CRITICALLY APPRAISED PAPER (CAP)

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1 CRITICALLY APPRAISED PAPER (CAP) Desrosiers, J., Noreau, L., Rochette, A., Carbonneau, H., Fontaine, L., Viscogliosi, C., & Bravo, G. (2007). Effect of a home leisure education program after stroke: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 88(9), CLINICAL BOTTOM LINE The purpose of this study was to evaluate leisure participation and satisfaction, wellbeing, depressive symptoms, and quality of life after participation in an empowerment-focused leisure education program for persons after stroke. This study was a Level I randomized controlled trial conducted from 2002 to 2003 with 62 participants who were poststroke and living in their community. Randomly assigned participants in the experimental group (n = 33) received a leisure education program at home or in the community once a week for 8 to 12 weeks. The program emphasized empowerment for people with stroke; it was provided by a recreational therapist, with an occupational therapist as a consultant. The program included three components: leisure awareness, self-awareness, and competency development. Participants in the control group (n = 29) were also visited at home by the recreational therapist at a similar frequency; however, no specific leisure education was provided. Participants were evaluated before and after the program by an occupational therapist not involved with the program; outcomes were leisure participation and satisfaction, general well-being, depressive symptoms, and health-related quality of life (HRQOL). After the leisure education program, participants significantly increased their participation in active leisure activities and were more satisfied with their activities, compared with the control group. Both groups general well-being increased, as well as their HRQOL, indicating no significant difference between groups. However, the experimental group s depressive symptoms were reduced by nearly 50%, a significant difference from the control group. The empowerment-focused leisure education program demonstrated a positive impact on leisure satisfaction and participation, as well as reducing depressive symptoms among persons poststroke. General well-being and HRQOL were also enhanced through the program s emphasis on empowerment. These findings indicate the importance of referral to and collaborationz with recreational therapists as interdisciplinary team members providing services for individuals after stroke. In practice, occupational therapists can provide education and support for their client s leisure participation, as well as incorporating leisure components into intervention planning. Emphasizing the physical and mental health benefits of leisure

2 participation can help to motivate individuals to participate more frequently in leisure activities and lead a healthier lifestyle, as well as achieve higher performance levels in and satisfaction with daily living. RESEARCH OBJECTIVE(S) Compare the effect of a home leisure education program with the effect of a home visitation control condition for persons poststroke relative to leisure activity participation and satisfaction, overall well-being, depressive symptoms, and quality of life DESIGN TYPE AND LEVEL OF EVIDENCE Level I: Randomized controlled trial PARTICIPANT SELECTION How were participants recruited and selected to participate? The researchers selected participants for the study through a review of medical charts. Individuals who experienced a stroke and were admitted to a rehabilitation or acute care facility up to 5 years before the study were identified and invited to participate in the study. Inclusion criteria: In addition to a diagnosis of stroke, participants in the study had to be living in the community. Participants had to have reported problems with leisure satisfaction and problems with participation in leisure activities. Exclusion criteria: Individuals with cognitive deficits (identified by scores 5th percentile on the Modified Mini- Mental State Examination), problems in language comprehension for simple conversation, and severe comorbidities PARTICIPANT CHARACTERISTICS N= 62 #/ % Male: 30/(48%) #/ % Female: 32/(51%) Ethnicity: NR Disease/disability diagnosis: Stroke INTERVENTION AND CONTROL GROUPS (Add groups if necessary) Group 1: Intervention group Brief description of the The program was developed to enhance the participants

3 intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? Group 2: Control group Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? empowerment to optimize their leisure experiences and was divided into three components. The components included leisure awareness; self-awareness; and competency development, which included constraints and knowledge of alternatives to leisure participation. The program included 12 steps, ending with competency in autonomous leisure practice and satisfaction. 33 In the participant s home and in the community A recreational therapist facilitated the intervention, and an occupational therapist acted as a consultant. Once per week for slightly more than 60 minutes (due to various locations in the community) 8 to 12 weeks: It was determined that participants reached the end of the program when they had progressed through all 12 steps and when they had integrated significant leisure activities into their life. Discussion was provided in the individual sessions that was unrelated to leisure participation; topics included family, cooking, politics, news, and everyday life. 29 In the participant s home A recreational therapist facilitated the discussions, and an occupational therapist acted as a consultant. Once per week for 60 minutes 8 to 12 weeks INTERVENTION BIASES (Check yes or no, and include a brief explanation) Contamination: YES NR Co-intervention: Explanation: Although it was not addressed in the study, it is possible that the participants in different groups discussed their experiences with each other. If so, sharing of the information among the participants might have contaminated the study.

4 YES NR Explanation: Cointervention was not addressed in the study; however, it was likely a bias, given the individualized treatment program and the community integration of the program. Factors outside of the study might have influenced the results. Timing of intervention: YES NR Site of intervention: Explanation: Timing bias is likely because the control group received treatment for anywhere between 8 and 12 weeks. In the experimental group, treatment was provided for a significantly longer duration and frequency; treatment was discontinued when participants completed all 12 steps of the program. Explanation: In the control group, individualized treatment took place at each participant s home. The experimental group received treatment in their home and in the community. Use of different therapists to provide intervention: YES NO Explanation: One recreational therapist was responsible for intervention, and one occupational therapist acted as consultant. Baseline equality: Explanation: The control group and experimental group were equivalent at baseline for all variables, with the exception of HRQOL. MEASURES AND OUTCOMES Measure 1: Leisure participation Name/type of Participation in leisure reliable (as reported in the article)? ( article)? Minutes of leisure activity per day and number of leisure activities. Recorded in a log book; however, who recorded this was not reported. Activities were classified as active or passive. YES Not Reported YES Not Reported Over a 7-day time period Measure 2: Leisure Satisfaction Scale Name/type of Leisure Satisfaction Scale

5 in the The 24-item questionnaire measures the degree to which leisure participation provides personal satisfaction and meets needs. Not Reported Not Reported Measure 3: Individualized Leisure Profile Name/type of Individualized Leisure Profile Two sections were used as a secondary measure of leisure satisfaction. The sections measured needs and expectations in regard to leisure and use of spare time. in the Not Reported YES Not Reported Measure 4: General Well-Being Schedule Name/type of in the General Well-Being Schedule Perceived well-being and symptoms of distress, including the dimensions of anxiety, depression, positive well-being, emotional control, vitality, and general health Not Reported YES Not Reported Measure 5: Center for Epidemiological Studies Depression Scale Name/type of Center for Epidemiological Studies Depression Scale

6 in the Used as a screening tool for assessing levels of depressive symptoms Not Reported Not Reported Measure 6: Stroke-Adapted Sickness Impact Profile Name/type of in the Stroke-Adapted Sickness Impact Profile Primary outcome measure for HRQOL, both psychosocial and physical components Not Reported Not Reported MEASUREMENT BIASES Were the evaluators blind to treatment status? NR Explanation: The occupational therapist responsible for administering the outcome measures was not involved in the study and was blinded to group assignment. Was there recall or memory bias? YES NR Explanation: Bias is unlikely, given the 8 12-week span between initial outcome measurement assessment and program completion. Other measurement biases: Dropouts: Four participants from the experimental group (n = 2 because of sickness, n = 2 because of refusal to participate beyond first session) and 2 participants from the control group were not measured at posttest for technical reasons.

7 RESULTS After the leisure education program, participants significantly increased participation in active leisure activities (p =.01) and number of leisure activities (p =.002) over the control group, on the basis of a 95% confidence level. Participants in the leisure education group were also more satisfied with their leisure activities than the control group (p =.003). General well-being and HRQOL improved with both groups; no statistical difference was found between groups. There was a significant reduction in depressive symptoms (reduced by nearly 50%) after the program for the experimental group only (95% confidence interval, 12.5 to 1.9, p =.01). Was this study adequately powered (large enough to show a difference)? Explanation: The researchers aimed to recruit a minimum of 26 participants per group, which was achieved. This allowed them to detect a moderate to large effect size (.70) with a statistical power of 80%. Were the analysis methods appropriate? Explanation: The purpose of the study was to compare the outcomes of two interventions. Comparison of pretest and posttest data was done with a paired t test, which was appropriate. Between-groups differences were examined with an independent-groups t test but would have been more appropriately analyzed by an analysis of variance. Were statistics appropriately reported (in written or table format)? Explanation: Baseline equality characteristics and group comparisons were reported in table format, along with narrative description. Was participant dropout less than 20% in total sample and balanced between groups? YES NO Explanation: A total of 6 participants dropped out of the study: 4 from the experimental group, and 2 from the control group. What are the overall study limitations? The first limitation of the study was the reliability and validity of leisure duration and the number of activities not being tested, which made random error a factor that would affect this measure. In the experimental program (n = 33) conducted in the community, there was a significant difference in the duration and frequency with the interventions. Next, the dropout bias was a limitation. Four participants dropped out: Two dropped out because of sickness, and 2 dropped out by refusal to continue after the first session. Last, the study design lacked follow-up at the 6-month and 1-year timeline. CONCLUSIONS

8 In this randomized controlled trial, participants poststroke who received a leisure education program provided by a recreational therapist participated in a greater number of active leisure activities, were more satisfied with their leisure activities, and experienced fewer depressive symptoms than the control group. Both groups experienced benefits in their general well-being and HRQOL. The aim of the leisure education program was for participants to recognize the importance of leisure in their life, to gain a better perception of the value of leisure activities, to gain a better perception of their residual abilities, and to develop competency in using available resources related to leisure. In sum, empowerment-focused home leisure education programming of a 12-week duration had a positive impact on leisure satisfaction and participation, as well as decreasing depressive symptoms, for community-dwelling individuals poststroke. This study s findings hold implications for occupational therapists to consider the added value of leisure participation education for their clients poststroke to promote a higher quality of life as they return to community living. This work is based on the evidence-based literature review completed by Kelsey Glatt, OTS, Tracy Perish, OTS, and Jan Stube, PhD, OTR/L, faculty advisor, University of North Dakota. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, and M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: