Home programs for upper extremity recovery post-stroke: a survey of occupational therapy practitioners

Self-Reported Home Program Adherence by People With Aphasia: Exploring Construct Validity

PURPOSE

The study purpose was to compare the practice patterns captured by self-reported logbook data and those recorded by a computerized home program application. The current study is part of a larger single-case research design study aimed at investigating the effect of logbook use on home program adherence in people with aphasia poststroke.

METHOD

Data from six adults with chronic aphasia with interest in improving their reading were used in this secondary analysis. Participants completed reading comprehension therapy tasks using a mobile application and tablet. The activities were self-directed and designed for people with aphasia to complete independently. We created an aphasia-friendly logbook based on best practices to allow participants to record their estimated total minutes practiced. Participants received instructions to practice the reading therapy application 80 min a day 7 days a week for the duration of the study. We calculated the difference in the total time per day recorded by each participant to the application data collected.

RESULTS

All participants used the logbook to record their practice. There was a strong relationship between self-reported logbook practice and application-recorded practice for four of the six participants. Individual differences were noted and explored.

CONCLUSION

These results suggest that some people with aphasia can use logbooks with aphasia-friendly modifications to accurately estimate the amount of practice completed outside of therapy sessions.

Efficacy Studies of Home-Based Occupational Therapy Services Following Stroke: A Scoping Review

The aim of this scoping review was to review and assess recent studies on the efficacy of home-based occupational therapy interventions for adults post-stroke. The number of efficacy studies is limited. The few studies available suggest that occupational therapy delivered in home settings may improve outcomes for stroke patients. There is also limited use of occupation-based assessments, interventions, and outcome measures in studies addressing home-based occupational therapy. Methodologies should be improved to include contexts, caregiver training, and self-efficacy. Further high-quality studies are needed on the efficacy home-based occupational therapy services.

Occupational Therapy Practice: Time From Stroke Onset to Outpatient Upper Limb Rehabilitation

Upper limb stroke rehabilitation has been understudied in usual occupational therapy. The study's purpose was to describe the timing and amount of usual occupational therapy in the stroke population for hospital-based outpatient upper limb rehabilitation. A multi-site study of timing and amount of occupational therapy was calculated for mild and moderate upper limb stroke impairments using the Fugl-Meyer Assessment-Upper Extremity (FMA-UE). Mild stroke participants (n = 58) had a mean of 164.25 days, and the moderate stroke participants (n = 64) had a mean of 106.75 days from the date of stroke onset to first treatment which was significantly different (p = .047). There were no significant differences in the amount of therapy between mild or moderate stroke patients. Mild stroke patients experience a longer delay in receiving outpatient occupational therapy compared with moderate impairments which may be attributed to the subtlety of the impairments that impact participation in daily activities.

Perseverance with home-based upper limb practice after stroke: perspectives of stroke survivors and their significant others

PURPOSE

The aim of this study was to explore factors that influence stroke survivors' ability to persevere with home-based upper limb practice.

METHODS

A qualitative descriptive study embedded within a theoretical framework was conducted. Data were collected through semi-structured focus group, dyadic, and individual interviews. The Theoretical Domains Framework and Capability, Opportunity, Motivation - Behaviour (COM-B) model guided data collection and directed content analysis.

FINDINGS

Participants were 31 adult stroke survivors with upper limb impairment, with 13 significant other/s, who were living at home in Queensland, Australia. Three central tenants aligned with the COM-B and six themes were identified. Stroke survivors' capability to persevere was influenced by being physically able to practice and being able to understand, monitor and modify practice, their opportunity to persevere was influenced by accessing therapy and equipment required for practice and fitting practice into everyday life, and their motivation to persevere was influenced by having goals and experiencing meaningful outcomes and having support and being accountable.

CONCLUSION

Persevering with practice is multifaceted for stroke survivors. All facets need to be addressed in the design of strategies to enhance stroke survivors' ability to persevere and in turn, enhance their potential for continued upper limb recovery.IMPLICATIONS FOR REHABILITATIONMany stroke survivors do not persevere with long-term home-based upper limb practice despite the belief that high dose practice will promote continued recovery.Therapists need to support stroke survivors to setup individualised goal-based home programs that they can complete independently, or with support, within their everyday life.Stroke survivors need coaching to monitor and modify their practice and map their progress, so that they can recognise and experience meaningful recovery.To optimise upper limb recovery after stroke, strategies to enhance stroke survivors' capability, opportunity, and motivation to persevere across the continuum of recovery, need to be co-designed by stroke survivors, therapists and researchers.

Occupational Therapy Practitioners' Implementation of Home Programs for Individuals Post Burn: An Initial Cross-Sectional Survey

Occupational therapy practitioners who care for individuals post burn often prescribe home programs to facilitate continued progress toward occupational therapy goals. This study identified the components included in home programs, how practitioners create and prescribe home programs, and perceived supports and barriers to adherence in this population. Thirty-nine practitioners employed at American Burn Association-verified centers completed an online survey. Results suggest that home programs are primarily designed to address range of motion with less emphasis on function. The highest-ranked barriers to adherence were pain and lack of motivation while the highest-ranked supports were client motivation and family/caregiver support. Practitioners reported using handouts and demonstration frequently for delivery, with infrequent use of technology. Recommendations for incorporating evidence-based strategies into home program creation and administration are included.

Occupational Therapists' Perceptions of Home Program Provision for Stroke Survivors in a Lower- and Middle-Income Country: An Exploratory Study

This qualitative study aimed to understand occupational therapists' experiences of providing home programs to stroke survivors in India. Using an interpretative phenomenological approach, eight practicing occupational therapists were interviewed in depth about home programs for individuals recovering from stroke. Two broad themes with subthemes emerged describing the organizational factors, sociocultural and economic influences on home program provision as well as describing how the occupational therapists addressed the challenges to facilitate home program provision and adherence. The findings can inform occupational therapy practice in lower- and middle-income countries like India and other countries where existing practice recommendations for stroke rehabilitation and core professional tenets may be challenged.

Development of Supportive-Educative Range of Motion Exercise for Post-stroke Patients: A Pilot Study

The purpose of this pilot study was to assess of home care intervention on post-stroke related outcome of range of motion and muscle strength. Sample in 40 participants were divided into the intervention group and control group and included in this study according to the following criteria: post-stroke period of <12 months with hemiparesis, age of ≥18 years, and willingness to participate in the study. The intervention was carried out by nurses by providing education for 2 consecutive days and mentoring for 5 consecutive days, while the control group was given standard care and measured using a grip track, handheld dynamometer, and goniometer examination on June to September 2019. For the intervention group, paired t-test analysis confirmed a significant increase in the mean upper extremity muscle strength before (35.770 ± 46.063) and after (51.073 ± 50.866) the 7 day intervention ( p = .002), whereas the control group showed a value 36.570 ± 33.684 and then 31.400 ± 31.760 p = .256 and lower extremity strength before (3.627 ± 1.585) and after (4.365 ± 1.698) the 7-days intervention ( p = .000), whereas the control group showed a value 3.657 ± 1.671 and then 4.043 ± 1.849 p = .013. Almost all the items assessed from Range of Motion (ROM) in the upper and lower extremities showed a significant increase ( p < .05). Supportive-educative ROM exercise significantly contributed to an increase in the average muscle strength and ROM in post-stroke patients.

Attitudes and use patterns for mobile technology and upper extremity home exercises in stroke survivors in the United States

Introduction

The use of mobile technology (MT) in home-based occupational therapy is expected to continue growing. This study describes daily use patterns for MT and upper extremity (UE) home exercise programs (HEPs) for community-dwelling stroke survivors in the United States.

Method

Cross-sectional survey. Data were analyzed using descriptive statistics and bivariate comparisons.

Results

N = 61 (30 stroke and 31 controls). Individuals with stroke had similar levels of knowledge, skill, and use of MT compared with non-disabled age-matched adults. Stroke participants used MT more frequently for information searching, social media, and reminders compared to control participants. Stroke participants were motivated to improve UE function (93.3%) and reported a need for additional HEP training (56.7%). Perceived facilitators to improve UE use included talking to peers (73.3%), getting more information (73.3%), and talking to a therapist (63.3%).

Conclusions

MT may have multiple potential benefits when integrated into occupational therapy practice including supporting instrumental ADLs, facilitating social connection, and increasing adherence to UE HEPs. Future work should focus on maximizing adherence and providing performance feedback through the use of social media to promote peer support and consistent remote communication using text messaging, phone calls, or video calls to deliver information and reminders on exercises.

Speech-Language Pathologists' Practice Patterns When Designing Home Practice Programs for Persons With Aphasia: A Survey

Purpose We aimed to describe the current practices of speech-language pathologists regarding the creation and implementation of home practice programs for persons with poststroke aphasia. Method Survey participants were American Speech-Language-Hearing Association-certified speech-language pathologists, had 30% of their caseload include persons with aphasia, and had recently created at least two home programs for persons with aphasia. Respondents completed a web-based survey on home program creation, training, technology, and methods for tracking adherence with closed and open-ended questions. Results We analyzed 80 complete surveys. Most of the participants (n = 56) created home programs for greater than 75% of their caseload. Common interventions in home programs addressed functional practice and spoken expression. Participants describe instructional techniques including building skill practice in daily routines and guided practice. Applications of technology and formal mechanisms to monitor adherence were less frequently reported. Various factors were identified as facilitators and barriers to home program creation with environmental support from others and client factors (i.e., motivation, impairments) most evident. Conclusions This study provides insight into speech-language pathologists' home program creation and implementation. Results can be used to consider mechanisms to improve use of and adherence to home programs to further support recovery. Supplemental Material https://doi.org/10.23641/asha.16840204.

Home program practices for supporting and measuring adherence in post-stroke rehabilitation: a scoping review

BACKGROUND

After stroke, individuals face a variety of impairments that impact function. Increasingly, rehabilitation for these impairments has moved into the community and home settings through the use of home programs. However, adherence to these programs is often low, limiting effectiveness.

OBJECTIVE

This scoping review investigated home program implementation and measurement of adherence with persons post-stroke to identify commonly reported practices and determine areas for further research.

METHODS

The electronic databases of PubMed, CINAHL, Scopus, Cochrane Database of Systematic Reviews, and PEDro were searched. Studies focused on post-stroke rehabilitation with an independent home program were selected. Qualitative studies, commentaries, and single-case studies were excluded. Title and abstract screenings were completed by two reviewers with a third for tie-breaking. The full-text review was completed by two reviewers using consensus to resolve any differences. Of the 1,197 articles initially found only 6% (n = 70) met criteria for data extraction. Elements for data extraction included: type of study, area of intervention, description of home program, presence of strategies to support adherence, methods to measure adherence and reported adherence.

RESULTS

Most commonly reported strategies to support home practice were the use of technology, personalization, and written directions. Only 20 studies reported achieving adherence at or greater than 75% and 18 studies did not report adherence outcomes.

CONCLUSIONS

Future investigations that directly compare and identify the most effective strategies to support adherence to home programs for this population are warranted. The implementation of guidelines for reporting adherence to home programs is recommended.

Participants' perceptions of an aphasia-friendly occupational therapy home program

BACKGROUND

Upper extremity impairments post-stroke impact participation in valued occupations. Home programs are used to extend the frequency and amount of upper extremity practice for people post-stroke, but novel ways of increasing adherence to these programs is needed to ensure intense repetitive practice.

OBJECTIVES

The purpose of this process evaluation, was to examine the perceptions of people with aphasia as it relates to modifications to home programs that could influence participation, specifically listening to music and aphasia-friendly adaptations of written materials.

METHODS

Seven people with chronic aphasia completed an upper extremity home program that included the use of music and aphasia-friendly modified materials (ClinicalTrials.gov ID:2016/06/18). After the home program, participants completed semi-structured interviews to understand their perceptions of the program and the modifications.

RESULTS

Five themes were identified including (1) music, (2) activities, (3) instructions, (4) logistics, and (5) progress. Most participants perceived music as helpful, but a few reported it being distracting. Participants found the variety of activities helpful as well as specific characteristics of the instructions such as photographs and images. Some participants expressed elements of the home program to be barriers to practice such as using the activity monitors and logbook, which required assistance at times. Finally, participants noted their own progress resulting from the program and liked that they could adjust the intensity of the program as they progressed.

CONCLUSIONS

Overall participants in this study with aphasia perceived the modifications to home programs including aphasia friendly written instructions and music to facilitate successful home practice.

Intensive therapy after botulinum toxin in adults with spasticity after stroke versus botulinum toxin alone or therapy alone: a pilot, feasibility randomized trial

Background

Botulinum toxin-A is provided for adults with post-stroke spasticity. Following injection, there is a variation in the rehabilitation therapy type and amount provided. The purpose of this study was to determine if it is feasible to add intensive therapy to botulinum toxin-A injections for adults with spasticity and whether it is likely to be beneficial.

Methods

Randomized trial with concealed allocation, assessor blinding, and intention to treat analysis. Thirty-seven adults (n = 3 incomplete or lost follow-up) with spasticity in the upper or lower limb were allocated to one of three groups: experimental group received a single dose of botulinum toxin-A plus an intensive therapy for 8 weeks, control group 1 received a single dose of botulinum toxin-A only, and control group 2 received intensive therapy only for 8 weeks. Feasibility was measured by examining recruitment, intervention (adherence, acceptability, safety), and measurement. Benefit was measured as goal achievement (Goal Attainment Scale), upper limb activity (Box and Block Test), walking (6-min walk test) and spasticity (Tardieu scale), at baseline (week 0), immediately after (week 8), and at three months (week 12).

Results

Overall recruitment fraction for the trial was 37% (eligibility fraction 39%, enrolment fraction 95%). The 26 participants allocated to receive intensive rehabilitation attended 97% of clinic-based sessions (mean 11 ± 2 h) and an averaged 58% (mean 52 ± 32 h) of prescribed 90 h of independent practice. There were no study-related adverse events reported. Although participants in all groups increased their goal attainment, there were no between-group differences for this or other outcomes at week 8 or 12.

Conclusion

Providing intensive therapy following botulinum toxin-A is feasible for adults with neurological spasticity. The study methods are appropriate for a future trial. A future trial would require 134 participants to detect a between-group difference of 7 points on Goal Attainment Scale t-scores with an alpha of 0.05 and power of 80%.

Trial registration

ACTRN12612000091808. Registered 18/01/2012, retrospective