Rehabilitation in the home versus the hospital: the importance of context

A wearable system for visual cueing gait rehabilitation in Parkinson's disease: a randomized non-inferiority trial

BACKGROUND

Gait disturbances represent one of the most disabling features of Parkinson's disease (PD).

AIM

The aim of this study was to evaluate the non-inferiority of a new wearable visual cueing system (Q-Walk) for gait rehabilitation in PD subjects, compared to traditional visual cues (stripes on the floor).

DESIGN

Open-label, monocentric, randomized controlled non-inferiority trial.

SETTING

Outpatients.

POPULATION

Patients affected by idiopathic PD without cognitive impairment, Hoehn and Yahr stage II-IV, Unified Parkinson's Disease Rating Scale motor section III ≥2, stable drug usage since at least 3 weeks.

METHODS

At the enrollment (T0), all subjects underwent a clinical/functional evaluation and the instrumental gait and postural analysis; then they were randomly assigned to the Study Group (SG) or Control Group (CG). Rehabilitation program consisted in 10 consecutive individual sessions (5 sessions/week for 2 consecutive weeks). Each session included 60 minutes of conventional physiotherapy plus 30 minutes of gait training by Q-Walk (SG) or by traditional visual cues (CG). Follow-up visits were scheduled at the end of the treatment (T1) and after 3 months (T2).

RESULTS

Fifty-two subjects were enrolled in the study, 26 in each group. The within-groups analysis showed a significant improvement in clinical scales and instrumental data at T1 and at T2, compared to baseline, in both groups. According to the between-group analysis, Q-Walk cueing system was not-inferior to the traditional cues for gait rehabilitation. The satisfaction questionnaire revealed that most subjects described the Q-Walk cueing system as simple, motivating and easily usable, possibly suitable for home use.

CONCLUSIONS

Data showed that motor rehabilitation of PD subjects performed by means of the new wearable Q-Walk cueing system was feasible and as effective as traditional cues in improving gait parameters and balance.

CLINICAL REHABILITATION IMPACT

Wearable devices can act as an additional rehabilitation strategy for long-term and continuous care, allowing patients to train intensively and extensively in household settings, favoring a tailor-made and personalized approach as well as remote monitoring.

Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis

BACKGROUND

Worldwide there is an increasing demand for Hospital at Home as an alternative to hospital admission. Although there is a growing evidence base on the effectiveness and cost-effectiveness of Hospital at Home, health service managers, health professionals and policy makers require evidence on how to implement and sustain these services on a wider scale.

OBJECTIVES

(1) To identify, appraise and synthesise qualitative research evidence on the factors that influence the implementation of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home, from the perspective of multiple stakeholders, including policy makers, health service managers, health professionals, patients and patients' caregivers. (2) To explore how our synthesis findings relate to, and help to explain, the findings of the Cochrane intervention reviews of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home services.

SEARCH METHODS

We searched MEDLINE, CINAHL, Global Index Medicus and Scopus until 17 November 2022. We also applied reference checking and citation searching to identify additional studies. We searched for studies in any language.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with qualitative data collection and analysis methods examining the implementation of new or existing Hospital at Home services from the perspective of different stakeholders.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the studies, extracted study characteristics and intervention components, assessed the methodological limitations using the Critical Appraisal Skills Checklist (CASP) and assessed the confidence in the findings using GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research). We applied thematic synthesis to synthesise the data across studies and identify factors that may influence the implementation of Hospital at Home.

MAIN RESULTS

From 7535 records identified from database searches and one identified from citation tracking, we included 52 qualitative studies exploring the implementation of Hospital at Home services (31 Early Discharge, 16 Admission Avoidance, 5 combined services), across 13 countries and from the perspectives of 662 service-level staff (clinicians, managers), eight systems-level staff (commissioners, insurers), 900 patients and 417 caregivers. Overall, we judged 40 studies as having minor methodological concerns and we judged 12 studies as having major concerns. Main concerns included data collection methods (e.g. not reporting a topic guide), data analysis methods (e.g. insufficient data to support findings) and not reporting ethical approval. Following synthesis, we identified 12 findings graded as high (n = 10) and moderate (n = 2) confidence and classified them into four themes: (1) development of stakeholder relationships and systems prior to implementation, (2) processes, resources and skills required for safe and effective implementation, (3) acceptability and caregiver impacts, and (4) sustainability of services.

AUTHORS' CONCLUSIONS

Implementing Admission Avoidance and Early Discharge Hospital at Home services requires early development of policies, stakeholder engagement, efficient admission processes, effective communication and a skilled workforce to safely and effectively implement person-centred Hospital at Home, achieve acceptance by staff who refer patients to these services and ensure sustainability. Future research should focus on lower-income country and rural settings, and the perspectives of systems-level stakeholders, and explore the potential negative impact on caregivers, especially for Admission Avoidance Hospital at Home, as this service may become increasingly utilised to manage rising visits to emergency departments.

Factors that influence the provision of home-based rehabilitation services for people needing rehabilitation: a qualitative evidence synthesis

BACKGROUND

To increase people's access to rehabilitation services, particularly in the context of the COVID-19 pandemic, we need to explore how the delivery of these services can be adapted. This includes the use of home-based rehabilitation and telerehabilitation. Home-based rehabilitation services may become frequently used options in the recovery process of patients, not only as a solution to accessibility barriers, but as a complement to the usual in-person inpatient rehabilitation provision. Telerehabilitation is also becoming more viable as the usability and availability of communication technologies improve.

OBJECTIVES

To identify factors that influence the organisation and delivery of in-person home-based rehabilitation and home-based telerehabilitation for people needing rehabilitation.

SEARCH METHODS

We searched PubMed, Global Health, the VHL Regional Portal, Epistemonikos, Health Systems Evidence, and EBM Reviews as well as preprints, regional repositories, and rehabilitation organisations websites for eligible studies, from database inception to search date in June 2022.  SELECTION CRITERIA: We included studies that used qualitative methods for data collection and analysis; and that explored patients, caregivers, healthcare providers and other stakeholders' experiences, perceptions and behaviours about the provision of in-person home-based rehabilitation and home-based telerehabilitation services responding to patients' needs in different phases of their health conditions.   DATA COLLECTION AND ANALYSIS: We used a purposive sampling approach and applied maximum variation sampling in a four-step sampling frame. We conducted a framework thematic analysis using the CFIR (Consolidated Framework for Implementation Research) framework as our starting point. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach.  MAIN RESULTS: We included 223 studies in the review and sampled 53 of these for our analysis. Forty-five studies were conducted in high-income countries, and eight in low-and middle-income countries. Twenty studies addressed in-person home-based rehabilitation, 28 studies addressed home-based telerehabilitation services, and five studies addressed both modes of delivery. The studies mainly explored the perspectives of healthcare providers, patients with a range of different health conditions, and their informal caregivers and family members.  Based on our GRADE-CERQual assessments, we had high confidence in eight of the findings, and moderate confidence in five, indicating that it is highly likely or likely respectively that these findings are a reasonable representation of the phenomenon of interest. There were two findings with low confidence. High and moderate confidence findings Home-based rehabilitation services delivered in-person or through telerehabilitation  Patients experience home-based services as convenient and less disruptive of their everyday activities. Patients and providers also suggest that these services can encourage patients' self-management and can make them feel empowered about the rehabilitation process. But patients, family members, and providers describe privacy and confidentiality issues when services are provided at home. These include the increased privacy of being able to exercise at home but also the loss of privacy when one's home life is visible to others.  Patients and providers also describe other factors that can affect the success of home-based rehabilitation services. These include support from providers and family members, good communication with providers, the requirements made of patients and their surroundings, and the transition from hospital to home-based services. Telerehabilitation specifically Patients, family members and providers see telerehabilitation as an opportunity to make services more available. But providers point to practical problems when assessing whether patients are performing their exercises correctly. Providers and patients also describe interruptions from family members.  In addition, providers complain of a lack of equipment, infrastructure and maintenance and patients refer to usability issues and frustration with digital technology. Providers have different opinions about whether telerehabilitation is cost-efficient for them. But many patients see telerehabilitation as affordable and cost-saving if the equipment and infrastructure have been provided. Patients and providers suggest that telerehabilitation can change the nature of their relationship. For instance, some patients describe how telerehabilitation leads to easier and more relaxed communication. Other patients describe feeling abandoned when receiving telerehabilitation services.  Patients, family members and providers call for easy-to-use technologies and more training and support. They also suggest that at least some in-person sessions with the provider are necessary. They feel that telerehabilitation services alone can make it difficult to make meaningful connections. They also explain that some services need the provider's hands. Providers highlight the importance of personalising the services to each person's needs and circumstances.

AUTHORS' CONCLUSIONS

This synthesis identified several factors that can influence the successful implementation of in-person home-based rehabilitation and telerehabilitation services. These included factors that facilitate implementation, but also factors that can challenge this process. Healthcare providers, program planners and policymakers might benefit from considering these factors when designing and implementing programmes.

Therapists acting as data collectors in a post stroke research project - a door to development

METHODS

Participants in the present study were eight clinically experienced occupational therapists and physiotherapists who collected data in an observational longitudinal study of the rehabilitation process after stroke. Semi-structured interviews were conducted, and transcripts of the interviews were analyzed using content analysis. The transcripts revealed the informants' perspectives and their experiences of follow-ups in the patient's home.

RESULTS

There was one main category, a door to development, and three subcategories: the entrance, discovery in place, and the exit. All informants expressed that they had gained new knowledge of the situation of people who have had a stroke and that taking part in research uncovered a wider perspective of the patients' situations and the importance of follow-ups in general.

CONCLUSION

New insights into the patients' situation with clinical implications for interprofessional care can be gained by collecting data in a research project that is related to, but different from, everyday clinical practice. Such an assignment can be experienced as professionally rewarding, and we propose that offering such a role change/transition may open the door to development for rehabilitation team members.

The challenges and gains of delivering a home-exercise intervention: a qualitative study of physiotherapists and physiotherapy assistants

OBJECTIVES

The paper presents insights from the Community based Rehabilitation after Knee Arthroplasty (CORKA) trial. We aimed to explore physiotherapists and physiotherapy assistants' experiences of delivering a home-base exercise intervention following knee replacement surgery. We were particularly interested in the feasibility, potential benefits and barriers of a community-based exercise programme from the perspective of physiotherapists and physiotherapy assistants and to understand any constraints or training needs that arose.  DESIGN: Qualitative thematic analysis of semi-structured interviews.  SETTING: The Community based Rehabilitation after Knee Arthroplasty (CORKA) trial.

PARTICIPANTS

Five physiotherapists and six physiotherapy assistants with a range of clinical experience.

METHODS

Interviews were digitally recorded and transcribed verbatim. We used the stages of reflexive thematic analysis suggested by Braun and Clarke. One researcher conducted the interviewers whilst three researchers with experience in qualitative research methods contributed to the coding and analysis of data.

RESULTS

We developed seven themes that help to understand the benefits and challenges of delivering treatment interventions in a person's home: seeing the person in their own world; thinking outside the cubicle;developing people skills; enjoying the above and beyond; treading a fine line between patient and friend; feeling outside my comfort zone; needing a support network.

CONCLUSIONS

Treating people in their own homes facilitates a holistic approach. Our findings highlight areas for clinical education: (1) how do we help clinicians to tread the fine line between friend and professional (2) how do we balance the need to provide support and structure with the freedom to work creatively and independently?

Activities in Daily Living: The development of a new client-centred ADL intervention for persons with stroke

BACKGROUND

An intervention that contains several interacting components can be defined as a complex intervention. This intervention was developed in accordance with the Medical Research Council (MRC) guidance for complex interventions.

AIM

To describe the development, theoretical framework, and content of a client-centred activities in daily living intervention (CADL) for people with stroke.

MATERIAL AND METHODS

Different steps were used; identifying the evidence base, identifying/developing theory and the modelling process and outcomes in the development of the CADL. The remodelling of the process and content of the intervention that emerged are defined.

RESULTS

Findings from a series of qualitative studies of people with stroke demonstrated the need to develop an ADL intervention based on the clients' lived experiences. The theoretical framework is based on empirical research, theories about human occupation and client-centredness. The CADL is applying an occupational and phenomenological perspective in order to enable agency in daily activities and participation in everyday life among persons with stroke.

CONCLUSIONS AND SIGNIFICANCE

The article can be used as an example of how to present the development and theoretical framework of a new complex intervention in occupational therapy.

Profile of practitioners, and factors influencing home care physiotherapy model of practice in Nigeria

The present study investigated factors that influenced home care physiotherapy (HCP) services and profile of the practitioners in Nigeria. It also investigated if the service was registered with the Regulatory Agency. Three hundred and thirty conveniently sampled physiotherapists in Nigeria participated in the cross-sectional survey. A newly developed, nine-part, content-validated questionnaire was used to obtain information about the demographics, sources of referral, case types, frequency of treatment, costing, benefits, and challenges of the HCP, job satisfaction, and registration status. Data were analyzed using descriptive statistics. All the respondents (100%) were involved in HCP irrespective of their professional profile. The mean duration of practice experience was 9.09 ± 7.34 years. Stroke (41.8%) was the most prevalent case treated. Poor working environment (M = 4.16, R = 1-5), transportation cost (M = 4.16, R = 1-5) and intrusion by impostors (M = 3.66, R = 1-5), were some of the factors that had impact on the HCP services. A preponderance of HCP services was not registered with the Regulatory Agency in Nigeria.

Wearable technology in stroke rehabilitation: towards improved diagnosis and treatment of upper-limb motor impairment

Stroke is one of the main causes of long-term disability worldwide, placing a large burden on individuals and society. Rehabilitation after stroke consists of an iterative process involving assessments and specialized training, aspects often constrained by limited resources of healthcare centers. Wearable technology has the potential to objectively assess and monitor patients inside and outside clinical environments, enabling a more detailed evaluation of the impairment and allowing the individualization of rehabilitation therapies. The present review aims to provide an overview of wearable sensors used in stroke rehabilitation research, with a particular focus on the upper extremity. We summarize results obtained by current research using a variety of wearable sensors and use them to critically discuss challenges and opportunities in the ongoing effort towards reliable and accessible tools for stroke rehabilitation. Finally, suggestions concerning data acquisition and processing to guide future studies performed by clinicians and engineers alike are provided.

Factors influencing the implementation of Home-Based Stroke Rehabilitation: Professionals' perspective

Background

Stroke has a major impact on survivors and their social environment. Care delivery is advocated to become more client-centered and home-based because of their positive impact on client outcomes. The objective of this study was to explore professionals’ perspectives on the provision of Home-Based Stroke Rehabilitation (HBSR) in the Netherlands and on the barriers and facilitators influencing the implementation of HBSR in daily practice.

Methods

Semi-structured focus groups were conducted to explore the perspectives of health and social care professionals involved in stroke rehabilitation. Directed content analysis was performed to analyze the transcripts of recorded conversations.

Results

Fourteen professionals participated in focus groups (n = 12) or, if unable to attend, an interview (n = 2). Participants varied in professional backgrounds and roles in treating Dutch clients post stroke. Barriers and facilitators influencing the implementation of HBSR in daily practice were identified in relation to: the innovation, the user, the organization and the socio-political context. Participants reported that HBSR can be efficient and effective to most clients because it facilitates client- and caregiver-centered rehabilitation within the clients’ own environment. However, barriers in implementing HBSR were perceived in a lack of (structured) inter-professional collaboration and the transparency of expertise of primary care professionals. Also, the current financial structures for HBSR in the Netherlands are viewed as inappropriate.

Discussion

In line with previous studies, we found that HBSR is recognized by professionals as a promising alternative to institution-based rehabilitation for clients with sufficient capabilities (e.g. their own health and informal support).

Conclusion

Multiple factors influencing the implementation of HBSR were identified. Our study suggests that, in order to implement HBSR in daily practice, region specific implementation strategies need to be developed. We recommend developing strategies concerning: organized and coordinated inter-professional collaboration, transparency of the expertise of primary care professionals, and the financial structures of HBSR.

Effects of (music-based) rhythmic auditory cueing training on gait and posture post-stroke: A systematic review & dose-response meta-analysis

Gait dysfunctions are common post-stroke. Rhythmic auditory cueing has been widely used in gait rehabilitation for movement disorders. However, a consensus regarding its influence on gait and postural recovery post-stroke is still warranted. A systematic review and meta-analysis was performed to analyze the effects of auditory cueing on gait and postural stability post-stroke. Nine academic databases were searched according to PRISMA guidelines. The eligibility criteria for the studies were a) studies were randomized controlled trials or controlled clinical trials published in English, German, Hindi, Punjabi or Korean languages b) studies evaluated the effects of auditory cueing on spatiotemporal gait and/or postural stability parameters post-stroke c) studies scored ≥4 points on the PEDro scale. Out of 1,471 records, 38 studies involving 968 patients were included in this present review. The review and meta-analyses revealed beneficial effects of training with auditory cueing on gait and postural stability. A training dosage of 20–45 minutes session, for 3–5 times a week enhanced gait performance, dynamic postural stability i.e. velocity (Hedge’s g: 0.73), stride length (0.58), cadence (0.75) and timed-up and go test (−0.76). This review strongly recommends the incorporation of rhythmic auditory cueing based training in gait and postural rehabilitation, post-stroke.

Home setting after stroke, facilitators and barriers: A systematic literature review

This paper seeks to improve the understanding of the interaction between patients with stroke and the physical environment in their home settings. Stroke care is increasingly performed in the patient's home. Therefore, a systematic review was conducted to identify the existing knowledge about facilitators and barriers in the physical environment of home settings for the stroke rehabilitation process. Based upon Arksey and O'Malley's framework, a Boolean search strategy was performed in the databases; CINAHL, Medline, Web of Science and Scopus. Fifteen articles were retained from the literature search conducted between August and November 2016, and two researchers independently assessed their quality based on the Swedish Council on Health Technology Assessment guidelines. The results suggest that despite the healthcare system's ongoing shift towards home-based rehabilitation, the role played by the physical environment of home settings is still considered a side finding. Moreover, the research appears to focus mainly on how this environment supports mobility and activities of daily living, whereas information regarding the psychosocial and emotional processes that mediate the interaction between stroke survivors and their home setting are missing. A lack of information was also found with regard to the influence of different geographic locations on the stroke rehabilitation process. Future investigations are therefore needed to advance the understanding of the role played by the physical environment of home settings in supporting stroke recovery.

Consulting Service Users: The Stroke Association Home Therapy Project

In 1999, the Stroke Association set up a project to promote home-based occupational therapy for patients who had had a stroke and been discharged home from hospital. As part of the service evaluation, focus groups for service users and carers were set up in two of the sites to consult users about the changes in their quality of life during the period of the home therapy. A total of 11 service users and 9 carers attended the groups, representing 30% of the service users and 27% of the carers involved in the project. The group discussion was taped and transcribed and then analysed using a framework approach.

The group members described their personal experiences of recovery from and limitations after the stroke and reported improvements in life issues during the period of their home therapy. The content and organisation of the service and the relationships with project staff were felt to influence the effectiveness of the occupational therapy. Other issues that affected the perceived outcome for the service users included individual choice, age, stroke consequences, other rehabilitation and community services and social limitations. This consultation process allowed the service users to describe the strengths and weaknesses of the service and provided valuable feedback that could be used to design the content and application of future home therapy services.

Usual Clinical Practice for Early Supported Discharge after Stroke with Continued Rehabilitation at Home: An Observational Comparative Study

INTRODUCTION

Based on randomised controlled trials, evidence exists that early supported discharge (ESD) from the hospital with continued rehabilitation at home has beneficial effects after stroke; however, the effects of ESD service in regular clinical practice have not been investigated. The purpose of the current study was to compare ESD service with conventional rehabilitation in terms of patient outcomes, caregiver burden at 3 and 12 months and the use and costs of healthcare during the first year after stroke.

MATERIAL AND METHODS

This study was a subgroup analysis of a longitudinal observational study of patients who received care in the stroke unit at Karolinska University Hospital in Sweden. Patients who met the inclusion criteria for ESD in previous experimental studies were included. The patients were referred to available rehabilitation services at discharge, and comparisons between those who received ESD service (the ESD group, n = 40) and those who received conventional rehabilitation (the NoESD group, n = 110) were performed with regard to independence in activities of daily living (ADL), the frequency of social activities, life satisfaction, and caregiver burden and the use and costs of healthcare during the first year after stroke.

RESULTS

At 3 and 12 months, no differences were observed with regard to patient outcomes; however, ESD was associated with a lower caregiver burden (p = 0.01) at 12 months. The initial length of stay (LOS) at the hospital was 8 days for the ESD group and 15 days for the NoESD group (p = 0.02). The median number of outpatient rehabilitation contacts was 20.5 for the ESD group (81% constituting ESD service) and 3 for the NoESD group (p<0.001). There was no difference between the groups with regard to overall healthcare costs.

CONCLUSIONS

ESD service in usual clinical practice renders similar health benefits as conventional rehabilitation but a different pattern of resource use and with released capacity in acute stroke care.

Home-Based versus Hospital-Based Rehabilitation Program after Total Knee Replacement

OBJECTIVES

To compare home-based rehabilitation with the standard hospital rehabilitation in terms of improving knee joint mobility and recovery of muscle strength and function in patients after a total knee replacement.

MATERIALS AND METHODS

A non-randomised controlled trial was conducted. Seventy-eight patients with a prosthetic knee were included in the study and allocated to either a home-based or hospital-based rehabilitation programme. Treatment included various exercises to restore strength and joint mobility and to improve patients' functional capacity. The primary outcome of the trial was the treatment effectiveness measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

RESULTS

The groups did not significantly differ in the leg side (right/left) or clinical characteristics (P > 0.05). After the intervention, both groups showed significant improvements (P < 0.001) from the baseline values in the level of pain (visual analogue scale), the range of flexion-extension motion and muscle strength, disability (Barthel and WOMAC indices), balance, and walking.

CONCLUSIONS

This study reveals that the rehabilitation treatments offered either at home or in hospital settings are equally effective.

Caregiver-Mediated Intervention Can Improve Physical Functional Recovery of Patients With Chronic Stroke

Background and Purpose. Patients with chronic stroke may benefit from continuing rehabilitation training after hospital discharge. This study examined whether caregiver-mediated, home-based intervention (CHI) could improve physical functioning and social participation in these patients. Methods. A single-blind, randomized, controlled 12-week trial conducted with 51 patients from 3 hospitals in Taiwan who had chronic stroke (>6 months; Brunnstrom recovery stages III-V). Patients and their caregivers in the intervention arm (n = 25) were given weekly personalized CHI trainings designed by a physical therapist. Patients in the control arm (n = 26) received visits from the therapist without intervention. All were evaluated for physical recovery through the Stroke Impact Scale, Berg Balance Scale, 10-Meter Walk Test, 6-Minute Walk Test, and Barthel Index at baseline and endpoint. Caregivers were evaluated with the Caregiver Burden Scale. Results were analyzed through Mann-Whitney U test. Results. CHI significantly improved scores of the Stroke Impact Scale: strength (control vs intervention, respectively: 1.4 vs 15.5; P = .002), mobility (–0.5 vs 13.7; P < .001), composite physical (–0.7 vs 11.2; P < .001), and general recovery domain (0.2 vs 17.4; P < .001). CHI also significantly improved free-walking velocity (–1.4 vs 7.5 cm/s; P = .006), 6-minute walk distance (–10.5 vs 15.8 m; P = .003), Berg Balance Scale score (–0.8 vs 4.5; P = .006), and Barthel Index score (0.6 vs 7.2; P = .008). CHI did not significantly increase caregiver burden at endpoint. Conclusion. CHI can improve physical functional recovery and, possibly, social participation in patients with chronic stroke.

Ambulant cognitive assessment using a smartphone

The focus of neuropsychology is to understand the relationship between assessment results and everyday cognitive abilities and disabilities. However, the generalizability of traditional neuropsychological tests to real-life behaviors, the ecological validity, is compromised by the test environment, among other things. Neuropsychological tests are often completed in a laboratory setting that is typically quiet with few distractions. This is very unlike most everyday environments. The aim of the present study was to investigate the possibility of using a smartphone in standardized cognitive assessment. A short-term memory task was obtained from young adults in either an everyday-life environment or a controlled test setting at four time points during a day. Results show no significant differences between the task performances in both conditions. There was no indication that fatigue, tension, or environmental noise had an effect on task performance. High correlations between subsequent time points were found in the everyday-life environment, suggesting a high test-retest reliability and commitment of the participants. The present study demonstrates that smartphones can be used to assess cognitive functions outside a laboratory setting.

The power of home rehabilitation: a single case study

This single case study reports on an 81-year-old woman who underwent a rehabilitation programme initially in a hospital inpatient setting, then in a home setting. There was a clinically significant improvement in functional outcomes following the home-based rehabilitation, but not following the inpatient rehabilitation programme. This case study illustrates that empowerment of the patient may sometimes be greater in the home environment, possibly due to different roles taken by the patient and therapist in the home compared with roles taken in a hospital environment. This patient reported feelings of being in more control at home, with greater capacity to set their own goals, and improved feelings of motivation with this increased level of engagement. This increased empowerment can lead to more effective outcomes for patients undergoing rehabilitation in the home, and must be considered as an ideal rehabilitation environment for some patients.

Patient-centered integrated motor imagery delivered in the home with telerehabilitation to improve walking after stroke

BACKGROUND AND PURPOSE

This case report describes the clinical reasoning process used to examine a person after stroke and intervene with a novel integrated motor imagery treatment designed for the rehabilitation of walking and delivered in the home through telerehabilitation. The integrated motor imagery treatment consisted of patient-centered goal setting and physical practice combined with motor and motivational imagery.

CASE DESCRIPTION

The patient was a 38-year-old woman who had had a diffuse left subarachnoid hemorrhagic stroke 10 years earlier. She lived independently in an assisted living complex and carried a straight cane during long walks or in unfamiliar environments. Examination revealed a slow gait speed, reduced walking endurance, and decreased balance confidence. Although she was in the chronic phase, patient-centered integrated motor imagery was predicted to improve her community mobility. Treatment sessions of 45 to 60 minutes were held 3 times per week for 4 weeks. The practiced tasks included transitioning from sitting to standing, obstacle clearance, and navigation in interior and exterior environments; these tasks were first executed and then imagined at ratios of 1:5. Task execution allowed the creation of a scene based on movement observation. Imagery scenarios were customized to address the patient's goals and observed movement problems. Motivational elements of arousal, problem solving, and reward were embedded in the imagery scenarios. Half of the sessions were provided on site, and the remaining sessions were delivered remotely. Seven sessions were delivered by the clinician in the home, and 5 sessions were delivered using telerehabilitation.

OUTCOMES

Improvements in motor imagery ability, gait parameters, and balance were observed after training. Most gains were retained at the 3-month follow-up. Compared with on-site delivery, the telerehabilitation sessions resulted in less therapist travel time and cost, as well as shorter therapy sessions.

DISCUSSION

The delivery of integrated motor imagery practice for walking recovery was feasible both on site and remotely.

A new era in speech-language pathology practice: innovation and diversification

A new era in speech-language pathology practice is pending, and one that impels us to innovate and diversify as we move forward into the 21(st) century. The impetus for this transformation will include the increasing cost and demand for healthcare services as the population ages, changes in Australian society, rapid developments in technology, and major advances in neuroscience. New models of service delivery will need to be considered in line with evidence-based treatment protocols, the concept of a continuum of care for chronic disorders, and the need to engage clients in self-management. Innovations in technology will provide the means by which these new models of service delivery might be achieved. The exponential increase in electronic therapy resources and devices will transform the therapeutic process and provide clinicians with engaging and flexible therapy options. Clinicians will be challenged by this paradigm shift in service delivery, and their long-held perceptions of their clients' capacity to respond to these changes. Other challenges will include the preparation of future speech-language pathologists, reimbursement for services, availability of appropriate technology, and widespread connectivity. The future of the profession is an exciting one as we move forward into an era of unprecedented change.

Impact of environmental factors in home rehabilitation--a qualitative study from the perspective of older persons using the International Classification of Functioning, Disability and Health to describe facilitators and barriers

PURPOSE

The aim of this study was to explore older people's experience of environmental factors that impact on their activity and participation in home rehabilitation.

METHOD

Older people aged between 68 and 93 years and receiving home rehabilitation were interviewed. A qualitative content analysis was performed on the interview text using the predetermined structure of the International Classification of Functioning, Disability and Health (ICF) environmental domain. The text was linked to the closest ICF category.

RESULTS

The results identified environmental facilitators and barriers that influenced activity and participation among older people receiving home rehabilitation. Approaches that provided a facilitative environment were access to assistive products and technologies, alterations to the physical environment, social support and relationships, and adjusted health and social care services.

CONCLUSIONS

A qualitative study using ICF-listed environmental factors contributed a holistic view of facilitators and barriers in home rehabilitation for older people. Awareness of the importance of the impact of the social environment on activities and participation could improve home rehabilitation services for older people. The study represents an important step towards a holistic approach using the ICF, which aims to enable all health care professionals to describe, plan and evaluate rehabilitation services together with older people across the health and social care sectors.

Telepractice Supported Delivery of LSVT®LOUD

This article outlines the essential features and underlying principles of Lee Silverman Voice Treatment (LSVT®LOUD) and explores the delivery of this treatment via telepractice. A detailed summary of the core features of LSVT®LOUD and the principles underpinning this treatment are presented. Current evidence to support the feasibility and validity of synchronous and asynchronous delivery of LSVT®LOUD to people with Parkinson disease (PD) is reviewed. Technology specifications, cost-benefit analyses, and patient satisfaction are discussed. The challenges involved in delivery of LSVT®LOUD via telepractice, such as inconsistent audio and video quality during videoconferencing, accurate measurement of vocal parameters, technical skill level of the clinician, and patient candidacy, are highlighted. LSVT®LOUD can be effectively and reliably delivered via telepractice. Improvements in telecommunications are required to overcome some of the technology challenges encountered in this mode of delivery. Positive benefits of online treatment in relation to savings in time and money and reduced carer burden are emerging. Patient satisfaction with telepractice in the management of the speech disorder associated with PD is high. The uptake of LSVT®LOUD into telepractice is likely to steadily increase with advances in mobile technologies and web-based applications designed to deliver this treatment.

Telepractice in Speech-Language Pathology: The Evidence, the Challenges, and the Future

This article provides a review of the evidence base for telepractice in speech-language pathology, the challenges that exist, and the future directions for this field. It describes the benefits of telepractice for clients and their families and outlines the evidence currently available to support the validity and reliability of this mode of delivery in the management of adult neurogenic communication disorders (aphasia, dysarthria, apraxia of speech); voice disorders; stuttering; dysphagia; laryngectomy; and articulation, language, and literacy disorders in children. The challenges facing telepractice in speech-language pathology and the future directions for this field are discussed.

Telepractice is an emerging area of service delivery in speech-language pathology that is likely to become an integral part of mainstream practice in the future. In order to achieve this, it is imperative that the profession accelerates its program of research and clinical endeavor in this area.

Enhancing quality of life through telerehabilitation

Telerehabilitation is an emerging method of delivering rehabilitation services that uses technology to serve clients, clinicians, and systems by minimizing the barriers of distance, time, and cost. The driving force for telerehabilitation has been as an alternative to face-to-face rehabilitation approaches to reduce costs, increase geographic accessibility, or act as a mechanism to extend limited resources. A rationale for telerehabilitation is the potential to enhance outcomes beyond what may result from face-to-face interventions by enabling naturalistic, in vivo interventions. There is considerable support for the value of interventions delivered in the natural environment, ranging from addressing efficacy concerns by addressing problems of generalization, to increasing patient participation, including environmental context in rehabilitation, and increasing patient satisfaction. Further clinical and research exploration should explore telerehabilitation as a tool for the delivery of rehabilitation services in vivo.

Characteristics of physiotherapy sessions from the patient's and therapist's perspective

PURPOSE

The purpose was to explore, describe and compare the characteristics of physiotherapy sessions with patients after stroke from two perspectives: the patients' and the physiotherapists', in relation to observed behaviour.

METHODS

A qualitative, descriptive, comparative approach was used. Nine patients and 10 physiotherapists participated. Data from observations and semi-structured interviews were used.

RESULTS

Six themes were identified: setting and attaining goals, focusing on motor activity, finding the optimal training strategy, facilitating active patient involvement, making use of environmental factors and adjusting to the structural reorganization of the rehabilitation services. The physiotherapists and the patients made similar descriptions in some of the themes but differed in some. The physiotherapists expressed what they perceived to be their lack of scientific knowledge, while the patients trusted their physiotherapists' competence. The physiotherapists wanted to take the patients' personal experiences into account in the sessions, which was not obvious to the patients.

CONCLUSION

Differences in physiotherapists' and patients' descriptions of characteristics of physiotherapy sessions have to be taken into consideration in the rehabilitation of stroke patients. In order to empower the patient to take a more active part in the rehabilitation process, there is a need to explore how to incorporate the patients' personal experiences and knowledge into the rehabilitation process.

Evaluation of a 5-level Functional Independence Measure in a longitudinal study of elderly stroke survivors

PURPOSE

The aim of the present study was to evaluate a modified 5-level Functional Independence Measure (FIM), by using the assessments from a longitudinal study of elderly stroke survivors.

METHOD

One hundred and seventy-three patients were followed longitudinally. Firstly, the 7-level FIM was used at 0-3 days, 3 weeks, and 3 months and then after 1 year following acute stroke. The data, in total 8996 assessments, were presented on the item level. Secondly, the data were recoded with the help of a modified 5-level FIM according to the cut-off levels suggested in a previous study of the same target group. Two registered occupational therapists did the assessments in the patients' natural environment, i.e., in their own homes or in different kinds of assisted living. The data were obtained both by interviews and with the help observations, when the occupational therapist asked the patients to perform specific activities.

RESULTS

The assessments on all four occasions were found to polarise when using the 7-level FIM, and the intermediate levels of assistance were more seldom used. After the assessment data were recoded with the modified 5-level FIM, it was shown that it was easier to follow the process of activity by using an instrument with fewer levels. A modified 5-level FIM had enough levels to ensure sensitivity and was easier to handle when evaluating performance of daily activities in a large population study.

CONCLUSIONS

A modified 5-level FIM can be useful in large population studies and most likely increase reliability without losing in sensitivity.

A comparison of a hospital-based and two home-based rehabilitation programmes

PURPOSE

This paper compares the service models of three different types of rehabilitation programmes provided in Victoria, Australia: One hospital-based and two types of rehabilitation in the home (RITH).

METHOD

Nine focus group interviews were conducted with multidisciplinary staff working in rehabilitation teams in one hospital-based and eight RITH programmes. Additional data were collected for 164 clients and 75 carers from eight of these programmes at admission, discharge and three months post discharge. Interviews were conducted with 32 clients and 14 carers.

RESULTS

The criteria for admission and model of rehabilitation adopted in the three programmes were similar. There were differences in programme aims, characteristics of the clients admitted and the type and level of therapy clients received, both between hospital and home-based programmes and between the three programmes. In general, staff and clients saw the home as providing a relevant context that enabled individualized, goal directed therapy for medically stable rehabilitation clients. The hospital offered an opportunity to socialize with others and specialized equipment.

CONCLUSIONS

Results of this study suggest clients and carers require a mix of hospital and home-based rehabilitation that is able to respond to their needs and preferences at each phase of the rehabilitation continuum.

A review of the early discharge experiences of stroke survivors and their carers

AIMS AND OBJECTIVES

Understanding the experiences of stroke patients and their carers during the early days following discharge from hospital is an important aspect of providing appropriate care during this crucial time.

BACKGROUND

Due to the diverse changes that can result from a stroke, adjustment to returning home may raise many issues for those involved. A review of research was undertaken with the aim of identifying what is already known about experiences at this time.

DESIGN

Systematic review.

METHOD

Search of electronic databases.

RESULTS

The review revealed that recognition of the impact of stroke on patients and carers is improving, with many studies focussing on the longer-term aspects of stroke recovery. Research into the early discharge experiences of stroke patients and/or their carers is often limited to retrospective, longitudinal studies. With the continuing shift towards care in the community, patients and carers can increasingly expect more recovery to be taking place at home at an even earlier stage. Earlier discharge may have important implications for those involved. The review also highlighted that patients with aphasia have frequently been excluded from stroke research and that social roles are important aspects in stroke recovery.

CONCLUSIONS

To prepare patients and carers better for the impact of returning home, further research is needed into their experiences at this significant time, particularly in the UK. There is also a need to facilitate the inclusion of those with aphasia in stroke research.

RELEVANCE TO CLINICAL PRACTICE

An improved understanding of the issues facing stroke patients and carers during their early days at home should facilitate the preparation for discharge in the hospital setting and allow more focussed follow-up services in the community.

Achieving Optimal Functional Outcomes in Community-Based Rehabilitation following Acquired Brain Injury: A Qualitative Investigation of Therapists' Perspectives

The aim of this study was to explore therapists' opinions about the rehabilitation approaches that they perceived contributed to positive outcomes for people with acquired brain injury in community-based rehabilitation settings in order to develop a set of practice principles for clinicians working in this area. Semi-structured interviews were conducted with eight Australian and three British therapists, with a mean of 5.2 years' experience of working with people with acquired brain injury in community-based rehabilitation settings. The interviews were analysed thematically. A summary of the themes was presented to a larger group of acquired brain injury service providers (n = 35) for validation.

The participants emphasised the importance of environmental factors, such as collaboration with and inclusion of others in rehabilitation, especially those in the person's support network. Strategy use, client-centred goal setting, the provision of education and the development of a therapeutic relationship were identified as facilitators in community-based rehabilitation. Problems with self-awareness and motivation, drug and alcohol use, and behavioural difficulties were commonly identified barriers to optimal outcomes. The key practice principles derived from the findings were the need for community-based rehabilitation for people with acquired brain injury to be (1) environment focused and contextually appropriate, (2) collaborative and (3) goal directed and client centred.

The meaning of rehabilitation in the home environment after acute stroke from the perspective of a multiprofessional team

BACKGROUND AND PURPOSE

Intervention programs for home-based rehabilitation are not fully described in the literature, and rehabilitation team members' experiences and tacit understanding of working with patients after stroke in the home environment need to be further understood. The aim of this study was to identify the meaning of rehabilitation in the home environment after stroke from the perspective of members of a multiprofessional team.

SUBJECTS

Thirteen members of a multiprofessional outreach team (physical therapists, occupational therapists, speech and language therapists, and a social worker) working at a geriatric hospital in Stockholm, Sweden, participated in the study.

METHODS

A qualitative method (the Empirical Phenomenological Psychological method) was used, with data being obtained from retrospective interviews of the team members after completing home-based rehabilitation of patients after acute stroke.

RESULTS

One main theme ("supporting continuity") and 4 subthemes ("making a journey together from hospital to home," "enabling experiences of functioning," "refraining from interventions-encouraging patient problem-solving skills," and "looking for a new phase-uncertain endings") were revealed.

DISCUSSION AND CONCLUSION

The findings suggest that contextual factors, both environmental and personal, were considered to be of great importance by the members of the multiprofessional team and were accounted for when they were working in the home environment in the rehabilitation of patients after stroke. Contextual factors detected in the home environment gave valuable information to the team members, who used the information in their strategies to assist the patients in finding continuity in their daily life and to link the past to the present and the "new body" to the "old body."

Early Supported Discharge and Continued Rehabilitation at Home After Stroke: 5-Year Follow-up of Resource Use

BACKGROUND

Early supported discharge (ESD) with continued rehabilitation at home has shown a beneficial effect on extended activities of daily living 5 years after stroke. The long-term effect of ESD on resource use has not been explored.

METHODS

At 5 years, 54 patients with mild to moderate disability, enrolled in a randomized controlled trial of ESD, were followed up. Data were collected from a county register and by interviewing the patient or the patient's spouse.

RESULTS

There were differences in mean length of hospitalization, 51 versus 32 days (P = .02). There was no significant difference between the groups in regard to total outpatient rehabilitation, ESD visits included, but there was a difference in where the services were obtained. The ESD group had more rehabilitation at home (ESD service) and the control group had more outpatient rehabilitation (P = .04), including physiotherapy in primary care (P = .05). There were no other differences.

CONCLUSION

We conclude that, 5 years after stroke, our ESD service was favorable with regard to resource use.

OCCUPATIONAL GAPS IN EVERYDAY LIFE 1–4 YEARS AFTER ACQUIRED BRAIN INJURY

OBJECTIVE

To explore adaptation, by examining the occupational gaps occurring between what individuals want to do and what they actually do in terms of their everyday activities before and after brain injury. In addition, the relationships between occupational gaps and impairment/activity limitations and the time lapse since the brain injury were explored.

DESIGN

A cross-sectional study.

SUBJECTS

A total of 187 persons, affected by traumatic brain injury or subarachnoid haemorrhage 1-4 years previously.

METHODS

A postal questionnaire encompassing questions concerning gaps in the performance of activities in everyday life before and after the brain injury and perceived impairment/activity limitations.

RESULTS

The numbers of occupational gaps increased after the injury, with the number of gaps having increased from 46% to 71%. The number of occupational gaps was significantly related to executive impairment/activity limitations, and motor impairment/activity limitations and other somatic impairments, such as headache, also had an impact. The time lapse since the brain injury had no significant effect on the number of occupational gaps.

CONCLUSION

The results suggests that there is a need for adaptation in everyday activities, even several years after a brain injury, which indicates that follow-up and access to individualized rehabilitation interventions in the long-term are required.

A Randomized Controlled Trial of Early Supported Discharge and Continued Rehabilitation at Home After Stroke

BACKGROUND AND PURPOSE

The optimal organization of rehabilitation services after discharge from a stroke unit has not been determined. This study sought to evaluate the effect of early supported discharge and continued rehabilitation at home (ESD), in terms of patient outcome 5 years after stroke and changes in selected data over time.

METHODS

Eighty-three patients from Southwest Stockholm, mildly or moderately impaired 5 to 7 days after acute stroke, were enrolled in a randomized controlled trial. The core components of the ESD service were initial treatment in a stroke unit and the involvement of an outreach team to deliver and coordinate home-based rehabilitation in partnership with the patient. At the 5-year follow-up, measures used to assess patient outcome included survival, motor capacity, dysphasia, activities of daily living (ADL), social activities, subjective dysfunction, and self-reported falls.

RESULTS

Fifty-four patients (30 in the intervention group and 24 in the control group) were evaluated 5 years after stroke, at which time a significantly larger proportion of patients in the intervention group were independent in extended ADL and active in household activities.

CONCLUSIONS

This ESD service has a beneficial effect on extended ADL 5 years after stroke for mildly to moderately impaired patients.

Motor Imagery for Gait Rehabilitation in Post-Stroke Hemiparesis

Background and Purpose. Reports have described the contribution of motor imagery (MI) practice for improving upper-extremity functions in patients with hemiparesis following stroke. The purpose of this case report is to describe the use of MI practice to attempt to improve walking in an individual with hemiparesis. Case Description. A 69-year-old man with left hemiparesis received MI gait practice for 6 weeks. Intervention focused on task-oriented gait and on impairments of the affected lower limb. Preintervention, midterm, postintervention, and follow-up measurements of temporal-distance stride parameters and sagittal kinematics of the knee joint were taken. Main Outcomes. At 6 weeks postintervention, the patient had a 23% increase in gait speed and a 13% reduction in double-support time. An increase in range of motion of the knees also was observed. No changes in gait symmetry were noted. Discussion. The outcomes suggest that MI may be useful for the enhancement of walking ability in patients following stroke. Because improvement was mainly in temporal-distance gait variables and knee movement, imagery practice probably should focus on its specific impairments during gait in order to affect the performance of the paretic lower extremity.