Family-delivered rehabilitation services at home: is the glass empty?

Let families decide: Barriers and enablers to participation in family-assisted therapy for older people in transition care

OBJECTIVE

To understand the barriers and enablers to participation in family-assisted therapy for older people in Transition Care.

METHODS

A qualitative study, underpinned by interpretive description, was conducted at two public health services in Melbourne, Australia. Participants included patients in Transition Care, or their family members, who either participated in or chose not to participate in a family-assisted therapy trial. Semi-structured interviews were conducted, transcribed verbatim and analysed thematically.

RESULTS

Forty-four participants were interviewed (17 patients and 27 family members). The unifying theme was to let families decide about participation in family-assisted therapy. The unifying theme was illustrated by three subthemes. The first, what is possible for the family now, described practical considerations including geography, paid and unpaid work structure and commitments and the presence of fit and willing social networks. The second, what is important to the family now, recognised the role of family priorities in deciding. Physical rehabilitation and extra therapy were of high importance to some families. For others, emotional support or searching for a residential aged care bed were more important at the time. Finally, how the family functions described the complexity of relationships and family history that impacted the decision to participate.

CONCLUSIONS

The decision to participate in family-assisted therapy is complex and is best made by patients and their families. Clinicians offering family-assisted therapy are encouraged to avoid assuming what will or will not work for families and instead, to let families decide.

Caregiver-mediated exercises with e-health support for early supported discharge after stroke (CARE4STROKE): A randomized controlled trial

BACKGROUND AND PURPOSE

We designed an 8-week caregiver-mediated exercise program with e-health support after stroke (CARE4STROKE) in addition to usual care with the aim to improve functional outcome and to facilitate early supported discharge by increasing the intensity of task specific training.

METHODS

An observer-blinded randomized controlled trial in which 66 stroke patient-caregiver couples were included during inpatient rehabilitation. Patients allocated to the CARE4STROKE program trained an additional amount of 150 minutes a week with a caregiver and were compared to a control group that received usual care alone. Primary outcomes: self-reported mobility domain of the Stroke Impact Scale 3.0 (SIS) and length of stay (LOS). Secondary outcomes: motor impairment, strength, walking ability, balance, mobility and (Extended) Activities of Daily Living of patients, caregiver strain of caregivers, and mood, self-efficacy, fatigue and quality of life of both patients and caregivers. Outcomes were assessed at baseline, 8 and 12 weeks after randomization.

RESULTS

No significant between-group differences were found regarding SIS-mobility after 8 (β 6.21, SD 5.16; P = 0.229) and 12 weeks (β 0.14, SD 2.87; P = 0.961), and LOS (P = 0.818). Significant effects in favor of the intervention group were found for patient's anxiety (β 2.01, SD 0.88; P = 0.023) and caregiver's depression (β 2.33, SD 0.77; P = 0.003) post intervention. Decreased anxiety in patients remained significant at the 12-week follow-up (β 1.01, SD 0.40; P = 0.009).

CONCLUSIONS

This proof-of concept trial did not find significant effects on both primary outcomes mobility and LOS as well as the secondary functional outcomes. Treatment contrast in terms of total exercise time may have been insufficient to achieve these effects. However, caregiver-mediated exercises showed a favorable impact on secondary outcome measures of mood for both patient and caregiver.

CLINICAL TRIAL REGISTRATION

NTR4300, URL- http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4300.

Experiences of patients with stroke and their caregivers with caregiver-mediated exercises during the CARE4STROKE trial

Purpose: Caregiver-mediated exercises are a novel way of delivering augmented exercise therapy for patients with stroke, in which patients do additional therapeutic exercises together with a caregiver. This explorative qualitative study is part of the CARE4STROKE trial and focused on how participants manage these exercises together. The research questions were: (1) how do the patient-caregiver couples exercise together? and (2) what does exercising together bring about, besides more hours of practice?Methods: Semi-structured interviews were conducted with patients and caregivers who participated in the CARE4STROKE intervention. Inductive thematic data analysis was applied.Results: Seven patients and seven caregivers were interviewed. Three different role-dynamics were found during caregiver-mediated exercises: (1) patient in control, (2) in concert, and (3) the caregiver as informal carer. In addition, three themes were identified about what exercising together brings about: (a) tailor-made exercises through active involvement, (b) preparation for the home situation, and (c) opportunity to be involved.Conclusion: Different role-dynamics are at play in caregiver-mediated exercises, and it is important for participating staff to be aware of their possible effects on the strain of patient or caregiver. Caregiver-mediated exercises were found to enhance individualization of the treatment plan and preparation for home discharge.Implications for rehabilitationCaregiver-mediated exercises, in which a caregiver does exercises with a patient, are currently under investigation as a new form of augmented exercise delivery after strokeDoing exercises together seems to make patient and caregivers actively involved in rehabilitation, which they appreciate, and which seems to help them prepare for the home situationCaregiver selection and monitoring role-dynamics during exercising is an important task of the rehabilitation team.

Family-led rehabilitation in India (ATTEND)-Findings from the process evaluation of a randomized controlled trial

BACKGROUND

Training family carers to provide evidence-based rehabilitation to stroke patients could address the recognized deficiency of access to stroke rehabilitation in low-resource settings. However, our randomized controlled trial in India (ATTEND) found that this model of care was not superior to usual care alone.

AIMS

This process evaluation aimed to better understand trial outcomes through assessing trial implementation and exploring patients', carers', and providers' perspectives.

METHODS

Our mixed methods study included process, healthcare use data and patient demographics from all sites; observations and semi-structured interviews with participants (22 patients, 22 carers, and 28 health providers) from six sampled sites.

RESULTS

Intervention fidelity and adherence to the trial protocol was high across the 14 sites; however, early supported discharge (an intervention component) was not implemented. Within both randomized groups, some form of rehabilitation was widely accessed. ATTEND stroke coordinators provided counseling and perceived that sustaining patients' motivation to continue with rehabilitation in the face of significant emotional and financial stress as a key challenge. The intervention was perceived as an acceptable community-based package with education as an important component in raising the poor awareness of stroke. Many participants viewed family-led rehabilitation as a necessary model of care for poor and rural populations who could not access rehabilitation.

CONCLUSION

Difficulty in sustaining patient and carer motivation for rehabilitation without ongoing support, and greater than anticipated access to routine rehabilitation may explain the lack of benefit in the trial. Nonetheless, family-led rehabilitation was seen as a concept worthy of further development.