Objective To compare the clinical effectiveness of a programme of physiotherapy and occupational therapy with standard care in care home residents who have mobility limitations and are dependent in performing activities of daily living. Design Cluster randomised controlled trial, with random allocation at the level of care home. Setting Care homes within the NHS South Birmingham primary care trust and the NHS Birmingham East and North primary care trust that had more than five beds and provided for people in the care categories "physical disability" and "older people." Participants Care home residents with mobility limitations, limitations in activities of daily living (as screened by the Barthel index), and not receiving end of life care were eligible to take part in the study. Intervention A targeted three month occupational therapy and physiotherapy programme. Main outcome measures Scores on the Barthel index and the Rivermead mobility index. Results 24 of 77 nursing and residential homes that catered for residents with mobility limitations and dependency for activities of daily living were selected for study: 12 were randomly allocated to the intervention arm (128 residents, mean age 86 years) and 12 to the control arm (121 residents, mean age 84 years). Participants were evaluated by independent assessors blind to study arm allocation before randomisation (0 months), three months after randomisation (at the end of the treatment period for patients who received the intervention), and again at six months after randomisation. After adjusting for home effect and baseline characteristics, no significant differences were found in mean Barthel index scores at six months post-randomisation between treatment arms (mean effect 0.08, 95% confidence interval −1.14 to 1.30; P=0.90), across assessments (−0.01, −0.63 to 0.60; P=0.96), or in the interaction between assessment and intervention (0.42, −0.48 to 1.32; P=0.36). Similarly, no significant differences were found in the mean Rivermead mobility index scores between treatment arms (0.62, −0.51 to 1.76; P=0.28), across assessments (−0.15, −0.65 to 0.35; P=0.55), or interaction (0.71, −0.02 to 1.44; P=0.06).Conclusions The three month occupational therapy and physiotherapy programme had no significant effect on mobility and independence. On the other hand, the variation in residents' functional ability, the prevalence of cognitive impairment, and the prevalence of depression were considerably higher in this sample than expected on the basis of previous work. Further research to clarify the efficacy of occupational therapy and physiotherapy is required if access to therapy services is to be recommended in this population. Trial registration ISRCTN79859980

BackgroundThe occupational therapy (OT) in care homes study (OTCH) aims to investigate the effect of a targeted course of individual OT (with task training, provision of adaptive equipment, minor environmental adaptations and staff education) for stroke survivors living in care homes, compared to usual care.Methods/DesignA cluster randomised controlled trial of United Kingdom (UK) care homes (n = 90) with residents (n = 900) who have suffered a stroke or transient ischaemic attack (TIA), and who are not receiving end-of-life care. Homes will be stratified by centre and by type of care provided and randomised (50:50) using computer generated blocked randomisation within strata to receive either the OT intervention (3 months intervention from an occupational therapist) or control (usual care). Staff training on facilitating independence and mobility and the use of adaptive equipment, will be delivered to every home, with control homes receiving this after the 12 month follow-up.Allocation will be concealed from the independent assessors, but the treating therapists, and residents will not be masked to the intervention. Measurements are taken at baseline prior to randomisation and at 3, 6 and 12 months post randomisation. The primary outcome measure is independence in self-care activities of daily living (Barthel Activities of Daily Living Index). Secondary outcome measures are mobility (Rivermead Mobility Index), mood (Geriatric Depression Scale), preference based quality of life measured from EQ-5D and costs associated with each intervention group. Quality adjusted life years (QALYs) will be derived based on the EQ-5D scores. Cost effectiveness analysis will be estimated and measured by incremental cost effectiveness ratio. Adverse events will be recorded.DiscussionThis study will be the largest cluster randomised controlled trial of OT in care homes to date and will clarify the currently inconclusive literature on the efficacy of OT for stroke and TIA survivors residing in care homes.Trial registrationISRCTN00757750

References Audit Commission (2000) Fully equipped: the provision of equipment to older or disabled people by the NHS and Social Services in England and Wales. London: Audit Commission. Carpenter GI, Field J, Challis D, Swift CG (2002) Needs and resourcescomparing levels of care provided to older people in two social services departments.

The provision of adaptive equipment to older people living at home maintains and improves independence and reduces health and social care costs (Logan et al 1997, Mann et al 1999). Physical disability is the best predictor of adaptive equipment use (Tomita et al 2004). Despite legislation that attributes the statutory responsibility for such services to local authorities (National Health Service and Community Care Act 1990), the Audit Commission (2000) has found that provision is inadequate and geographically variable. Questionnaire and interview studies have shown that provision is influenced adversely by inconsistencies in referral mechanisms, eligibility criteria and funding (Cowan and Turner-Smith 1999, Carpenter et al 2002). This led to the first national eligibility framework for adult services and, in April 2003, Fair Access to Care Services (FACS) (Department of Health 2002) was implemented. The assessment criteria focused on the person's autonomy, health and /or safety, management of daily routines and /or the person's ability to maintain meaningful participation in family or community life, all considered vital aspects of independence. The eligibility framework is graded into four bands, which describe the seriousness of the risk to independence for the individual or other consequences if needs are not addressed. The four bands are summarised as follows

Collin C, Wade DT, Davies S, Horne V (1988) The Barthel ADL Index: a reliability study. International Disability Studies, 10(2), 61-63. Cowan D, Turner-Smith A (1999) The role of assistive technology in alternative models of health care for older people, Appendix 4, Research volume 2, With respect to old age: long term care -rights and responsibilities. London: HMSO, 325-46.