Factors affecting outcome in participation after stroke
structure for a client-centred approach when interacting
with the client. The intervention included training the
occupational therapists in having the client’s unique
life-world experiences as the point of departure, and
seeing the client as an active agent in goal setting, and
in collaboration with the therapist in the rehabilitation
process (15). The concept of ADL was widened to in-
clude both self-maintenance and domestic activities, as
well as other ADL, such as leisure and social activities,
that were meaningful for the client (11, 17).
The results from the RCT showed no difference in
participation between participants who had received en-
hanced client-centred rehabilitation and those who had
received usual rehabilitation (16). There was, however, a
trend towards a clinically meaningful positive change in
perceived participation in favour of the enhanced client-
centred rehabilitation (16). Among all participants, both
those receiving the enhanced client-centred rehabilitation
and those receiving usual rehabilitation, some individuals
reported a positive outcome in participation in everyday
life at 12 months. In this present study secondary analyses
were performed on data from the previous RCT in order
to explore what characterized those individuals.
Thus, the aim of the current study was to explore the
importance of client characteristics (age, sex, stroke
severity, and participation before stroke), rehabilita-
tion context (inpatient or client’s home) and approach
(enhanced client-centeredness or not) on participation
in everyday life after stroke.
METHODS
This study was a secondary analysis of participants from the
RCT (15, 16) and included data on participants from both the
intervention group and the control group. The enhanced client-
centred ADL intervention was performed in 3 county councils in
Sweden. Sixteen units within primary care and inpatient hospital-
based rehabilitation units were randomized to the enhanced
client-centred intervention or usual interventions, i.e. a control
group (15). The intervention group received an enhanced client-
centred intervention comprising 9 components (see Table I) and
Table I. The client-centred activities of daily living intervention
1.
2.
3.
4.
5.
6.
7.
8.
9.
The first meeting with the client (focus on creating an understanding
of the client’s unique lived experiences after stroke).
Observation in an activity (chosen by the client).
Scoring the activity together (a strategy to support the client to
understand his/her abilities, and enables goal setting).
Formulating the goals by using the Canadian Occupational
Performance Measure (clarifies the client’s wishes and needs).
Using the ”goal-plan-do-check” strategy to facilitate the learning and
problem-solving process.
Using a diary as a structure for training (provides a structure for
implementation of the problem-solving strategy).
Reporting and involving others (enables significant others and other
professionals within rehabilitation to support the client).
Training to perform and integrate activities (to practice and integrate
problem-solving strategies in everyday life).
Evaluation of the goals (creates a base for further planning of the
rehabilitation process).
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provided by trained occupational therapists. The control group
received usual interventions that included a variety of strategies
commonly used at each unit. The number of sessions and length
of treatment period were not predetermined, but instead based
on the needs of the clients (15). The number of sessions or con-
tacts with an occupational therapist thus varied between 2 and
74 (mean 24) for the intervention group and between 1 and 167
(mean 18) for the control group during 1 year, between inclusion
and the 12-month follow-up (16). Ethical approval has been
obtained for this study from the Regional Ethical Review Board
in Stockholm, Sweden. Registration Clinical Trials government
identifier: NTCO 1417585.
Participants
Included in the previous RCT (15, 16) were: people treated for
acute stroke, less than 3 months after onset and referred to one of
the 16 participating units; dependent in at least 2 ADL domains
according to the Katz Extended Index of Independence in ADL
(18); not diagnosed with dementia; and able to understand and
follow instructions. Included in the present secondary analysis
were participants from the RCT (15, 16) with complete data
on at least 1 of 3 measurements on participation. Demographic
data were collected at inclusion regarding the participants’ age,
sex and co-habitation. The Barthel Index (19) was used to grade
levels of stroke severity into mild = 50–100, moderate = 15–49,
and severe ≤15 (18). Independence/dependence in ADL before
stroke was assessed according to the Katz Extended Index of
Independence in ADL (21) and the Frenchay Activities Index
(FAI) was used as a pre-stroke measurement for participation
in everyday social and domestic activities 3–6 months before
the stroke (21).
Data collection
Because a client-centred approach was adopted with the client’s
perspective in focus, self-reported outcome measures were used
to capture the complexity of participation in everyday life.
Stroke Impact Scale 3.0 (SIS), domain 8 “participation” was
used at 3 and 12 months after inclusion to measure perceived
impact of stroke on participation in ADL (22, 23). The score
ranges from 0–100 and the higher the score the less impact of
stroke. An improvement of ≥ 15 points or a maximum score of
100 at 12 months was defined as a clinically meaningful change
(22) and considered to be a positive outcome.
Frenchay Activities Index (FAI) was used at inclusion as a
pre-stroke measurement and at 12 months after inclusion to
assess the frequency of participation in everyday social and
domestic activities during the previous 3 or 6 months (21). The
score ranges from 0 (inactive) to 45 (very active). A return to
pre-stroke level of activity or a level of activity within age- and
sex-related norms at 12 months were considered to be a positive
outcome (24).
Occupational Gaps Questionnaire (OGQ) was used at 3 and
12 months after inclusion to measure the gap between activities
a person performs (or not) and wishes to perform (or not) (25).
A positive outcome was defined as: no gaps were reported, the
number of gaps was reduced to a normal level according to
age (26), or the number of gaps was reduced by 4 gaps (< 49
years of age); 2 gaps (50–64 years) or 1 gap (> 65 years of age).
Data analysis
In the analyses, the same covariates that were included in the
previous RCT (15) were included as independent variables.
J Rehabil Med 51, 2019