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      An occupational therapy intervention for residents with stroke related disabilities in UK care homes (OTCH): cluster randomised controlled trial

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          Abstract

          Objective To evaluate the clinical efficacy of an established programme of occupational therapy in maintaining functional activity and reducing further health risks from inactivity in care home residents living with stroke sequelae.

          Design Pragmatic, parallel group, cluster randomised controlled trial.

          Setting 228 care homes (>10 beds each), both with and without the provision of nursing care, local to 11 trial administrative centres across the United Kingdom.

          Participants 1042 care home residents with a history of stroke or transient ischaemic attack, including those with language and cognitive impairments, not receiving end of life care. 114 homes (n=568 residents, 64% from homes providing nursing care) were allocated to the intervention arm and 114 homes (n=474 residents, 65% from homes providing nursing care) to standard care (control arm). Participating care homes were randomised between May 2010 and March 2012.

          Intervention Targeted three month programme of occupational therapy, delivered by qualified occupational therapists and assistants, involving patient centred goal setting, education of care home staff, and adaptations to the environment.

          Main outcome measures Primary outcome at the participant level: scores on the Barthel index of activities of daily living at three months post-randomisation. Secondary outcome measures at the participant level: Barthel index scores at six and 12 months post-randomisation, and scores on the Rivermead mobility index, geriatric depression scale-15, and EuroQol EQ-5D-3L questionnaire, at all time points.

          Results 64% of the participants were women and 93% were white, with a mean age of 82.9 years. Baseline characteristics were similar between groups for all measures, personal characteristics, and diagnostic tests. Overall, 2538 occupational therapy visits were made to 498 participants in the intervention arm (mean 5.1 visits per participant). No adverse events attributable to the intervention were recorded. 162 (11%) died before the primary outcome time point, and 313 (30%) died over the 12 months of the trial. The primary outcome measure did not differ significantly between the treatment arms. The adjusted mean difference in Barthel index score at three months was 0.19 points higher in the intervention arm (95% confidence interval −0.33 to 0.70, P=0.48). Secondary outcome measures also showed no significant differences at all time points.

          Conclusions This large phase III study provided no evidence of benefit for the provision of a routine occupational therapy service, including staff training, for care home residents living with stroke related disabilities. The established three month individualised course of occupational therapy targeting stroke related disabilities did not have an impact on measures of functional activity, mobility, mood, or health related quality of life, at all observational time points. Providing and targeting ameliorative care in this clinically complex population requires alternative strategies.

          Trial registration Current Controlled Trials ISRCTN00757750.

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          Most cited references 29

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          The Barthel ADL Index: a reliability study.

          The Barthel Index is a valid measure of disability. In this study we investigated the reliability of four different methods of obtaining the score in 25 patients: self-report, asking a trained nurse who had worked with the patient for at least one shift, and separate testing by two skilled observers within 72 hours of admission. Analysis of total (summed) scores revealed a close correlation between all four methods: a difference of 4/20 points was likely to reflect a genuine difference. In individual items, most disagreement was minor and involved the definition of middle grades. Asking an informed nurse or relative was as reliable as testing, and is quicker.
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            Establishing the minimal clinically important difference of the Barthel Index in stroke patients.

            The interpretation of the change scores of the Barthel Index (BI) in follow-up or outcome studies has been hampered by the fact that its minimal clinically important difference (MCID) has not been determined. This article was written to establish the MCID of the BI in stroke patients. Both anchor-based and distribution-based methods were used to establish the MCID. In the anchor-based method, 43 stroke inpatients participated in a follow-up study designed to determine the MCID of the BI using patients' global ratings of the activities of daily living function on a 15-point Likert-type scale. The mean change scores on the 20-point scale of the BI of the MCID group, based on the patients' ratings on the Likert-type scale, served as the first estimate of the MCID. In the distribution-based method, 56 chronic stroke patients participated in the test-retest reliability study to determine the MCID of the BI. One standard error of measurement (SEM) served as the second estimate for the MCID. The larger MCID value of the 2 estimates was chosen as the MCID of the BI. In the anchor-based study, there were 20 patients in the MCID group, with a mean change score of 1.85 points (ie, the first MCID estimate). In the distribution-based study, the SEM based on test-retest agreement was 1.45 points (ie, the second MCID estimate). The MCID of the BI in stroke patients was estimated to be 1.85 points. The authors' results, within the limitations of their design, suggest that if the mean BI change score within a stroke group has reached 1.85 points in a study, the change score on the BI can be perceived by patients as important and beyond measurement error (ie, such a change score is clinically important).
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              The Rivermead Mobility Index: a further development of the Rivermead Motor Assessment.

               F Collen,  D Wade,  G F Robb (2015)
              This paper reports on a development of the Rivermead Motor Assessment Gross Function scale, the Rivermead Mobility Index (RMI), a new measure of mobility disability which concentrates on body mobility. An early development included a second scale concentrating on elective mobility, but the results showed this to be unreliable. The RMI comprises a series of 14 questions and one direct observation, and covers a range of activities from turning over in bed to running. Its inter-observer reliability was tested on two groups of patients (n = 23 and 20 respectively) and it is reliable to a limit of 2 points (out of 15). Its validity as a measure of mobility after head injury and stroke was tested by concurrent measurement of mobility using gait speed and endurance, and by standing balance. The RMI does form a scale. It is short, simple, and clinically relevant, and can be used in hospital or at home.
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                Author and article information

                Contributors
                Role: professor of rehabilitation
                Role: professor of stroke rehabilitation
                Role: senior research fellow
                Role: professor of stroke and older people’s care
                Role: professor of primary care research
                Role: senior lecturer in medical statistics
                Role: professor of medical statistics
                Role: consultant in liaison psychiatry
                Role: dissemination officer
                Role: study coordinator
                Role: research occupational therapist
                Role: occupational therapist
                Role: research fellow
                Role: senior research associate in health economics
                Role: senior research associate
                Journal
                BMJ
                BMJ
                bmj
                BMJ : British Medical Journal
                BMJ Publishing Group Ltd.
                0959-8138
                1756-1833
                2015
                5 February 2015
                : 350
                Affiliations
                [1 ]Department of Physiotherapy, King’s College London, London, UK
                [2 ]Division of Rehabilitation and Ageing, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
                [3 ]School of Healthcare Sciences, Bangor University, Bangor, Gwynedd, UK
                [4 ]School of Health, UCLan, Preston, Lancashire, UK
                [5 ]Primary Care Unit, Department of Public Health & Primary Care, Cambridge, UK
                [6 ]Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
                [7 ]Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
                [8 ]Directorate of Acute Medicine and Rehabilitation, John Radcliffe Hospital, Oxford, UK
                [9 ]Faculty of Medical and Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
                [10 ]Occupational Therapy, Queen Elizabeth Hospital Birmingham, Birmingham, UK
                Author notes
                Correspondence to: G Peryer g.peryer@ 123456uea.ac.uk
                Article
                sacc019614
                10.1136/bmj.h468
                4353312
                25657106
                © Sackley et al 2015

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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