Leisure & Participation

Evidence Reviewed as of before: 16-12-2009
Author(s)*: Johanne Desrosiers, PhD OT; Nicol Korner-Bitensky, PhD OT; Maxim Ben Yakov, BSc. PT; Hélène Carbonneau, recreologist, PhD candidate
Patient/Family Information Table of contents

Introduction

The benefits of leisure are numerous. Leisure benefits everyone’s well-being and quality of life. Leisure also helps to improve physical and mental health, along with personal growth.

Patient/Family Information

Authors: Johanne Desrosiers, PhD OT, Nicol Korner-Bitensky, PhD OT; Hélène Carbonneau, PhD recreologist

Myths about leisure activities

  • Leisure is impossible after having a stroke.
    It is possible to resume your leisure activities after having a stroke. If needed, many adaptations exist to help you to return to your activities. It is important to talk to your rehabilitation health professional about your desires and needs. You can also consult our Assistive Devices module for more information
  • Leisure activities require a lot of skill.
    Leisure is much more than just the activities that we do in our spare time. Leisure is first and foremost an enjoyable part of life. After a stroke it is possible for you to do leisure activities, even if you have some problems that were caused by the stroke. Most activities can be done without any previous skills, or involve skills that are easy to learn.
  • Healthy people are not interested in participating in activities with individuals who have had a stroke.
    Some of the reservations you may notice in people are related to a lack of knowledge about stroke and about how to interact with someone who has had a stroke. It is important to have a conversation with relatives and friends about leisure activities and to inform them of what you can and cannot do. Because of your stroke they may also be experiencing a loss, and will need to adapt and learn new ways of interacting and participating in activities with you.
  • It’s better to stay home…
    It is better to find some continuity whenever possible with what you used to do before the stroke, whether in your daily habits or in leisure. For example, if you decide to stay home and play cards with your neighbor, while you normally used to go to your community center – you’ll lose out on some of the social contacts that are important to maintain following a stroke. So, it is better to try to find ways of getting to the community center so that you can maintain your social activities, instead of just staying home.

Why do leisure activities?

The benefits of leisure are numerous. Leisure benefits everyone’s well-being and quality of life. Leisure also helps to improve physical and mental health, along with personal growth.

Can I participate in my leisure activities after a stroke?

Leisure is a right for everyone. It is always possible to experience pleasant and positive moments in life, regardless of what state of health you are in. While the types of leisure activities you did before the stroke might be different from those you do after your stroke, the feeling of wellbeing that you get from leisure activities should remain the same.

Can I participate in the same leisure activities as before?

Sometimes it can be difficult to resume the exact same activities after a stroke that you enjoyed before the stroke. You may have to accept the fact that you will need to modify your way of doing your leisure activities so that they are easier and less demanding to engage in. As mentioned above, some Assistive Devices can help you achieve this.

Can I take the plane to travel?

Most people can take the plane after a stroke. However, you may want to check if there are any specifities with your travel insurance company. The following link is an an article from England and Wales entitled “Flying after a stroke” which includes information on: Airport Assistance, first hand experiences from stroke survivors, how Airports could improve their services and much more!

Who can help me resume my leisure activities?

Your family and friends are an excellent source of support. Sometimes people don’t know exactly how to help when faced with a loved one who has had a stroke. It is possible that your family and friends are waiting for a sign from you before they offer support. If you ask them for help, you may be pleasantly surprised. It is very possible that your family and friends are feeling overwhelmed by the situation and have difficulty supporting you in your leisure activities. If that is the case, there are various professionals who can help. Occupational therapists, physiotherapists, social workers, and psychologists are all able to help you resume your leisure activities. Also, some centers offer the services of recreational therapists. Don’t hesitate to seek out these resources.

Are there any risks to participating in leisure activities?

There are no additional risks that someone who has had a stroke faces in participating in leisure activities – as long as these activities are practiced in a manner that fits the person’s abilities. Consult your physician or rehabilitation healthcare professional for the best advice on how to participate in leisure safely, and with little effort.

*Family member/friend: It is important that you allow the person who has had a stroke the freedom to pursue pleasant activities without being overly protective.

How to find pleasant and satisfying leisure activities in my life?

This section will offer you a structured way of finding an enjoyable leisure activity that suits your lifestyle. This process has been part of an educational program for the past 15 years for people who have lost their independence. It can be a helpful way to reflect about leisure choices. It is useful for the person who has had a stroke, family and friends, and for clinicians working in rehabilitation.

Steps to follow to help find pleasing leisure activities:

  • Step 1: Think about the role of leisure in your life
    First, you have to ask yourself about the value of leisure for you. You have to believe that it is important for you. Your family and friends can help you find new pleasure in leisure. You have to think about what brought you pleasure and fun before the stroke, and then try to find activities you can do to get the same feelings. By clicking here you can find a questionnaire that may help you reflect on your feelings with respect to leisure. (Link coming soon waiting for author approval)
  • Step 2: Evaluate how much satisfaction you get from your current leisure activities
    Assess the satisfaction that you get from your leisure activities and from how you spend your free time (Link coming soon waiting for author approval)
  • Step 3: Identify your current activities and interests in leisure
    Now it is time to reflect on the things you like to do during your free time. Think about what activities are pleasant for you – from things as simple as watering your plants to more structured activities like golf. Leisure consists of both small and big activities. The important thing is the pleasure that these activities give you. Think about your leisure activities – more specifically about:

    • The activities that you enjoy
    • The activities that you do
    • The activities you used to do but stopped doing and would like to resume
    • The pleasure you derive from each of the activities

    After you have reflected on these things, you will be better prepared to decide on which activities you want to work on resuming.

  • Step 4: Think about what you expect from the leisure activities
    Once your interests in leisure are clearer, it is helpful to understand the reasons why you prefer to do one activity over another. Some people like the socializing part most of all, while others like to push themselves to experience new challenges. If you have trouble sorting out the reason why you like certain activities more than others, try completing this quick test. (Link coming soon waiting for author approval).
  • Step 5: Identify where, how and with whom you will spend your leisure time
    This step helps you think about where, with whom, when, and how you participate in activities. This step is useful for identifying the obstacles you may face during your leisure activities. The grid provided here (link coming soon waiting for author approval) will guide you through steps 5 through 8.
  • Step 6: Think of some of the obstacles you might face when engaging in your leisure activities
    You have to think about concerns you have about resuming your favorite leisure activities and which of these are real and which are more likely based on misconceptions.
  • Step 7: Look for different ways to accomplish your leisure activities
    Sometimes you have to think about doing your leisure activities differently. You may need special equipment or Assistive Devices, or you may need to find a more suitable place in which to do your preferred activity – one that is adapted for your needs. For example, you may enjoy swimming but may need to find a pool that has special safety equipment and adaptations for someone who has a disability. Therefore, you might change the location of your activities for more suitably adapted locations. It is a good idea to consult with a rehabilitation professional once you reach this step. Also, you may want to visit our Assistive Devices module for an example of equipment and adaptations that may make it easier to resume certain activities.
  • Step 8 : Identify alternative activities
    If you have come to the realization that you really cannot return to your previous leisure activities, it is important to consider some alternative activities that can bring you the same pleasure. Here is an example: Three people enjoyed walking in the forest and in nature in general. They no longer had the physical ability to take walks in the forest after the stroke. The first person enjoyed the relaxation aspect of nature- so he chose to listen to relaxation tapes with sounds of nature. This new leisure satisfied him because he was still able to relax while enjoying some aspects of nature. The second person chose to paint drawings of nature to satisfy his interest of reflecting on nature. The third individual enjoyed the sightseeing and the fauna. So she decided to build a terrace in her backyard, where she could eat while enjoying the flowers and the trees. All three found alternatives to satisfy their interests in nature, but in different and unique ways.
    The important thing is not the activity, but what it brings to you!
  • Step 9 : Learn to integrate your activities into daily life
    Once you have your leisure interests set, you now need to consider the knowledge and skills required to make these activities part of your life. This means that you may have to learn some new skills. Here again, seeking the help of a rehabilitation professional may be valuable. Family and friends are also an important source of support and help at this point. They can help you to focus on enjoying these activities rather than on doing them correctly.
  • Step 10: Persevere!
    Even if the obstacles seem huge, keep going! You will congratulate yourself later. The support of family and friends is really important at this point.

Leisure Therapy

Evidence Reviewed as of before: 25-07-2021
Author(s)*: Annabel McDermott, OT; Shawn Aitken, OT
Expert Reviewer: Hélène Carbonneau, PhD
Patient/Family Information Table of contents

Introduction

Many people have difficulty participating in leisure activities after a stroke. Common obstacles to re-engaging in leisure activities include mobility limitations, inaccessibility of community-based activities and the perceived social stigma towards stroke. The reduction in leisure participation can be a source of frustration and can impact on mood and wellbeing. Support can be helpful to increase participation in leisure activities.

Leisure therapy typically involves interventions that enable participation in leisure activities and achieving leisure goals. These interventions can include discovering leisure activities, training in leisure activities, adapting leisure activities and making use of community resources. Leisure therapy is often provided by recreational therapists and occupational therapists, and can be offered individually or in a group. Individual leisure therapy is often tailored to work towards individual leisure goals, whereas leisure therapy groups often involve participating in leisure activities in a social context and group education / discussions.

Patient/Family Information

What is leisure therapy?

Leisure therapy helps people engage in leisure activities and achieve their goals for resuming leisure after stroke. There are many different forms of leisure therapy, including practising specific leisure activities, improving skills, finding ways to adapt to changes from the stroke, using community resources, or discovering new leisure activities.

Why use leisure therapy?

After a stroke, many people have difficulty returning to leisure activities. Leisure activities are a good way to stay active, both physically and mentally. Leisure activities have many benefits on quality of life and mood. Leisure therapy is often as effective as other treatments to improve general skills after a stroke, which in turn can make it easier to do other daily activities.

Is leisure therapy effective?

Studies on leisure therapy differ in the type of intervention they use, and how long or how often they do the leisure activity. This makes it difficult to decide whether leisure therapies are all effective. However, research shows that doing leisure therapy after a stroke can improve physical skills, cognitive skills and satisfaction with leisure. Leisure therapy is as effective as other stroke treatments (such as standard care, occupational therapy and physical activity) for emotional wellbeing, mood and ability to do activities of daily living.

Are there risks or side effects?

If your medical and rehabilitation team have cleared you to do physical rehabilitation, there are no specific risks or side effects associated with leisure therapy. However, it is important to work with a rehabilitation professional (e.g. an occupational therapist or recreational therapist), because your skills after a stroke may have changed. Your rehabilitation professional will help you do leisure activities safely, or find alternative activities that you can do safely. No studies report leisure therapy to be associated with any negative side effects.

Who provides leisure therapy?

Leisure therapy is often provided by occupational therapists or recreational therapists, but can also be provided by other people such as volunteers.

How much does it cost?

The cost of leisure therapy depends on public health or insurance policies. In Canada, costs are covered if you are receiving care in a rehabilitation setting that offers this form of treatment. If you are receiving private rehabilitation, it is important to verify that your insurance covers leisure therapy.

How long does it take?

In the studies used for this StrokEngine module, the duration and intensity of leisure therapy varied greatly. Most treatments were provided over several months; sessions were held once a week, and lasted between 30-60 minutes. In a rehabilitation setting, it is likely that leisure therapy will be tailored to suit each individual’s goals and needs.

Is leisure therapy for me?

If you’ve had a stroke or know a relative who has had a stroke and is having difficulty with leisure activities, leisure therapy is an excellent treatment option to re-engage in activities or help discover new interests. Leisure activities benefit physical and psychological health and are a great way to stay active. Additionally, leisure therapy has been shown to provide additional benefits such as improving physical ability and skills for other types of activities.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

A total of ten studies (six high quality RCTs, two fair quality RCTs, one poor quality RCT and one pre-post design study) that investigate the use of leisure therapy in post-stroke rehabilitation were reviewed in this StrokEngine module. Leisure therapy typically included participation in leisure activities, training in leisure activity, adapting leisure activities, leisure education/discussion and accessing community resources. Frequency of leisure therapy varied from 30 minutes to 2 hours per session, from one to 3 days per week, for 5 to 36 weeks duration. Some studies offered leisure therapy combined with physical activity sessions. Control groups included delayed leisure therapy (in the case of crossover studies), discussions not related to leisure, occupational therapy, activities of daily living (ADL) therapy, physical activity or no intervention.

A systematic review on leisure therapy (Dorstyn et al., 2014) that comprised 12 RCTs from ten independent studies reported statistically significant differences in favour of leisure therapy compared to control interventions for health-related quality of life, emotional wellbeing, leisure satisfaction, leisure participation and activity satisfaction. The review concluded that leisure therapy is effective for improving short-term psychological and leisure outcomes after stroke. All but one of the studies from this systematic review met criteria for inclusion in this StrokEngine module.

This review includes three studies (two high quality RCTs and one non-randomized study) conducted with participants in the chronic phase of stroke recovery. In this phase of recovery, leisure therapy was more effective than comparison interventions for improving executive function, occupational performance and walking endurance. The remaining studies were conducted with participants across the stroke continuum (i.e. participants’ stage of stroke was not specific to one phase or was not reported). Results found that leisure therapy was more effective than comparison interventions for improving leisure satisfaction alone, with potential benefits on emotional wellbeing, instrumental ADLs and leisure participation.

Results Table

View results table

Outcomes

Chronic phase

Balance
Not effective
1b

One high quality RCT (Liu-Ambrose & Eng, 2014) investigated the effect of leisure therapy on balance in the chronic phase of stroke recovery. This high quality crossover RCT randomized patients to receive exercise training + recreation/leisure therapy or usual care. Balance was measured by the Berg Balance Scale at mid-treatment (3 months) and post-treatment (6 months). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that exercise training + recreation/leisure therapy is not more effective than a comparison intervention (usual care) for improving balance in the chronic phase of stroke recovery.

Executive function
Effective
1b

One high quality RCT (Liu-Ambrose & Eng, 2014) and one non-randomized study (Rand et al., 2010) investigated the effect of leisure therapy on executive function in the chronic phase of stroke recovery.

The high quality crossover RCT (Liu-Ambrose & Eng, 2014) randomized patients to receive exercise training + recreation/leisure therapy or usual care. Executive function was measured by the Stroop Test, Trail Making Tests – Part A and B and verbal digit span forward/backward test at mid-treatment (3 months) and post-treatment (6 months). A significant between-group difference was found in one measure (Trail Making Tests) at mid-treatment, favouring the exercise + recreation/leisure program vs. usual care. Significant between-group differences were found in two measures (Stroop Test; verbal digit span forward/backward test) at post-treatment, favouring the exercise + recreation/leisure program vs. usual care.

The pre-post design study (Rand et al., 2010) provided patients with physical exercise + recreation/leisure sessions. Executive function was measured by the Verbal Digits Span Test – Backward, Trail Making Test – B, Rey Auditory Verbal Learning Test (RAVLT – Short delay, Long delay), Walking While Talking test (WWT), Digit Symbol Test (DST) and Stroop Test at mid-treatment (3 months) and post-treatment (6 months). Significant improvements were found on the RAVLT (Long delay) and WWT at mid-treatment, and on the Stroop Test at post-treatment.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that exercise training + recreation/leisure is more effective than a comparison intervention (usual care) for improving some measures of executive function in the chronic phase of stroke recovery. A pre-post study also found improvements on certain measures of executive function after a physical exercise and recreation/leisure intervention.

Health status
Not effective
1b

One high quality RCT (Corr, Phillips & Walker, 2004) investigated the effect of leisure therapy on health status in the chronic phase of stroke recovery. This high quality crossover RCT randomized patients to receive community leisure therapy or no treatment (delayed intervention). Health status was measured by the Medical Outcomes Short Form (SF-36 – Physical, Mental subscales) at post-treatment (6 months) and follow-up (12 months). A significant between-group difference was found in one measure (SF-36 – Physical) at post-treatment, in favour of no treatment vs. leisure therapy.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that leisure therapy is not more effective than no treatment for improving health status in the chronic phase of stroke recovery.

Instrumental Activities of Daily Living
Not effective
1b

One high quality RCT (Corr, Phillips & Walker, 2004) investigated the effect of leisure therapy on instrumental activities of daily living (IADLs) in the chronic phase of stroke recovery. This high quality crossover RCT randomized patients to receive community leisure therapy or no treatment (delayed intervention). IADLs were measured by the Nottingham Extended ADL Scale (NEADL) at post-treatment (6 months) and follow-up (12 months). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that leisure therapy is not more effective than no treatment for improving IADLs in the chronic phase of stroke recovery.

Knee strength
Not effective
1b

One non-randomized study (Rand et al., 2010) investigated the effect of leisure therapy on knee strength after stroke. This pre-post design study provided patients with physical exercise + recreation/leisure sessions. Isometric muscle strength of the paretic knee was measured by handheld dynamometer at mid-treatment (3 months) and post-treatment (6 months). A significant improvement in knee strength was found at mid-treatment but was not maintained at post-treatment.

Conclusion: There is limited evidence (level 2b) from one pre-post study that physical exercise and recreation/leisure sessions are not effective for improving paretic knee strength after stroke.

Leisure participation
Not effective
2b

One high quality RCT (Corr, Phillips & Walker, 2004) investigated the effect of leisure therapy on leisure participation in the chronic phase of stroke recovery. This high quality crossover RCT randomized patients to receive community leisure therapy or no treatment (delayed intervention). Leisure participation was measured by the Nottingham Leisure Questionnaire (NLQ – Total leisure activities carried out; activities carried out regularly) at post-treatment (6 months) and follow-up (12 months). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that leisure therapy is not more effective than no treatment for improving leisure participation in the chronic phase of stroke recovery.

Mood
Not effective
1a

Two high quality RCTs (Corr, Phillips & Walker, 2004; Liu-Ambrose & Eng, 2014) and one non-randomized study (Rand et al., 2010) investigated the effect of leisure therapy on mood in the chronic phase of stroke recovery.

The first high quality crossover RCT (Corr, Phillips & Walker, 2004) randomized patients to receive community leisure therapy or no treatment (delayed intervention). Mood was measured by the Hospital Anxiety and Depression Scale (HADS – Anxiety, Depression subscales) at post-treatment (6 months) and follow-up (12 months). No significant between-group difference was found at either time point.

The second high quality crossover RCT (Liu-Ambrose & Eng, 2014) randomized patients to receive exercise training + recreation/leisure therapy or usual care. Mood was measured by the Geriatric Depression Scale (GDS) at mid-treatment (3 months) and post-treatment (6 months). No significant between-group difference was found at either time point.

The pre-post design study (Rand et al., 2010) provided patients with physical exercise + recreation/leisure sessions. Mood was measured by the GDS at mid-treatment (3 months) and post-treatment (6 months). No significant change in mood was found at either time point.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that leisure therapy (with or without physical activity) is not more effective than comparison interventions (no intervention, usual care) for improving mood in the chronic phase of stroke recovery. A non-randomized study also found no significant improvement in mood following physical exercise and recreation/leisure sessions.

Occupational performance
Effective
1b

One high quality RCT (Corr, Phillips & Walker, 2004) investigated the effect of leisure therapy on occupational performance in the chronic phase of stroke recovery. This high quality crossover RCT randomized patients to receive community leisure therapy or no treatment (delayed intervention). Occupational performance was measured by the Canadian Occupational Performance Measure (COPM – Performance, Satisfaction) at post-treatment (6 months) and follow-up (12 months). Significant between-group differences were found on both measures at post-treatment, in favour of community leisure therapy vs. no treatment. Differences were not maintained at follow-up.

Conclusion: There is moderate evidence (level 1b) from one high quality that leisure therapy is more effective than no treatment (delayed intervention) for improving occupational performance in the chronic phase of stroke recovery.

Self-concept
Not effective
1b

One high quality RCT (Corr, Phillips & Walker, 2004) investigated the effect of leisure therapy on self-concept in the chronic phase of stroke recovery. This high quality crossover RCT randomized patients to receive community leisure therapy or no treatment (delayed intervention). Self-concept was measured by the Semantic Differential Self Concept Scale at post-treatment (6 months) and follow-up (12 months). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that leisure therapy is not more effective than no treatment (delayed intervention) for improving self-concept in the chronic phase of stroke recovery.

Walking endurance
Effective
1b

One high quality RCT (Liu-Ambrose & Eng, 2014) and one non-randomized study (Rand et al., 2010) investigated the effect of leisure therapy on walking endurance in the chronic phase of stroke recovery.

The high quality crossover RCT (Liu-Ambrose & Eng, 2014) randomized patients to receive exercise training + recreation/leisure therapy or usual care. Walking endurance was measured by the 6 Minute Walk Test (6MWT) at mid-treatment (3 months) and post-treatment (6 months). A significant between-group difference was found at post-treatment only, in favour of exercise training + recreation/leisure therapy vs. usual care.

The pre-post design study (Rand et al., 2010) provided patients with physical exercise + recreation/leisure sessions. Walking endurance was measured by the 6MWT at mid-treatment (3 months) and post-treatment (6 months). Significant within-group differences were found at both time points.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that exercise training + recreation/leisure therapy is more effective than a comparison intervention (usual care) for improving walking endurance in the chronic phase of stroke recovery. A non-randomized study also found significant improvements in walking endurance after a physical exercise and recreation/leisure intervention.

Walking speed
Not effective
2b

One non-randomized study (Rand et al., 2010) investigated the effect of leisure therapy on walking speed in the chronic phase of stroke recovery. This pre-post design study provided patients with physical exercise + recreation/leisure sessions. Walking speed was measured by a 5-meter walk test at mid-treatment (3 months) and post-treatment (6 months). A significant improvement in walking speed was found at mid-treatment but was not maintained at post-treatment.

Conclusion: There is limited evidence (level 2b) from one non-randomized study that physical exercise + recreation/leisure sessions are not effective for improving walking speed in the chronic phase of stroke recovery.

Phase not specific to one period

Activities of Daily Living
4

One high quality RCT (Parker, Gladman & Drummond, 2001) and one poor quality RCT (Logan et al., 2003) investigated the effect of leisure therapy on Activities of Daily Living (ADLs) after stroke.

The high quality RCT (Parker, Gladman & Drummond, 2001) randomized patients to receive leisure-based occupational therapy (OT), ADL-based OT or no intervention. ADLs were measured by the Barthel Index (BI) at post-treatment (6 months) and follow-up (12 months). No significant between-group differences were found at either time point.

The poor quality RCT (Logan et al., 2003) randomized patients to receive leisure-based OT or ADL-based OT. ADLs were measured by the BI (Dressing, Bathing, Transfers) at post-treatment (6 months). No significant between-group difference was found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and 1 poor quality RCT that found that leisure therapy is not more effective than comparison interventions (ADL-based OT, no intervention) for improving ADLs after stroke.

Activity participation and satisfaction
Not effective
1b

One fair quality RCT (Jongbloed & Morgan, 1991) investigated the effect of leisure therapy on activity participation and satisfaction after stroke. This fair quality RCT randomized patients to receive a leisure program or time-matched leisure/stroke-related conversations (no program). Activity participation and satisfaction was measured by the Katz Adjustment Index (Level of free-time activities; Level of satisfaction with free-time activities) at post-treatment (5 weeks) and follow-up (18 weeks). No significant between-group difference was found at either time point.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that leisure therapy is not more effective than a comparison intervention (conversation) for improving activity participation after stroke.

Emotional wellbeing
Not effective
1a

Three high quality RCTs (Drummond & Walker, 1996; Parker, Gladman & Drummond, 2001; Desrosiers et al., 2007) investigated the effect of leisure therapy on emotional wellbeing after stroke.

The first high quality RCT (Drummond & Walker, 1996) randomized patients with acute/subacute stroke to receive leisure therapy, conventional occupational therapy (OT) or no intervention. Emotional wellbeing was measured by the Nottingham Health Profile (NHP – Energy, Emotions, Pain, Isolation, Sleep, Mobility, Total score) at mid-treatment (3 months) and post-treatment (6 months). Comparison of leisure therapy and conventional OT found significant between-group differences in three measures (NHP – Energy, Mobility, Total) at mid-treatment, in favour of leisure therapy vs. OT; only one measure (NHP – Mobility) remained significant at post-treatment. Comparison of leisure therapy and no treatment found significant between-group differences in two measures (NHP – Mobility, Total) at mid-treatment, in favour of leisure therapy vs. no treatment; only one measure (NHP – Mobility) remained significant at post-treatment.
Note: No significant between-group difference was found between OT vs. no intervention at either time point.

The second high quality RCT (Parker, Gladman & Drummond, 2001) randomized patients to receive leisure-based OT, ADL-based OT or no intervention. Emotional wellbeing was measured by General Health Questionnaire at post-treatment (6 months) and follow-up (12 months). No significant between-group differences were found at either time point.

The third high quality RCT (Desrosiers et al., 2007) randomized patients to receive a leisure education program or social home visits. Emotional wellbeing was measured by the General Well-being Schedule at post-treatment (8-12 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs that leisure therapy is not more effective than comparison interventions (OT, social home visits, no treatment) for improving emotional wellbeing after stroke.
Note
: One high quality RCT found that leisure therapy was more effective than comparison interventions (OT, no intervention) for improving one measure of wellbeing (mobility).

Emotional wellbeing of carers
Not effective
1b

One high quality RCT (Parker, Gladman & Drummond, 2001) investigated the effect of leisure therapy on emotional wellbeing of carers after stroke. This high quality RCT randomized patients to receive leisure-based occupational therapy (OT), ADL-based OT or no intervention. Carer emotional wellbeing was measured by the Short General Health Questionnaire at post-treatment (6 months) and at follow-up (12 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that leisure therapy is not more effective than comparison interventions (ADL-based OT, no intervention) for improving emotional wellbeing of carers after stroke.

Executive function
Not effective
1b

One high quality RCT (Lund et al., 2012) investigated the effect of leisure therapy on executive function after stroke. This high quality RCT randomized patients to receive a lifestyle + physical activity program or physical activity alone. Executive function was measured by the Trail-Making Test (TMT-A, TMT-B) at post-treatment (9 months). No significant between-group difference was found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a lifestyle + physical activity program is not more effective than a comparison intervention (physical activity alone) for improving executive function after stroke.

Health-related quality of life
Not effective
1b

One high quality RCT (Desrosiers et al., 2007) and one fair quality RCT (Nour et al., 2002) investigated the effect of leisure therapy on health-related quality of life after stroke.

The high quality RCT (Desrosiers et al., 2007) randomized patients to receive a leisure education program or social home visits. Health-related quality of life was measured by the Stroke-Adapted Sickness Impact Profile at post-treatment (8-12 weeks). No significant between-group difference was found.

The fair quality RCT (Nour et al., 2002) randomized patients to receive a leisure education program or social home visits. Health-related quality of life was measured by the Sickness Impact Profile (SIP – Psychological, Physical, Total scores) at post-treatment (10 weeks). A significant between-group difference was found, in favour of leisure education vs. social visits.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a leisure education program is not more effective than a comparison intervention (social home visits) for improving health-related quality of life after stroke.
Note
: However, a fair quality RCT found better outcomes in quality of life following a leisure education program vs. social home visits. This study used a different measure of quality of life than the high quality RCT.

Health status
Not effective
1a

One high quality RCT (Lund et al., 2012) investigated the effect of leisure therapy on health status after stroke. This high quality RCT randomized patients to receive a lifestyle + physical activity program or physical activity alone. Health status was measured by the Medical Outcomes Short Form (SF-36 – Mental health, Vitality, Bodily pain, General health, Social functioning, Physical functioning, Role physical, Role emotional subscales) at post-treatment (9 months). No significant between-group difference was found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a lifestyle + physical activity program is not more effective than a comparison intervention (physical activity alone) for improving health status after stroke.

Instrumental Activities of Daily Living
Not effective

Two high quality RCTs (Drummond & Walker, 1996; Parker, Gladman & Drummond, 2001) and one poor quality RCT (Logan et al., 2003) investigated the effect of leisure therapy on Instrumental Activities of Daily Living (IADLs) after stroke.

The first high quality RCT (Drummond & Walker, 1996) randomized patients to receive leisure therapy, conventional occupational therapy (OT) or no intervention. IADLs were measured by the Nottingham Extended ADL Scale (NEADL – Mobility, Kitchen, Domestic, Leisure scores) at mid-treatment (3 months) and post-treatment (6 months). Significant between-group differences were found in two measures (NEADL – Mobility, Leisure) at post-treatment only, in favour of leisure therapy vs. no intervention, and leisure therapy vs. OT.
Note: No significant between-group differences were found between OT vs. no intervention at either time point.

The second high quality RCT (Parker, Gladman & Drummond, 2001) randomized patients to receive leisure-based OT, ADL-based OT or no intervention. IADLs were measured by the NEADL at post-treatment (6 months) and follow-up (12 months). No significant between-group differences were found at either time point.

The poor quality RCT (Logan et al., 2003) randomized patients to receive leisure-based OT or ADL-based OT. IADLs were measured by the NEADL (Cleaning, Cooking, Mobility outside, Mobility on uneven ground) at post-treatment (6 months). No significant between-group differences were found.

Conclusion: There is conflicting evidence (level 4) regarding the effect of leisure on IADLs following stroke. While one high quality RCT found that leisure therapy was more effective than comparison interventions (OT, no intervention) for improving some IADLs (mobility and leisure Activities), one high quality RCT and one poor quality RCT found that leisure therapy was not more effective than comparison interventions (ADL-based OT, no intervention).

Leisure participation
Conflicting
4

Three high quality RCTs (Drummond & Walker, 1995; Parker, Gladman & Drummond, 2001; Desrosiers et al., 2007) and one poor quality RCT (Logan et al., 2003) investigated the effect of leisure therapy on leisure participation after stroke.

The first high quality RCT (Drummond & Walker, 1995) randomized patients to receive leisure therapy, conventional occupational therapy (OT) or no intervention. Leisure participation was measured by (i) leisure activity frequency, and (ii) number of leisure activities at mid-treatment (3 months) and post-treatment (6 months). Significant between-group differences were found on both measures at mid-treatment and post-treatment, in favour of leisure therapy vs. no intervention, and leisure therapy vs. OT.
Note: No significant between-group differences were found between OT vs. no intervention.

The second high quality RCT (Parker, Gladman & Drummond, 2001) randomized patients to receive leisure-based OT, ADL-based OT or no intervention. Leisure participation was measured by the Nottingham Leisure Questionnaire (NLQ) at post-treatment (6 months) and follow-up (12 months). No significant between-group differences were found at either time point.

The third high quality RCT (Desrosiers et al., 2007) randomized patients to receive a leisure education program or social home visits. Leisure participation was measured using a time-adjusted logbook (passive activities, active activities, number of activities) at post-treatment (8-12 weeks). Significant between-group differences were found on two measures (active leisure activities, number of activities), in favour of leisure education vs. social visits.

The poor quality RCT (Logan et al., 2003) randomized patients to receive leisure-based OT or ADL-based OT. Leisure participation was measured by the NLQ (Sport, Games, Cooking, Shopping, Entertainment, Gardening, Hobbies) at post-treatment (6 months). No significant between-group difference was found.

Conclusion: There is conflicting evidence (level 4) regarding the effect of leisure activities on leisure participation after stroke. While two high quality RCTs found that leisure therapy was more effective than comparison interventions (OT, no intervention, social home visits) for improving leisure participation, one high quality RCT and one poor quality RCT found that leisure therapy was not more effective than comparison interventions (ADL-based OT, no intervention).

Leisure satisfaction
Effective
2a

One high quality RCT (Desrosiers et al., 2007) investigated the effect of leisure therapy on leisure satisfaction after stroke. This high quality RCT randomized patients to receive a leisure education program or social home visits. Leisure satisfaction was measured by the Leisure Satisfaction Scale (LSS) and Individualized Leisure Profile (ILP – Needs and expectations in regard to leisure, Use of spare time) at post-treatment (8-12 weeks). Significant between-group differences were found on two measures (LSS; ILP – Needs and expectations), in favour of leisure education vs. social visits.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a leisure education program is more effective than a comparison intervention (social home visits) for improving leisure satisfaction after stroke.

Mobility
Not effective
1b

One high quality RCT (Lund et al., 2012) investigated the effect of leisure therapy on mobility after stroke. This high quality RCT randomized patients to receive a lifestyle + physical activity program or physical activity alone. Mobility was measured by the Timed Up and Go Test at post-treatment (9 months). No significant between-group difference was found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that a lifestyle + physical activity program is not more effective than a comparison intervention (physical activity) for improving mobility after stroke.

Mood
Not effective

Three high quality RCTs (Drummond & Walker, 1996; Desrosiers et al., 2007; Lund et al., 2012) and one fair quality RCT (Nour et al., 2002) investigated the effect of leisure therapy on mood after stroke.

The first high quality RCT (Drummond & Walker, 1996) randomized patients to receive leisure therapy, conventional occupational therapy (OT) or no intervention. Mood was measured by the Wakefield Depression Inventory at mid-treatment (3 months) and post-treatment (6 months). No significant between-group differences were found at either time point.

The second high quality RCT (Desrosiers et al., 2007) randomized patients to receive a leisure education program or social home visits. Mood was measured by the Center for Epidemiological Studies Depression Scale at post-treatment (8-12 weeks). A significant between-group difference was found, in favour of leisure education vs. social visits.

The third high quality RCT (Lund et al., 2012) randomized patients to receive a lifestyle + physical activity program or physical activity alone. Mood was measured by the Hospital Anxiety and Depression Scale (HADS – Anxiety, Depression subscales) at post-treatment (9 months). No significant between-group difference was found.

The fair quality RCT (Nour et al., 2002) randomized patients to receive a leisure education program or social home visits. Mood was measured by the Beck Depression Inventory at post-treatment (10 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs and one fair quality RCT that leisure programs are not more effective than comparison interventions (conventional OT, physical activity alone, social home visits, no intervention) for improving mood following stroke.
Note
: However, one high quality RCT did find that a leisure education program was more effective than social home visits in improving Depression after stroke.

Occupational performance
Not effective
1b

One high quality RCT (Lund et al., 2012) investigated the effect of leisure therapy on occupational performance after stroke. This high quality RCT randomized patients to receive a lifestyle + physical activity program or physical activity alone. Occupational performance was measured by the Canadian Occupational Performance Measure (COPM – Performance, Satisfaction) at post-treatment (9 months). No significant between-group difference was found.

Conclusion: There is limited evidence (level 1b) from one high quality RCT that a lifestyle + physical activity program is not more effective than a comparison intervention (physical activity) for improving occupational performance after stroke.

Stroke outcomes
Not effective
1b

One high quality RCT (Parker, Gladman & Drummond, 2001) investigated the effect of leisure therapy on stroke outcomes after stroke. This high quality RCT randomized patients to receive leisure-based occupational therapy (OT), ADL-based OT or no intervention. stroke outcomes were measured by the International stroke Trial outcome questions, Oxford Handicap Scale and London Handicap Scale at post-treatment (6 months) and follow-up (12 months). No significant between-group differences were found on any of the measures at either time point.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that leisure therapy is not more effective than comparison interventions (ADL-based OT, no intervention) for reducing stroke outcomes after stroke.

References

Corr, S., Phillips, C. J., & Walker, M. (2004). Evaluation of a pilot service designed to provide support following stroke: a randomized cross-over design study. Clinical Rehabilitation, 18(1), 69-75.
https://pubmed.ncbi.nlm.nih.gov/14763721/

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), 1095-1100.
https://pubmed.ncbi.nlm.nih.gov/17826452/

Dorstyn, D., Roberts, R., Kneebone, I., Kennedy, P., & Lieu, C. (2014). Systematic review of leisure therapy and its effectiveness in managing functional outcomes in stroke rehabilitation. Topics in Stroke Rehabilitation, 21(1), 40-51.
https://pubmed.ncbi.nlm.nih.gov/24521839/

Drummond, A. E. R., & Walker, M. F. (1995). A randomized controlled trial of leisure rehabilitation after stroke. Clinical Rehabilitation, 9(4), 283-90.
https://journals.sagepub.com/doi/10.1177/026921559500900402

Drummond, A., & Walker, M. (1996). Generalisation of the effects of leisure rehabilitation for stroke patients. British Journal of Occupational Therapy, 59(7), 330-4.
https://journals.sagepub.com/doi/pdf/10.1177/030802269605900712

Jongbloed, L., & Morgan, D. (1991). An investigation of involvement in leisure activities after a stroke. American Journal of Occupational Therapy, 45(5), 420-7.
https://pubmed.ncbi.nlm.nih.gov/2048623/

Liu-Ambrose, T., & Eng, J. J. (2015). Exercise training and recreational activities to promote executive functions in chronic stroke: a proof-of-concept study. Journal of Stroke and Cerebrovascular Diseases, 24(1), 130-7.
https://pubmed.ncbi.nlm.nih.gov/25440324/

Logan, P. A., Gladman, J. R., Drummond, A. E., & Radford, K. A. (2003). A study of interventions and related outcomes in a randomized controlled trial of occupational therapy and leisure therapy for community stroke patients. Clinical Rehabilitation, 17(3), 249-55.
https://pubmed.ncbi.nlm.nih.gov/12735531/

Lund, A., Michelet, M., Sandvik, L., Wyller, T. B., & Sveen, U. (2012). A lifestyle intervention as supplement to a physical activity programme in rehabilitation after stroke: a randomized controlled trial. Clinical Rehabilitation, 26(6), 502-12.
https://pubmed.ncbi.nlm.nih.gov/22169830/

Nour, K., Desrosiers, J., Gauthier, P., & Carbonneau, H. (2002). Impact of a home leisure educational program for older adults who have had a stroke (home leisure educational program). Therapeutic Recreation Journal, 36(1), 48-64.
https://js.sagamorepub.com/trj/article/view/1048

Parker, C. J., Gladman, J. R., Drummond, A. E., Dewey, M. E., Lincoln, N. B., Barer, D., … & Radford, K. A. (2001). A multicentre randomized controlled trial of leisure therapy and conventional occupational therapy after stroke. Clinical rehabilitation, 15(1), 42-52.
https://pubmed.ncbi.nlm.nih.gov/11237160/

Rand, D., Eng, J. J., Liu-Ambrose, T., & Tawashy, A. E. (2010). Feasibility of a 6-month exercise and recreation program to improve executive functioning and memory in individuals with chronic stroke. Neurorehabilitation and neural repair, 24(8), 722-9.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3123336/

Excluded Studies:

Bastien, M., Korner-Bitensky, N., Lalonde, S., LeBrun, N., & Matte, D. (1998). A health and leisure program for community-dwelling individuals with stroke: A pilot study. Canadian Journal of Rehabilitation.
Reason for exclusion: No statistical analysis was reported in the study.

Lund, A., Michelet, M., Kjeken, I., Wyller, T. B., & Sveen, U. (2012). Development of a person-centred lifestyle intervention for older adults following a stroke or transient ischaemic attack. Scandinavian journal of occupational therapy, 19(2), 140-9.
https://pubmed.ncbi.nlm.nih.gov/21854103/
Reason for exclusion: The study also included patients with TIAs.

Hebblethwaite, S., & Curley, L. (2015). Exploring the role of community recreation in stroke recovery using participatory action research and photovoice. Therapeutic Recreation Journal, 49(1).
https://js.sagamorepub.com/trj/article/view/5433
Reason for exclusion: This paper reports changes in leisure after a stroke in the form of group discussions to identify common themes. There was no evaluation of the efficacy of an intervention.

Mulders, A. H. M., De Witte, L. P., & Diederiks, J. P. M. (1989). Evaluation of a rehabilitation after-care programme for stroke patients. J Rehabil Sci, 2(4), 97-103.
Reason for exclusion: This study was not publicly available and could not be evaluated for eligibility in this module. We reached out to the authors, but were not able to access the paper. This article was included in a systematic review (Dorstyn et al., 2014) from which findings are reported in this module.

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