Occupational therapy for adults with problems in activities of daily living after stroke

Lynn A Legg; Sharon R Lewis; Oliver J Schofield-Robinson; Avril Drummond; Peter Langhorne

doi:10.1002/14651858.CD003585.pub3

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Figure 1

Flow diagram of search conducted in January 2017.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1: Occupational therapy versus no routine input, Outcome 1: Activities of daily living

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Analysis 1.2

Comparison 1: Occupational therapy versus no routine input, Outcome 2: Death or 'poor outcome' (deterioration or dependency)

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Analysis 1.3

Comparison 1: Occupational therapy versus no routine input, Outcome 3: Death by the end of scheduled follow‐up

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Analysis 1.4

Comparison 1: Occupational therapy versus no routine input, Outcome 4: Death or requiring institutional care by the end of scheduled follow up

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Analysis 1.5

Comparison 1: Occupational therapy versus no routine input, Outcome 5: Death or dependency by the end of scheduled follow‐up

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Analysis 1.6

Comparison 1: Occupational therapy versus no routine input, Outcome 6: Extended activities of daily living scores

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Analysis 1.7

Comparison 1: Occupational therapy versus no routine input, Outcome 7: Mood or distress scores

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Analysis 1.8

Comparison 1: Occupational therapy versus no routine input, Outcome 8: Sensitivity to missing data (odds of poor outcome: better)

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Analysis 1.9

Comparison 1: Occupational therapy versus no routine input, Outcome 9: Sensitivity to missing data (odds of poor outcome: worse)

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Summary of findings 1. Occupational therapy compared to usual or no care for stroke

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
Occupational therapy compared to usual or no care for stroke
Patient or population: adults with stroke Setting: any (with the exception of care‐ or nursing‐home settings). Included studies conducted in: Hong Kong, UK, and USA Intervention: occupational therapy Comparison: no intervention or standard care/practice
	Assumed risk	Corresponding risk
	Usual or no care	Occupational therapy
Activities of daily living at end of scheduled follow‐up.	The mean activities of daily living score was 80.4³	The mean activities of daily living score in the intervention groups was 0.17 standard deviations higher (0.03 to 0.31 higher)		749 (7 studies)	⊕⊕⊝⊝ low^1,2	A standard deviation of 0.17 represents a small difference between groups
Odds of death or a poor outcome at end of scheduled follow‐up. Combined odds of death and deterioration, or death and dependence, or death and institutional care	Study population		Peto OR 0.71 (0.52 to 0.96)	771 (5 studies)	⊕⊕⊝⊝ low^1,2
	440 per 1000	313 per 1000 (229 to 423)
	Moderate

Extended Activities of Daily Livingat end of scheduled follow‐up. Measures of Extended Activities of Daily Living	The mean Extended Activities of Daily Living score was 33.3³	The mean Extended Activities of Daily Living score in the intervention groups was 0.22 standard deviations higher (0.07 to 0.37 higher)		665 (5 studies)	⊕⊕⊝⊝ low^1,2	A standard deviation of 0.22 represents a small difference between groups
Mood or distress scores Measures of mood or distress	The mean depression score was 19.8³	The mean mood or distress scores in the intervention groups was 0.08 standard deviations higher (‐0.09 lower to 0.26 higher)		519 (4 studies)	⊕⊕⊝⊝ low^1,2	A standard deviation of 0.08 represents a small difference between groups
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval;
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ We downgraded the quality of this evidence one level for serious risk of selection, performance and detection biases (the latter only for subjective outcomes) ² We further downgraded by one level for serious imprecision (due to small sample sizes, few events and wide confidence intervals). ³ Data taken from a study (Parker 2001) in the meta‐analysis that is representative of the population and intervention and at low risk of bias.

Summary of findings 1. Occupational therapy compared to usual or no care for stroke

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Table 1. Completeness of data: activities of daily living

Study	N (I)	n (I)	Dead (I)	Missing (I)	N (C)	n (C)	Dead (C)	Missing (C)
Chui 2004	30	30	0	0	23	23	0	0
Corr 1995	55	46	9	0	55	39	11	5
Gilbertson 2000	67	60	6	1	71	62	5	4
Logan 1997	53	45	5	3	58	38	7	13
Parker 2001	156	106	15	35	157	110	11	36
Radomski 2007	5	5	0	0	5	0	0	0
Walker 1996	15	12	0	3	15	15	0	0
Walker 1999	94	84	6	4	91	79	7	5
C: control group (usual care or no intervention) I: intervention group (occupational therapy) N: total number of randomised participants n: number of participants with reported outcome data

Table 1. Completeness of data: activities of daily living

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Table 2. Completeness of data: odds of a poor outcome

Study	N (I)	n (I)	Dead (I) or deteriorate	Missing (I)	N (C)	n (C)	Dead (C) or deteriorate	Missing (C)
Corr 1995	55	55	9 + 24 = 33	0	55	54	11 + 21 = 32	1
Logan 1997	53	53	5 + 1 = 6	0	58	58	7 + 7 = 14	0
Gilbertson 2000	67	66	6 + 27 = 33	1	71	67	5 + 36 = 41	4
Parker 2001	156	121	15 + 36 = 51	35	157	121	11 + 45 = 56	36
Walker 1999	94	90	6 + 12 = 18	4	91	86	7 + 20 = 27	5
C: control group (usual care or no intervention) I: intervention group (occupational therapy) N: total number of randomised participants n: number of participants with reported outcome data

Table 2. Completeness of data: odds of a poor outcome

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Table 3. Completeness of data: death

Study	N (I)	n (I)	Dead (I)	Missing (I)	N (C)	n (C)	Dead (C)	Missing (C)
Chui 2004	30	30	0	0	23	23	0	0
Corr 1995	55	55	9	0	55	55	11	0
Gilbertson 2000	67	67	6	0	71	71	5	0
Logan 1997	53	53	5	0	58	58	7	0
Parker 2001	156	156	15	0	157	157	11	0
Radomski 2007	5	5	0	0	5	5	0	0
Walker 1996	15	15	0	0	15	15	0	0
Walker 1999	94	94	6	0	91	91	7	0
C: control group (usual care or no intervention) I: intervention group (occupational therapy) N: total number of randomised participants n: number of participants with reported outcome data

Table 3. Completeness of data: death

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Table 4. Completeness of data: death or requiring institutional care

Study	N (I)	n (I)	Dead (I) or institutionalised	Missing (I)	N (C)	n (C)	Dead (C) or institutionalised	Missing (C)
Corr 1995	55	55	9 + 16 = 25	0	55	54	11 + 18 = 29	1
Logan 1997	53	53	5 + 1 = 6	0	58	58	7 + 7 = 14	0
Gilbertson 2000	67	67	6 + 4 = 10	0	71	71	5 + 4 = 9	0
Parker 2001	156	156	15 + 9 = 24	0	157	157	11+9 = 20	0
C: control group (usual care or no intervention) I: intervention group (occupational therapy) N: total number of randomised participants n: number of participants with reported outcome data

Table 4. Completeness of data: death or requiring institutional care

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Table 5. Completeness of data: death or dependency

Study	N (I)	n (I)	Dead (I) or dependent	Missing (I)	N (C)	n (C)	Dead (C) or dependent	Missing (C)	Measure
Corr 1995	55	55	9 + 32 = 41	0	55	54	11 + 30 = 41	1	Barthel < 15
Gilbertson 2000	67	66	6 + 21 = 27	1	71	66	6 + 14 = 20	5	Barthel < 15
Parker 2001	156	121	15+36 = 51	35	157	121	11 + 45 = 56	36	Barthel < 15
Walker 1999	94	90	6 + 12 = 18	4	91	86	7 + 20 = 27	5	Barthel < 15
C: control group (usual care or no intervention) I: intervention group (occupational therapy) N: total number of randomised participants n: number of participants with reported outcome data

Table 5. Completeness of data: death or dependency

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Table 6. Completeness of data: extended activities of daily living

Study	N (I)	n (I)	Dead (I)	Missing (I)	N (C)	n (C)	Dead (C)	Missing (C)
Corr 1995	55	45	9	1	55	39	11	5
Gilbertson 2000	67	60	6	1	71	62	5	4
Logan 1997	53	45	5	3	58	38	7	13
Parker 2001	156	104	15	37	157	109	11	37
Radomski 2007	5	5	0	0	5	5	0	0
Walker 1999	94	84	6	4	91	79	7	5
C: control group (usual care or no intervention) I: intervention group (occupational therapy) N: total number of randomised participants n: number of participants with reported outcome data

Table 6. Completeness of data: extended activities of daily living

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Table 7. Completeness of data: quality of life

Study	N (I)	n (I)	Dead (I)	Missing (I)	N (C)	n (C)	Dead (C)	Missing (C)
Gilbertson 2000	67	54	6	7	71	54	5	12
C: control group (usual care or no intervention) I: intervention group (occupational therapy) N: total number of randomised participants n: number of participants with reported outcome data

Table 7. Completeness of data: quality of life

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Table 8. Completeness of data: mood or distress

Study	N (I)	n (I)	Dead (I)	Missing (I)	N (C)	n (C)	Dead (C)	Missing (C)
Corr 1995	55	41	9	5	55	31	11	13
Logan 1997	53	39	5	9	58	34	7	17
Parker 2001	156	105	15	36	157	109	11	37
Walker 1999	94	83	6	5	91	77	7	7
C: control group (usual care or no intervention) I: intervention group (occupational therapy) N: total number of randomised participants n: number of participants with reported outcome data

Table 8. Completeness of data: mood or distress

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Comparison 1. Occupational therapy versus no routine input

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Activities of daily living Show forest plot	7	749	Std. Mean Difference (IV, Fixed, 95% CI)	0.17 [0.03, 0.31]

1.2 Death or 'poor outcome' (deterioration or dependency) Show forest plot	5	771	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.71 [0.52, 0.96]

1.3 Death by the end of scheduled follow‐up Show forest plot	8	950	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.02 [0.65, 1.61]

1.4 Death or requiring institutional care by the end of scheduled follow up Show forest plot	4	671	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.89 [0.60, 1.32]

1.5 Death or dependency by the end of scheduled follow‐up Show forest plot	4	659	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.89 [0.64, 1.23]

1.6 Extended activities of daily living scores Show forest plot	5	665	Std. Mean Difference (IV, Fixed, 95% CI)	0.22 [0.07, 0.37]

1.7 Mood or distress scores Show forest plot	4	519	Std. Mean Difference (IV, Fixed, 95% CI)	0.08 [‐0.09, 0.26]

1.8 Sensitivity to missing data (odds of poor outcome: better) Show forest plot	5	857	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.75 [0.56, 1.00]

1.9 Sensitivity to missing data (odds of poor outcome: worse) Show forest plot	5	857	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.75 [0.56, 0.99]

Comparison 1. Occupational therapy versus no routine input

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