house as often as wanted and to undertake more journeys in the month before assessment (table 2).
Table 2 Outcomes at four and 10 months for people receiving outdoor mobility intervention or leaflets describing local transport services for disabled people. Values are medians (interquartile ranges) unless stated otherwise
At four months, mobility scores on the Nottingham extended activities of daily living scale were significantly higher in the intervention group than in the control group, but the differences in the scores on the total and other subscores of the Nottingham extended activities of daily living scale, Nottingham leisure questionnaire, and general health questionnaire (for participants or carers) did not reach significance (fig 2). By 10 months we found no significant differences in the scores (fig 3).
Fig 2 Multivariate linear regression analysis of self reported mobility scores at four months, adjusted for sex, ethnic origin, age, and prior use of transport at baseline. Centre of diamonds represent estimated treatment effect when expressed as percentage of scale range for each scale, and ends of diamonds are 95% confidence intervals for effects
Fig 3 Multivariate linear regression analysis of self reported mobility scores at 10 months, adjusted for sex, ethnic origin, age, and prior use of transport at baseline. Centre of diamonds represent estimated treatment effect when expressed as percentage of scale range for each scale, and ends of diamonds are 95% confidence intervals for effects
Ancillary analyses
The effect of the intervention at four months was non-significantly greater in those (112 participants) who did not get out of the house as much as they wanted at baseline (relative risk 2.1, 95% confidence interval 1.32 to 3.34) compared with those (56 participants) who got out of the house as much as they wanted at baseline (1.42, 0.92 to 2.18); test for interaction, P = 0.21. Twenty three of the participants (41%) who got out of the house as much as they wanted at baseline did not get out of the house as much as they wanted at four months (seven in intervention group, 16 in control group).
Twenty seven participants who got out of the house as much as they wanted at four months reported that they did not do so at 10 months (17 in intervention group, 10 in control group). Twenty two participants who did not get out of the house as much as they wanted at four months reported that they did at 10 months (14 in intervention group, eight in control group). These differences were not statistically significant (P > 0.1).
The intervention group made a median of 16 more outside journeys at four months than at baseline, compared with a median change of 0 in the control group (P < 0.01). Both groups had a median 0 change in the number of journeys between four and 10 months (P < 0.01).
Discussion
Logan PA, Gladman JRF, Radford KA. The use of transport by stroke patients. Br J Occup Ther 2001;64: 261-4.
Pound P, Gompertz P, Ebrahim S. A patient-centred study of the consequences of stroke. Clin Rehabil 1998;12: 338-47.
Logan PA, Gladman JRF, Dyas J. An interview study of the use of transport by people who have had a stroke. Clin Rehabil 2004;18: 703-8.
Collin C, Wade DT, Davies S, Horne V. The Barthel ADL index: a reliability study. Int Disability Stud 1988;10: 61-3.
Nouri FM, Lincoln NB. An extended activities of daily living scale for stroke patients. Clin Rehabil 1987;1: 301-5.
Goldberg D. General health questionnaire (GHQ-12). Windsor: Nfer-Nelson, 1992.
Drummond AER, Parker CJ, Gladman JRF, Logan PA on behalf of the TOTAL study group. Development and validation of the Nottingham leisure questionnaire. Clin Rehabil 2001;15: 647-56.
Walker MF, Gladman JRF, Lincoln NB, Siemonsma P, Whiteley T. A randomised controlled trial of occupational therapy for stroke patients not admitted to hospital. Lancet 1999;354: 278-80.
Parker CJ, Gladman JRF, Drummond AER, Dewey ME, Lincoln NB, Barer BH, et al. A multi-centre randomised controlled trial of leisure therapy and conventional occupational therapy after stroke. Clin Rehabil 2001;15: 42-52.
Parker CJ, Dewey ME on behalf of the TOTAL study group. Assessing research outcomes by postal questionnaire with telephone follow up. Int J Epidemiol 2000;29: 1065-9.
Outpatient Therapy Trialists. Rehabilitation therapy services for stroke patients living at home: a systematic review of the randomised trials. Lancet 2004;363: 352-6.
Steultjens EMJ, Dekker J, Bouter LM, van de Nes JCM, Cup EHC, van den Ende CHM. Occupational therapy for stroke patients. A systematic review. Stroke 2002;34: 676-87.(P A Logan, research fello)