Logan, Philippa A.
(2005)
Occupational therapy to improve outdoor mobility after stroke.
PhD thesis, University of Nottingham.
Abstract
People who have suffered a stroke can become housebound and miserable because they cannot access suitable transport. They can have difficulty getting to the shops, doctors and hospital and this can have an effect on their quality of life. Occupational therapists routinely aim to help these people overcome their outdoor mobility problems by providing information and verbal instructions but these interventions do not appear to be effective. The aim of this research was to design and evaluate a new occupational therapy outdoor mobility intervention. The intervention was modeled on travel training that is provided for other conditions and the outdoor mobility experiences and needs of people with stroke.
Qualitative semi structured interviews were used to investigate 24 peoples experiences of both using transport and their outdoor mobility after they had suffered a stroke. It was found that people wanted to travel for a variety of reasons; shopping, work, getting to the doctors, social reasons, meeting friends, visiting family and just for the sake of traveling. People were prevented from traveling because of physical difficulties such as stepping onto the bus, psychological problems such as confidence and environmental barriers such as the weather or lack of information. The results were used to define the main components of an Occupational Therapy Outdoor Mobility Intervention.
A randomised controlled trial was used to evaluate the effects of this Occupational Therapy Outdoor Mobility Intervention (OTOMI) by comparing it to the routine occupational therapy intervention. Participants with stroke in the last 36 months were recruited from primary care services and randomly allocated to receive either the OTOMI or the routine occupational therapy. Participants in the OTOMI received up to seven individualised occupational therapy sessions. The sessions aimed to increase confidence, encourage use of different types of transport and provided tailor-made information. Outcomes were measured by postal assessment 4 and 10 months after recruitment. The primary outcome measure was a yes/ no question, Do you get out of the house as much as you would like? Secondary outcomes included the number of journeys, mood, performance of activities of daily living and leisure.
168 participants who had had a stroke in the last 36 months were recruited into the study over eighteen months, 82 in the control group and 86 to the OTOMI group. 10 people were unable to provide follow-up information at the four month assessment and 21 people at the ten month assessment. Intention-to-treat analyses were undertaken. For the principal outcome measure, participants who were dead at the point of assessment were allocated the worst outcome, and for others lost to follow up their baseline or last recorded responses were used. For the other analyses all missing values were imputed using baseline values.
Participants in the treatment group were more likely to get out of their house as often as they wanted at 4 months (RR 1.72,95% CI 1.25 to 2.37) and at 10 months (RR 1.74,95 Cl 1.24 to 2.44). The treatment group recorded more journeys outdoors in the month prior to assessment at 4 months (intervention group median 37, control group median 14, Mann-Whitney p<0.01) and at 10 months (intervention group median 42, control group median 14, Mann-Whitney: p<0.01). At 4 months the NEADL mobility scores were significantly higher in the intervention group, but there were no significant differences in the other secondary outcomes. There were no significant differences in these measures at 10 months.
The interview study demonstrated that participating in outdoor mobility is a major problem for people who have had a stroke. The randomised controlled trial demonstrated that a relatively simple and feasible, individualized, properly organised, focused and adequately resourced occupational therapy outdoor mobility intervention can increase participation in outdoor mobility activities, allowing people to get out of the house as much as they wish.
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