Occupational therapy improves independence in stroke survivors

Patients who participated in after-stroke rehabilitative therapy proved better able to perform self-care tasks and were more likely to maintain these abilities, compared to patients who did not undergo occupational therapy, the researchers found.

“The most important finding is that occupational therapy actually works,” said Lynn Legg, lead author of the review. “Very few interventions have had such an impact.”

Legg, project manager of the Stroke Therapy Evaluation Programme at the Glasgow Royal Infirmary in Scotland, and colleagues examined 10 randomized controlled trials comprising 1,348 participants. The studies took place in the United Kingdom, Canada and Hong Kong.

Based on the results, the authors calculated that for every 1,000 patients treated with occupational therapy, 97 patients avoid death, dependent care or deteriorating health.

The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

Rehabilitation services, such as physical and occupational therapy, aim to reduce disability and dependence by helping stroke survivors relearn skills lost due to stroke-related brain damage. Occupational therapists teach patients to perform everyday activities, such as making meals and getting in and out of bed on their own. Occupational therapists may also help stroke patients relearn tasks associated with work, leisure and family activities.

The studies selected for this review evaluated occupational therapy programs aimed at improving personal care skills. Patients who received occupational therapy for up to six months were compared to patients who received no or routine post-stroke therapy.

Researchers discovered that stroke survivors who received occupational therapy were significantly more independent in feeding, dressing, bathing, toileting and moving around, compared to patients who received routine or no rehabilitative care after stroke.

The positive effects of occupational therapy on self-care skills were unsurprising, according to Legg.

“It's like learning to play the piano. If you want to improve on a particular piece of music, you must practice; if you want to improve with a particular daily activity, you must practice that activity,” she said.

Patients undergoing occupational therapy also had a significantly lower risk of death or deterioration in their ability to perform personal care tasks, compared to those who did not undergo occupational therapy.

The authors do caution that these benefits may not be generalizable to some stroke patients. For example, the authors excluded studies that evaluated patients with communication difficulties. “However, from a practical point of view there is no sound reason to suspect that these people may not also benefit,” Legg said.

But Marianne Mortera, Ph.D., an editor with the American Occupational Therapy Association, suggested that this exclusion could be misleading. “Excluding those people is creating such an artificial situation. You're leaving out a huge population of people we treat,” she said.

“When you treat someone with stroke, you have so many problems to deal with, including motor, cognitive and sensory issues,” Mortera said. “There's also the context of the person's roles. Are they a mother, a worker or a child at school? We design our treatment approaches around each and every one of those roles, not just self-care issues,” said Mortera, an assistant professor of clinical occupational therapy at Columbia University.

Mortera said that the review failed to identify the team approach often used in stroke rehabilitation. “We co-treat with physical therapists, psychologists, speech therapists and nursing staff. Occupational therapists aren't the only ones working on self-care issues, so when you're talking about activities of daily living, it's difficult to isolate out the exact benefits of occupational therapy.”

With these caveats in mind, what should stroke patients and their family members take from the results of this review?

Yearly, about 700,000 people in the United States have a stroke. Recovery from stroke may be lengthy, and studies indicate that one-third of stroke survivors remain dependent on others for care.

Occupational therapy does work, say the study authors. Now “the debate should move from considering whether occupational services are effective to determining which elements make them effective,” Legg said.