Use of the Australian Therapy Outcome Measures for Occupational Therapy (AusTOMs-OT) in an early supported discharge programme for stroke patients in Singapore

Abstract

Introduction

This short report describes the use of the Australian Therapy Outcome Measures for Occupational Therapy (AusTOMs-OT) in an early supported discharge programme for stroke patients in Singapore.

Method

The Australian Therapy Outcome Measures for Occupational Therapy was assessed at the start and end of the early supported discharge programme and differences were statistically analysed.

Findings

All Australian Therapy Outcome Measures for Occupational Therapy scales demonstrated statistically significant change over time. The most commonly used scales were ‘Upper limb use’, ‘Functional walking and mobility’ and ‘Community life, recreation, leisure and play’, reflecting the pertinent types of occupational therapy intervention used in stroke rehabilitation in the home setting.

Conclusion

This study shows that the Australian Therapy Outcome Measures for Occupational Therapy is a useful outcome measure that can be used to articulate the administered occupational therapy interventions to members of the multi-disciplinary team and support the effectiveness of occupational therapy in stroke rehabilitation.

Keywords

Stroke rehabilitation occupational therapy Singapore

Stroke is the largest cause of long-term physical disability in Singapore (Singapore National Stroke Association, 2010). Occupational therapists in Singapore play an important role in stroke rehabilitation in a variety of settings, such as acute hospitals, subacute community hospitals and day rehabilitation centres. Little research exists to demonstrate the effectiveness of occupational therapy intervention for stroke patients in Singapore. The aim of this study was to examine the use of the Australian Therapy Outcome Measures for Occupational Therapy (AusTOMs-OT) to evaluate occupational therapy outcomes for patients undergoing stroke rehabilitation in an early supported discharge (ESD) programme in an acute hospital in Singapore.

Literature review

The AusTOMs-OT has been developed for use in Australia and internationally as an outcome measure for occupational therapy intervention, in conjunction with the scales for speech pathology and physiotherapy (Unsworth, 2005, 2008). The AusTOMs-OT consists of 12 scales: (1) Learning and applying knowledge; (2) Functional walking and mobility; (3) Upper limb use; (4) Carrying out daily life tasks and routines; (5) Transfers; (6) Using transport; (7) Self-care; (8) Domestic life-home; (9) Domestic life-managing resources; (10) Interpersonal interactions and relationships; (11) Work, employment and education; and (12) Community life, recreation, leisure and play.

According to Haigh et al. (2001), numerous assessment tools have been used to measure therapy outcomes for stroke, such as the Functional Independence Measure (FIM) (Dodds et al., 1993), the Barthel Index (Mahoney and Barthel, 1965), the Rivermead Behavioural Memory Test (Collen et al., 1991) and the Medical Outcomes Study Short Form General Health Survey (SF-36) (Ware and Sherbourne, 1992). In Singapore, the FIM and the Modified Barthel Index (Shah et al., 1989) are commonly used as outcome measures for the stroke population (Chua and Kong, 1996; Ng et al., 2013). However, these scales only measure a certain domain of performance in relation to activity limitation (Unsworth, 2005). It can also be time-consuming to use multiple scales to capture outcomes across a wide spectrum of domains including impairment, activity limitation, participation and wellbeing (Unsworth, 2005). Use of the AusTOMs-OT can overcome these limitations (Unsworth, 2005, 2008).

The AusTOMs-OT has been widely used in Australia, the United Kingdom and Sweden (Unsworth, 2005, 2008). To date, no published data exist on the use of the AusTOMs-OT in Singapore. Studies on the outcome of stroke rehabilitation in Singapore are also limited (Venketasubramaniam, 1999). Therefore, this study aims to explore the use of the AusTOMs-OT as an outcome measure to provide information on the types of occupational therapy intervention used in stroke rehabilitation for patients in an ESD programme in Singapore and to evaluate its effectiveness in documenting change in outcome performance after stroke.

Method

Participants

Consecutive stroke patients enrolled in the ESD programme in a tertiary hospital in Singapore from February 2009 to March 2013 were recruited. The programme was administered by a multi-disciplinary team comprising of a neurologist, a physiotherapist and an occupational therapist. The eligibility criteria for ESD include: acute stroke onset as diagnosed by a neurologist together with findings of radiological investigations, residual mild to moderate disability as assessed by the ESD therapists prior to recruitment, and availability of a caregiver. Once medically stable, stroke patients enrolled in the ESD programme were discharged with the provision of home therapy by the occupational therapist and the physiotherapist. Depending on their needs, patients received two to four home therapy sessions per week, with a duration of 45 minutes to one hour per session, over a period of 2 to 8 weeks.

Instrument

Scoring of the AusTOMs-OT is based on the four domains of impairment, activity limitation, participation restriction and distress/wellbeing. Each of these four ratings per scale is scored from 0 (most severe) to 5 (least severe), and half points may be awarded creating an 11-point ordinal scale. Each scale can be scored in approximately 5 minutes.

The AusTOMs-OT has been found to be a valid and reliable tool for documenting change in clients’ status over time. Validity and reliability of the AusTOMs-OT has been established in numerous studies. According to a reliability study on the self-care scale by Scott et al. (2004), inter-rater intraclass correlation coefficients (ICCs) were reported to be over 0.79 for the three domains of activity limitation, participation restriction and distress/wellbeing, and over 0.70 for impairment. Test–retest reliability was reported to be high, with ICCs of 0.74 for impairment, 0.88 for activity limitation, 0.81 for participation restriction and 0.94 for distress/wellbeing. A construct validity study also found that the AusTOMs and EuroQuol-5D (EQ-5D) are measuring similar constructs (Unsworth et al., 2004).

Procedure

Informed consent from all patients was sought prior to entry to the ESD programme. A data collection form was devised to document the pre- and post-ESD AusTOMs-OT scale scores at the initial and final home therapy sessions. For each patient, the occupational therapist chose the two most relevant AusTOMs-OT scales based on collaborative therapy goals set with patients and made four ratings reflecting the patient’s status in the impairment, activity limitation, participation restriction and distress/wellbeing domains for each of the chosen scale. All clinicians were trained in the use of the AusTOMs-OT by rating practice case vignettes.

Data analysis

Outcome change scores were calculated for each patient by taking the difference between the post-ESD and pre-ESD scores for the four domains in each AusTOMs-OT scale. These scores represent the changes in the patients’ level of impairment, activity limitation, participation restriction and distress/wellbeing over the duration of therapy. To investigate if the changes in scores on the four domains of each scale were statistically significant, the Wilcoxon Signed Ranks Test for repeated measures was used to analyse the non-parametric data. A p-value of 0.05 or less was considered statistically significant.

Findings

Data from 289 patients were available for analysis. Of the sample, 166 (57.4%) were male. The mean age was 63.4 years (SD 12.4), with a range from 23 to 90 years. Racial distribution was 208 (72.0%) Chinese, 58 (20.0%) Malays, 13 (4.5%) Indians and 10 (3.5%) other races. The average number of home therapy sessions received was 7.5 (range 5–25).

Table 1 shows the mean and median change over time made by patients on each domain and scale in the AusTOMs-OT and the pre- and post-ESD comparisons. Results of the Wilcoxon Signed Ranks Test showed that there were statistically significant changes over time in scores on the four domains for all AusTOMs-OT scales.

Table 1.

Change over time from pre-ESD to post-ESD for all AusTOMs-OT scales.

Scale and domain	N	Mean change	Median change	Std deviation	Range	Comparison
Scale 1: Learning and applying knowledge
Impairment	9	1.06	1	0.53	0.5–2	Z = −2.687 p < 0.01
Activity limitation	9	1.06	1	0.39	0.5–1.5	Z = −2.701 p < 0.01
Participation restriction	9	0.78	1	0.44	0–1.5	Z = −2.565 p < 0.05
Distress/wellbeing	9	0.72	1	0.44	0–1	Z = −2.530 p < 0.05
Scale 2: Functional walking and mobility
Impairment	88	0.69	0.5	0.52	0–2	Z = −7.431 p < 0.001
Activity limitation	88	1.27	1	0.62	0–3	Z = −8.184 p < 0.001
Participation restriction	89	0.97	1	0.56	0–3	Z = −8.028 p < 0.001
Distress/wellbeing	89	1.02	1	0.59	0–3	Z = −8.028 p < 0.001
Scale 3: Upper limb use
Impairment	128	0.87	1	0.60	0–3	Z = −9.134 p < 0.001
Activity limitation	128	1.27	1	0.62	0–3	Z = −9.528 p < 0.001
Participation restriction	129	0.93	1	0.65	0–2	Z = −8.932 p < 0.001
Distress/wellbeing	129	0.88	1	0.65	−1–2.5	Z = −8.887 p < 0.001
Scale 4: Carrying out daily life tasks and routines
Impairment	28	0.34	0.5	0.96	−4–1.5	Z = −3.000 p < 0.01
Activity limitation	28	0.93	1	1.10	−4–2	Z = −3.951 p < 0.001
Participation restriction	29	0.69	0.5	0.62	0–2	Z = −4.011^b p < 0.001
Distress/wellbeing	29	0.90	1	0.57	0–2	Z = −4.417 p < 0.001
Scale 5: Transfers
Impairment	8	0.94	1	0.50	0.5–2	Z = −2.565 p < 0.05
Activity limitation	8	1.13	1	0.79	0–2.5	Z = −2.410 p < 0.05
Participation restriction	8	0.75	0.5	0.71	0–2	Z = −2.226 p < 0.05
Distress/wellbeing	8	0.88	0.75	0.95	0–3	Z = −2.232 p < 0.05
Scale 6: Using transport
Impairment	38	0.66	0.75	0.49	0–2	Z = −4.770 p < 0.001
Activity limitation	38	1.75	1	1.42	0–5	Z = −5.235 p < 0.001
Participation restriction	38	1.07	1	0.55	0–3	Z = −5.487 p < 0.001
Distress/wellbeing	38	0.91	1	0.53	0–2	Z = −5.196 p < 0.001
Scale 7: Self-care
Impairment	62	0.79	1	0.55	0–2	Z = −6.265 p < 0.001
Activity limitation	62	1.28	1	0.71	0–3	Z = −6.684 p < 0.001
Participation restriction	62	0.87	1	0.70	0–2	Z = −5.977 p < 0.001
Distress/wellbeing	62	0.87	1	0.74	−1–3	Z = −5.925 p < 0.001
Scale 8: Domestic life – home
Impairment	71	0.73	0.5	0.53	0–2.5	Z = −6.712 p < 0.001
Activity limitation	71	2.20	2	1.46	0–5	Z = −7.131 p < 0.001
Participation restriction	71	1.02	1	0.62	0–2	Z = −6.978 p < 0.001
Distress/wellbeing	71	1.07	1	0.67	0–3	Z = −7.023 p < 0.001
Scale 9: Domestic life – managing resources
Impairment	14	0.75	0.75	0.38	0–1.5	Z = −3.250 p < 0.01
Activity limitation	14	1.39	1	0.81	1.4	Z = −3.401 p < 0.01
Participation restriction	14	0.68	0.5	0.58	0–2	Z = −2.992 p < 0.01
Distress/wellbeing	14	1	1	0.55	0.2	Z = −3.241 p < 0.01
Scale 10: Interpersonal interactions and relationships
Impairment	7	0.71	1	0.57	0–1.5	Z = −2.060 p < 0.05
Activity limitation	7	0.79	1	0.70	0–2	Z = −2.060 p < 0.05
Participation restriction	7	0.86	1	0.63	0–2	Z = −2.232 p < 0.05
Distress/wellbeing	7	0.93	0.5	0.98	0–2.5	Z = −2.032 p < 0.05
Scale 11: Work, employment and education
Impairment	38	0.76	0.75	0.67	0–4	Z = −5.069 p < 0.001
Activity limitation	38	2.29	2.25	1.89	0–5	Z = −4.733 p < 0.001
Participation restriction	38	0.75	0.75	0.53	0–2	Z = −4.949 p < 0.001
Distress/wellbeing	38	0.79	1	0.52	0–2	Z = −5.026 p < 0.001
Scale 12: Community life, recreation, leisure and play
Impairment	85	0.75	1	0.53	0–2.5	Z = −7.501 p < 0.001
Activity limitation	85	2.48	2	1.68	0–5	Z = −7.702 p < 0.001
Participation restriction	85	0.82	1	0.51	0–2	Z = −7.623 p < 0.001
Distress/wellbeing	85	0.97	1	0.56	0–3	Z = −7.849 p < 0.001

The results also showed that all AusTOMs-OT scales have been utilised in the ESD programme. In addition, the top three most frequently selected scales were found to be Upper limb use (44.6%), Functional walking and mobility (30.8%) and Community life, recreation, leisure and play (29.4%); while the least commonly used scales were Interpersonal interactions and relationships (2.4%), Transfers (2.8%) and Learning and applying knowledge (3.1%).

Discussion

When used in a sample of stroke patients in an ESD programme in Singapore, the AusTOMs-OT was sensitive to change in patients’ status over time and able to illustrate the common occupational therapy interventions used in such a stroke rehabilitation service in the home setting. It was found that the most frequently used AusTOMs-OT scales were Upper limb use, Functional walking and mobility, and Community life, recreation, leisure and play, which are similar to previous studies by Unsworth (2005). These scales highlight the unique role and expertise of occupational therapists in stroke rehabilitation, especially in the areas of upper limb rehabilitation and community reintegration after stroke (Richards et al., 2005).

According to Ng et al. (2005), a functional limitation inoutdoor activities is common in mild to moderate stroke survivors. Therefore the commonly used AusTOMs-OT scales in this study are related to therapy goals thatareoften highly pertinent for subacute stroke rehabilitation in the home and community settings, where the intervention foci are often on the resumption of functional and community mobility and the resumption of rolesandactivity participation in the community (Bhogal et al., 2003; Cott et al., 2007; Koch et al., 2000; Ng et al., 2005).

The least commonly used scales were Interpersonal interactions and relationships, Transfers, and Learning and applying knowledge. These scales tend to be less relevant to the stroke population in this study. Due to the ESD programme criteria, in which only patients who are of mild to moderate disability were recruited, most patients were able to ambulate with assistance. Therefore the AusTOMs-OT scale on Transfers was not as commonly used, as would be anticipated for stroke patients in the inpatient setting (Richards et al., 2005).

Use of the AusTOMs-OT has highlighted the role of occupational therapists in remediating impairments and retraining functional tasks in stroke rehabilitation, as illustrated by Richards et al. (2005). The AusTOMs-OT can help to illustrate how occupational therapists intervene at the levels of impairment, activity limitation, participation restriction and distress/wellbeing. This provides a holistic view of the effectiveness of occupational therapy interventions across a wide spectrum of therapy goals that are centred on the World Health Organization’s International Classification of Impairment, Disability and Handicap (World Health Organization, 2001). Instead of using a variety of outcome measures, the AusTOMs-OT can be used to capture change in multiple domains simultaneously and yet allow tailoring to suit individual clients’ goals (Unsworth, 2005).

This study has shown that the occupation-focused AusTOMs-OT can be used to articulate the administered occupational therapy interventions and measure treatment effectiveness for clients with stroke. This study may also indicate that the AusTOMs-OT is suitable for use in Singapore, which has a population of different racial and cultural backgrounds. All the AusTOMs-OT scales have been utilised in this study, indicating that they are relevant occupational therapy interventions for stroke rehabilitation in Singapore. The AusTOMs-OT is also an easy and convenient tool to use in the clinical setting, requiring approximately 5 minutes in administration time with practice (Unsworth, 2005).

Though changes in all the AusTOMs-OT scales were positive over time, the validity of the study in demonstrating the effectiveness of occupational therapy could be compromised by the role of spontaneous recovery in stroke patients and the lack of a comparison group in the research design. In addition, while positive changes were made in the occupation-focused goals in the AusTOMs-OT, patients in the study were also receiving treatment from a physiotherapist and therefore the specific contributions of occupational therapy to the patients’ outcomes cannot be delineated.

According to Skeat and Perry (2005), a change score of 1 is clinically significant in the AusTOMs for speech pathology. In this study, the median change in the 12 AusTOMs-OT scales ranges from 0.5 to 2.25. Though statistically significant, more research is needed to determine what the minimal clinically important difference is for each AusTOMs-OT scale. In addition, future research may also explore the use of Rasch analysis to determine the step difficulties of the 12 AusTOMs-OT scales to guide therapy intervention and to develop a Rasch-transformed score measured on an interval scale to better quantify improvement in performance (Avery et al., 2003).

This pilot study was based on a small sample of stroke patients enrolled in an ESD programme in a tertiary hospital and may not be representative of the stroke population across various settings in Singapore. Further research and data collection on the use of the AusTOMs-OT in different settings in Singapore is needed to benchmark services against one another to identify best practice in occupational therapy intervention for stroke and other conditions (Unsworth, 2005).

Conclusion

The AusTOMs-OT is a useful outcome measure for recording changes in patients’ status over time. Use of the occupation-focused AusTOMs-OT helps to support the effectiveness of occupational therapy intervention in an ESD programme for stroke patients in Singapore and highlight treatment goals and interventions commonly used in home therapy for stroke rehabilitation.

Key findings

The AusTOMs-OT can be used to measure treatment effectiveness in stroke rehabilitation.

Use of the AusTOMs-OT can help to articulate the administered occupational therapy interventions to members of the healthcare team.

What the study has added

Use of the AusTOMs-OT has supported the effectiveness of occupational therapy intervention in an early supported discharge programme for stroke patients and highlighted treatment goals and interventions commonly used in home therapy for stroke rehabilitation.

Footnotes

Acknowledgements

The authors would like to acknowledge Dr Shen Liang, Senior Biostatistician from the National University of Singapore, who assisted us in data analyses for this study. We also thank all clinicians and clients who participated in the data collection.

Research ethics

This study was based on a retrospective chart review in which anonymous outcome data were analysed in totality and individual patient’s identity was not included in the analysis. Therefore formal ethics approval was not sought.

Declaration of conflicting interests

None declared.

Funding

This research received no specific grant support from any funding agency in the public, commercial, or not-for-profit sectors.

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