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Individual patient data meta-analysis of randomized controlled trials of community occupational therapy for stroke patients |
Walker MF, Leonardi-Bee J, Bath P, Langhorne P, Dewey M, Corr S, Drummond A, Gilbertson L, Gladman JR, Jongbloed L, Logan P, Parker C |
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CRD summary This review concluded that community occupational therapy improved activities of daily living and leisure activity in patients with stroke. There was some uncertainty regarding the reliability of this conclusion and further work was required to characterise the necessary conditions for effective and efficient services. Authors' objectives To evaluate the effects of community occupational therapy for stroke patients Searching MEDLINE, EMBASE, CINAHL, PsycINFO, AMED, Wilson Social Sciences Abstracts, Science Citation Index, Social Sciences Citation Index and the Cochrane Stroke Group Trials Register were searched with no language restrictions to November 2003 using a Cochrane Collaboration Stroke Group search strategy. Conference proceedings, trial registers and reference lists of trial publications and reviews were searched. Collaborators on the review were asked about knowledge of additional studies. Study selection Randomised controlled trials (RCTs) in which a home-based occupational therapy intervention was provided to patients with a clinical diagnosis of stroke were eligible for the review. The primary outcome was Nottingham Extended Activities of Daily Living (NEADL) questionnaire results at the end of intervention. Secondary outcomes were measurement at the end of trial, death and activities of daily living measured on alternative scales.
Most trials assessed the effect of training in activities of daily living. The effect of leisure therapy in combination with activities of daily living training and alone were also assessed. Mean age of patients was 71.4 years (standard deviation 10.5) and 52.7% were male. Intervention lengths varied from six weeks to six months. End of trial assessment was at 4.5 to 12 months.
Two reviewers performed the study selection. Assessment of study quality The methodological quality of each trial was assessed as for a standard review based on randomisation, concealment of allocation and evidence of masked outcome assessments using Cochrane Collaboration criteria. Individual patient data (IPD) were checked for missing data and consistency.
The authors did not state how many reviewers performed the validity assessment. Data extraction Individual patient data were obtained for NEADL score at the end of intervention, Barthel Index, Rivermead Activities of Daily Living, General Health Questionnaire and Nottingham Leisure Questionnaire along with patient and intervention related characteristics.
The authors did not state how many reviewers performed data extraction. Methods of synthesis Continuous outcome metrics (NEADL and Nottingham Leisure Questionnaire) were analysed using linear regression with trial as a random effect and outcomes expressed as weighted mean difference (WMD). Dichotomous outcomes (death, dependency, Barthel Index<16, Rivermead Activities of Daily Living<10, General Health Questionnaire) were analysed using logistic regression with a random effect for study and expressed as odds ratios (OR).
Linear regressions were modelled with adjustments for the prognostic factors of age, gender, baseline dependency and method of follow-up. Subgroup analyses were undertaken for NEADL and Nottingham Leisure Questionnaire based on type of occupational therapy, method of follow-up, baseline dependency, gender, age and side of stroke.
Heterogeneity between trials was measured using I2. Publication bias was investigated through funnel plot asymmetry tested with the Egger test. Results of the review Nine RCTs fulfilled the inclusion criteria. IPD were available for meta-analysis from eight trials (n=1,143). The authors stated that there were no important differences in baseline characteristics between patients allocated to treatment or controls and there was no evidence of publication bias (Egger test p=0.52).
Patients who received community occupational therapy had a NEADL (22-point scale) score that was higher by 1.28 points (95% CI 0.39 to 2.16) compared to usual care at the end of intervention. When the NEADL score was adjusted for prognostic factors it was 1.30 points (95% CI 0.47 to 2.13 ) higher than usual care. Unadjusted analysis showed no effect at the end of trial (WMD 0.88, 95% CI -0.06 to 1.81).
Patients who received community occupational therapy showed no difference in Nottingham Leisure Questionnaire score (74-point scale) compared to usual care at the end of intervention (WMD 1.29, 95% CI -0.03 to 2.61). Adjustment for prognostic factors resulted in a more precise estimate (WMD 1.51, 95% CI 0.24 to 2.79). Small benefits of treatment were apparent at end of trial (WMD 1.53 points, 95% CI 0.10 to 2.96 and WMD 1.80 points, 95% CI 0.41 to 3.21 adjusted for prognostic factors).
Heterogeneity was low to moderate (I2<57.2%). The authors investigated but were unable to explain the heterogeneity, except for Nottingham Leisure Questionnaire method of follow-up, where independent assessors illustrated larger effects (WMD 4.80, 95% CI 2.27 to 7.33) than postal questionnaires (WMD 0.17, 95% CI -1.49 to 1.83).
Patients who received community occupational therapy had a 29% reduction (point estimate) in the odds of activity limitation compared to usual care (OR 0.71, 95% CI 0.52 to 0.98) at the end of intervention, but this did not persist to end of trial. No effects were detectable on minor psychiatric status in patients or carers at the end of intervention or on death at either the end of intervention or at the end of the trial. Authors' conclusions Community occupational therapy significantly improved activities of daily living and leisure activity in patients with stroke. Better outcomes were found with targeted interventions. CRD commentary The authors addressed a clear research question supported by appropriate inclusion criteria. A high sensitivity search included a wide range of sources. There were no language restrictions and both published and unpublished data were sought. Methods were used to reduce error and bias during study selection.
The authors reported that data were checked for validity and consistency, but they neither stated that it was verified by the original trialists nor presented results that showed patterns of treatment allocation and balance at baseline were used to assess the integrity of randomisation.
Appropriate methods of analysis were utilised, but there was no discussion of variable selection, model choice and missing data. Analysis of multiple outcomes, endpoints and subgroups presented problems associated with multiple testing. The measurement and exploration of heterogeneity was appropriate. The assessment of publication bias included multiple subgroups and may have been misleading.
This was a generally well-conducted review, but the conclusions were dependent on choice of endpoint and analysis. Effect magnitudes were small, precision was limited and the generalisability of subgroups based on small numbers of patients from a limited number of trials was unclear. Uncertainty surrounding the reliability of the authors' conclusions will likely persist until the available evidence becomes less equivocal. Implications of the review for practice and research Practice: The authors stated that the provision of occupational therapy was justified on evidence-based grounds.
Research: The authors stated that work was required to characterise the necessary conditions for effective and efficient services Bibliographic details Walker MF, Leonardi-Bee J, Bath P, Langhorne P, Dewey M, Corr S, Drummond A, Gilbertson L, Gladman JR, Jongbloed L, Logan P, Parker C. Individual patient data meta-analysis of randomized controlled trials of community occupational therapy for stroke patients. Stroke 2004; 35(9): 2226-2232 Indexing Status Subject indexing assigned by NLM MeSH Activities of Daily Living; Adult; Aged; Cross-Over Studies; Female; Home Care Services /statistics & Humans; Leisure Activities; Male; Middle Aged; Occupational Therapy /statistics & Randomized Controlled Trials as Topic /statistics & Recovery of Function; Single-Blind Method; Stroke /rehabilitation; Treatment Outcome; numerical data; numerical data; numerical data AccessionNumber 12004001538 Date bibliographic record published 15/11/2004 Date abstract record published 22/06/2011 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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