Evaluation and experiences of a client-centred ADL intervention after stroke

The overall aim: The overall aim of this thesis was to identify and better understand the effects, experiences and meaning of client-centred activity in daily living (ADL) interventions aiming to enable agency in daily activities and participation in everyday life among people with stroke.

Methods: Study I and II are based on a multicentre randomized controlled trial (RCT): Study I evaluated the effects of a client-centred ADL intervention (CADL) compared with the usual ADL intervention (UADL) 3 months after the start of the intervention on 280 people with stroke as regards the following: independence in ADL, perceived participation, life satisfaction, use of home help service and satisfaction with training. It also evaluated the effects on the significant others of people with stroke receiving CADL and UADL as regards caregiver burden, life satisfaction and provision of informal care. Study II compared changes regarding perceived participation, independence in ADL, life satisfaction between 3, 6 and 12 months after start of the intervention of CADL and UADL. Study III applied a phenomenological approach aiming to describe and understand what characterizes the meaning of CADL from the clients’ perspective. Study IV applied a grounded theory approach aiming to describe how occupational therapists (OTs) applied the CADL in their clinical practice by studying their experiences and reflections concerning their interaction with the clients with stroke.

The findings: Study I and II showed no statistically significant differences in the primary outcome in the Stroke Impact Scale (SIS) domain eight “participation” at 3 months or in change up to 12 months after inclusion between the CADL and the UADL group. No significant differences were found between the groups in the secondary outcomes at 3, 6 or 12 months. At 3 months a significant difference was found in the SIS domain “emotion”, in favour of CADL. In Study II, between 3 and 12 months, there was a trend toward a clinically meaningful positive change in perceived participation that favoured CADL. At 3 months there were no differences in outcome between the significant others in the CADL and the UADL group (Study I). The findings in Study III suggested that therapeutic components in CADL contributed to transparency, which seemed to enable agency in the therapeutic process for clients with stroke. The findings in Study IV indicated that therapeutic components in CADL supported the OTs to guide their clients to enable agency in daily activities through sharing. Sharing seemed to be a necessary condition throughout the intervention process.

Conclusion: No significant differences were shown in primary outcome (Study I and II) nevertheless in combination with the findings in the qualitative studies (Study III and IV), a client-centred ADL intervention seemed to enable agency and participation in everyday life. In the findings in Study III and IV, on how sharing and transparency facilitate each other and create change, from both the client’s and the therapist’s perspective, have not previously been described in the context of rehabilitation after stroke. A client-centred ADL intervention seemed to be of particular importance for the client's rehabilitation process in order to enable agency and for therapists to be able to support to the individual to enact agency. These contrasting findings confirm the importance of using qualitative methods for modeling the content of complex interventions. In addition, in this thesis, they facilitate our understanding of the therapeutic components underlying the rationale of the CADL.

List of scientific papers

I. Bertilsson AS, Ranner M, von Koch L, Eriksson G, Johansson U, Ytterberg C, Guidetti S, Tham K. A client-centred ADL intervention: three-month follow-up of a randomized controlled trial. Scandinavian Journal of Occupational Therapy 2014; 21:377-391.
https://doi.org/10.3109/11038128.2014.880126

II. Guidetti S, Ranner M, Tham K, Andersson M, Ytterberg C, von Koch L. A “client-centred activities of daily living” intervention for persons with stroke: one-year follow-up of a randomized controlled trial. Journal of Rehabilitation Medicine 2015; 47:605-611.
https://doi.org/10.2340/16501977-1981

III. Ranner M, von Koch L, Guidetti S, Tham K. The lived experience of participating in a client-centred ADL intervention after stroke. [Manuscript].

IV. Ranner M, von Koch L, Guidetti S, Tham K. Client-centred ADL intervention after stroke: Occupational therapists’ experiences. Scandinavian Journal of Occupational Therapy 2016; 23:81-90.
https://doi.org/10.3109/11038128.2015.1115549