Müller Christian, Glässel Andrea, Marotzki Ulrike, Voigt-Radloff Sebastian
Medizinische Psychologie und Medizinische Soziologie, Medizinische Fakultät, Albert-Ludwigs-Universität, Freiburg, Deutschland; Berufsakademie für Gesundheits- und Sozialwesen Saarland, Saarbrücken, Deutschland.
Swiss Paraplegic Research, Human Functioning Sciences, Nottwil, Schweiz.
Z Evid Fortbild Qual Gesundhwes. 2014;108 Suppl 1:S36-44. doi: 10.1016/j.zefq.2014.09.003. Epub 2014 Oct 22.
Every year about 200,000 people in Germany suffer from a first stroke and 65,000 persons from a recurrent stroke. Stroke is one of the major causes of acquired life-long disability. It is associated with multiple limitations in functioning, activities of daily living and social participation. People with stroke must develop and apply considerable coping and adaptation strategies to manage the consequences of disabilities in daily life. Insufficient adaptations may result in social isolation, depressive disorders, need for medical and nursing care and subsequently lead to increasing costs for care. Thus occupational therapy-led treatment addressing social participation as well as skills training, adaptation strategies and assistive technology for activities of daily living is essential for stroke patients after hospital discharge.
Based on nine randomised comparisons, a Cochrane review from 2006 revealed that occupational therapy-led training after stroke had positive effects on personal activities of daily living (8 studies; 961 participants; 0.18 SMD; 95 % CI [0.04 to 0.32]), on extended activities of daily living (6 studies; 847 participants; 0.21 SMD; 95 % CI [0.03 to 0.39]), and on poor outcome (7 studies; 1,065 participants; odds ratio 0.67; 95 % CI [0.51 to 0.87]). However, direct implementation into the German healthcare context is not recommendable due to (1) different settings and heterogeneity within the primary studies, (2) lack of manualisation of treatment programmes and (3) insufficient evaluation of client-oriented outcomes.
It is recommended to manualise client-centred standardised modules of a stage-specific occupational therapy-led training of activities of daily living and to pilot-test this intervention programme in a feasibility study. If this trial results in a set of reliable and valid client-oriented outcome measurements applicable within the German care context and in a feasible treatment programme well accepted by stroke patients and their treating occupational therapists, a large-scaled randomised clinical trial in terms of comparative effectiveness research may follow.
在德国，每年约有20万人首次中风，6.5万人再次中风。中风是后天性终身残疾的主要原因之一。它与功能、日常生活活动及社会参与方面的多种限制相关。中风患者必须制定并应用相当多的应对和适应策略来应对日常生活中的残疾后果。适应不足可能导致社会隔离、抑郁症、医疗和护理需求，进而导致护理成本增加。因此，以职业治疗为主导的治疗，包括针对社会参与以及日常生活活动的技能培训、适应策略和辅助技术，对于出院后的中风患者至关重要。
基于九项随机对照研究，2006年的一项Cochrane综述显示，中风后以职业治疗为主导的训练对个人日常生活活动有积极影响（8项研究；961名参与者；标准化均数差0.18；95%置信区间[0.04至0.32]），对扩展日常生活活动有积极影响（6项研究；847名参与者；标准化均数差0.21；95%置信区间[0.03至0.39]），对不良结局有积极影响（7项研究；1065名参与者；比值比0.67；95%置信区间[0.51至0.87]）。然而，由于（1）原始研究中的不同背景和异质性，（2）治疗方案缺乏手册化，以及（3）对以客户为导向的结局评估不足，不建议直接将其应用于德国的医疗保健环境。
建议对手册化以客户为中心的特定阶段日常生活活动职业治疗主导训练的标准化模块，并在可行性研究中对该干预方案进行预试验。如果该试验能得出一套适用于德国护理环境的可靠且有效的以客户为导向的结局测量方法，以及一个中风患者及其治疗职业治疗师都能很好接受的可行治疗方案，那么后续可能会开展一项关于比较有效性研究的大规模随机临床试验。
