Level 1: Likely reliable evidence
A systematic Cochrane review evaluated occupational therapy focused on personal skills (e.g., feeding, dressing, bathing, toileting, and “moving about” in social settings) in nine randomized trials involving a total 1,258 patients with stroke (BMJ. 2007;335:922; full-text available online free of charge at: www.bmj.com; accessed March 11, 2008). Trials were mostly high-quality: eight trials had clear allocation concealment, eight trials had blinded final outcome assessment, 7.6% of patients were lost to follow-up, and 71% of patients were enrolled in trials with stated intention-to-treat analysis. However, the increased attention in the treatment group was not controlled for in the usual-care group.
Occupational therapy was associated with improved measures of activities of daily living (ADLs) (P=.01) in a meta-analysis of eight trials with 961 patients and improved measures of extended ADLs (P=.02) in six trials with 847 patients. For a combined outcome of deterioration, death, or dependency, occupational therapy was associated with a lower rate than usual care (37.1% vs. 45.6%) in seven trials with 1,065 patients. The results were not significant for other analyses: death (nine trials with 1,163 patients), death or institutional care (three trials with 358 patients), and death or dependency (four trials with 788 patients).