Ability in daily activities after early supported discharge models of stroke rehabilitation

Early Occupational Therapy Intervention post-stroke (EOTIPS): A randomized controlled trial

BACKGROUND

Occupational therapy (OT) is an effective evidence-based intervention that positively influences stroke patients'independence recovery, leading to new opportunities for better quality of life outcomes.

OBJECTIVES

To explore the effectiveness of an early OT intervention program (EOTIPS) in the process of hospital to home discharge after stroke in Spain.

MATERIAL AND METHODS

We conducted a prospective, randomized controlled clinical trial that included 60 adults who suffered a stroke and were discharged home. Participants assigned to the experimental group (n = 30) were included in EOTIPS and compared with a control group (n = 30). Evaluations assessed quality of life (Stroke and Aphasia Quality of Life Scale [SAQOL-39]), functional independence (Modified Rankin Scale [mRS], Barthel Index [BI] and Stroke Impact Scale-16 [SIS-16]), perceptual-cognitive skills (Montreal Cognitive Assessment [MoCA]), upper limb function (Fugl Meyer Assessment [FMA]), mobility (Berg Balance Scale [BBS] and Timed Up & Go [TUG]), communication skills (Communicative Activity Log [CAL]) and mood disorders (Beck Depression Inventory-II [BDI-II] and Hamilton Anxiety Scale [HAM-A]); they were completed within two weeks post-stroke and after three months follow-up. Statistical analysis included intent-to-treat analysis, considering all participants (dropouts as failures), and efficacy analysis, considering only end-of-treatment participants.

RESULTS

Participants in the intervention group showed a significant better evolution in the main outcome measure of quality of life (SAQOL-39 p = .029), as well as for independence (mRSp = .004), perceptual-cognitive skills (MoCA p = .012)and symptoms of depression (BDI-II p = .011) compared to the control group.

CONCLUSIONS

EOTIPS was effective in improving quality of life, as well as enhancing perceptual-cognitive skills, independence and reducing levels of depression for patients who suffered a stroke in a Spanish cohort and could be considered as an applicable non-pharmacologic therapeutic tool that can lead to patients' positive outcomes after stroke. This study was registered on ClinicalTrials.gov with the identifier NCT04835363.

Rehabilitation models that support transitions from hospital to home for people with acquired brain injury (ABI): a scoping review

BACKGROUND

Research shows a lack of continuity in service provision during the transition from hospital to home for people with acquired brain injuries (ABI). There is a need to gather and synthesize knowledge about services that can support strategies for more standardized referral and services supporting this critical transition phase for patients with ABI. We aimed to identify how rehabilitation models that support the transition phase from hospital to home for these patients are described in the research literature and to discuss the content of these models.

METHODS

We based our review on the "Arksey and O`Malley framework" for scoping reviews. The review considered all study designs, including qualitative and quantitative methodologies. We extracted data of service model descriptions and presented the results in a narrative summary.

RESULTS

A total of 3975 studies were reviewed, and 73 were included. Five categories were identified: (1) multidisciplinary home-based teams, (2) key coordinators, (3) trained family caregivers or lay health workers, (4) predischarge planning, and (5) self-management programs. In general, the studies lack in-depth professional and contextual descriptions.

CONCLUSIONS

There is a wide variety of rehabilitation models that support the transition phase from hospital to home for people with ABI. The variety may indicate a lack of consensus of best practices. However, it may also reflect contextual adaptations. This study indicates that health care service research lacks robust and thorough descriptions of contextual features, which may limit the feasibility and transferability to diverse contexts.

A qualitative evidence synthesis exploring people after stroke, family members, carers and healthcare professionals' experiences of early supported discharge (ESD) after stroke

OBJECTIVE

Early supported discharge (ESD) after stroke has been shown to generate significant cost savings and reduce both hospital length of stay, and long-term dependency. This study aimed to systematically review and synthesise qualitative studies of the experiences and views of ESD from the perspective of people after stroke, their family members, carers and healthcare professionals.

METHOD

A systematic search of eleven databases; CINAHL, PubMed Central, Embase, MEDLINE, PsycINFO, Sage, Academic Search Complete, Directory of Open Access Journal, The Cochrane Library, PsycARTICLES and SCOPUS, was conducted from 1995 to January 2022. Qualitative or mixed methods studies that included qualitative findings on the perspectives or experiences of people after stroke, family members, carers and healthcare professionals of an ESD service were included. The protocol was registered with the Prospero database (Registration: CRD42020135197). The methodological quality of studies was assessed using the 10-item CASP checklist for qualitative studies. Results were synthesised using Thomas and Harden's three step approach for thematic synthesis.

RESULTS

Fourteen studies were included and five key themes were identified (1) ESD eases the transition home, but not to community services, (2) the home environment enhances rehabilitation, (3) organisational, and interprofessional factors are critical to the success of ESD, (4) ESD is experienced as a goal-focused and collaborative process, and (5) unmet needs persisted despite ESD.

CONCLUSION

The findings of this qualitative evidence synthesis highlight that experiences of ESD were largely very positive. The transition from ESD to community services was deemed to be problematic and other unmet needs such as information needs, and carer support require further investigation.

Effectiveness of outpatient geriatric rehabilitation after inpatient geriatric rehabilitation or hospitalisation: a systematic review and meta-analysis

BACKGROUND

Due to the increasing number of older people with multi-morbidity, the demand for outpatient geriatric rehabilitation (OGR) will also increase.

OBJECTIVE

To assess the effects of OGR on the primary outcome functional performance (FP) and secondary outcomes: length of in-patient stay, re-admission rate, patients' and caregivers' quality of life, mortality and cost-effectiveness. We also aim to describe the organisation and content of OGR.

METHODS

Systematic review and meta-analysis. Five databases were queried from inception to July 2022. We selected randomised controlled trials written in English, focusing on multidisciplinary interventions related to OGR, included participants aged ≥65 and reported one of the main outcomes. A meta-analysis was performed on FP, patients' quality of life, length of stay and re-admissions. The structural, procedural and environmental aspects of OGR were systematically mapped.

RESULTS

We selected 24 studies involving 3,405 participants. The meta-analysis showed no significant effect on the primary outcome FP (activity). It demonstrated a significant effect of OGR on shortening length of in-patient stay (P = 0.03, MD = -2.41 days, 95%CI: [-4.61-0.22]). Frequently used elements of OGR are: inpatient start of OGR with an interdisciplinary rehabilitation team, close cooperation with primary care, an OGR coordinator, individual goal setting and education for both patient and caregiver.

CONCLUSION

This review showed that OGR is as effective as usual care on FP activity. It shows low certainty of evidence for OGR being effective in reducing the length of inpatient stay. Further research is needed on the various frequently used elements of OGR.

Interventions within the Scope of Occupational Therapy in the Hospital Discharge Process Post-Stroke: A Systematic Review

Stroke is one of the main causes of disability in adulthood. Its rehabilitation is a complex process that requires a multidisciplinary team of specialised professionals. The main goal of this review was to determine the impact of occupational therapy intervention post-stroke on the home discharge process. A systematic search was carried out of the following databases: Pubmed, Web of Science, PsycINFO, Scopus, Otseeker, and Dialnet. A screening was performed taking into account the type of article, including exclusively RCT, and type of intervention, only including interventions within the scope of occupational therapy that take place during the process of hospital discharge post-stroke. A total of 2285 citations were identified in the search from which 13 articles met the inclusion criteria. Comparisons of the groups indicated that early occupational therapy intervention during the process of hospital discharge can be effective in terms of functional recovery and can lead to the caregiver seeing improvements in self-efficacy and fatigue. In addition, the inclusion of a caregiver in the intervention influences the patient's adherence to treatment, leading to a reduction in the cost of treatment and rehabilitation.

Effect of home-based interventions on basic activities of daily living for patients who had a stroke: a systematic review with meta-analysis

OBJECTIVES

To investigate the effectiveness of home-based interventions in improving the ability to do basic activities of daily living in patients who had a stroke.

METHODS

Randomised controlled trials were searched through MEDLINE, Embase and CINAHL from their inception to 31 December 2021. We included studies involving home-based intervention prescribed by professionals and implemented at patients' homes. The characteristics of these studies were collected. Risk of bias of individual study was assessed by Physiotherapy Evidence Database scale. Meta-analyses were performed where studies reported comparable interventions and outcomes.

RESULTS

In total, 49 studies were included in the systematic review and 16 studies had sufficient data for meta-analyses. The short-term effect of home-based intervention showed no significant difference when compared with institution-based intervention (standardised mean difference (SMD)=0.24, 95% CI -0.15 to 0.62, I²=0%). No significant difference was found between home-based intervention and usual care for long-term effect (SMD=0.02; 95% CI -0.17 to 0.22; I²=0%). Home-based rehabilitation combined with usual care showed a significant short-term effect on the ability to do basic daily activities, compared with usual care alone (SMD=0.55; 95% CI 0.22 to 0.87; p=0.001; I²=3%).

CONCLUSION

Home-based rehabilitation with usual care, which varied from no therapy to inpatient or outpatient therapy, may have a short-term effect on the ability to do basic activities of daily living for patients who had a stroke compared with usual care alone. However, the evidence quality is low because of the limited number of studies and participants included in the meta-analysis and the possible publication bias. Future research is needed to investigate the effectiveness of home-based rehabilitation in groups with stratification by stroke severity and time since stroke onset, with elaboration of details of the home-based and the control interventions. Moreover, more high-quality studies are required to prove the cost-effectiveness of newly developed strategies like caregiver-mediated rehabilitation and telerehabilitation.

THE PRIMARY SOURCE OF FUNDING

The Medical Research Fund of Guangdong Province (No: A2021041).

Occupational Therapy and the IMPACT Act: Part 2. A Systematic Review of Evidence for Functional Status, Medication Reconciliation, and Skin Integrity Interventions

IMPORTANCE

Interventions that promote function, medication reconciliation, and skin integrity assist occupational therapy practitioners in demonstrating professional value, improving quality, and reducing health care costs.

OBJECTIVE

In this systematic review, we focus on three outcome areas of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014: functional status, medication reconciliation, and skin integrity.

DATA SOURCES

We conducted a search of the literature published between 2009 and 2019 in CINAHL, Cochrane, MEDLINE, PsycINFO, OTseeker, and Scopus. We also hand searched the systematic reviews and meta-analyses in our search results for articles that met our inclusion criteria. Study Selection and Data Collection: This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

FINDINGS

We found 47 articles that address the three outcome areas. Regarding functional status, low strength of evidence is available for cognition and functional mobility interventions to support functional performance, moderate strength of evidence supports interventions for vision, and moderate evidence supports task-oriented and individualized interventions to promote activities of daily living (ADL) outcomes among people with neurological conditions. Strong strength of evidence supports individualized occupational therapy interventions focusing on medication adherence. Low strength of evidence was found for occupational therapy interventions to reduce pressure ulcers and promote skin integrity. Conclusion and Relevance: The evidence supports occupational therapy interventions to improve functional status in ADLs and medication management. Additional research is needed that examines the outcomes of occupational therapy interventions for other areas of function and skin integrity. What This Article Adds: We found evidence to support occupational therapy interventions that align with value-based measures in the three outcome areas of interest. The effectiveness of these interventions highlights the viability of occupational therapy as an essential profession and the worth of occupational therapy to the public, potential clients, and payers.

Early Occupational Therapy Intervention in the Hospital Discharge after Stroke

Stroke is the leading cause of acquired disability in adults which is a cerebrovascular disease of great impact in health and social terms, not only due to its prevalence and incidence but also because of its significant consequences in terms of patient dependence and its consequent impact on the patient and family lives. The general objective of this study is to determine whether an early occupational therapy intervention at hospital discharge after suffering a stroke has a positive effect on the functional independence of the patient three months after discharge—the patient’s level of independence being the main focus of this research. Data will be collected on readmissions to hospitals, mortality, returns to work and returns to driving, as well as an economic health analysis. This is a prospective, randomized, controlled clinical trial. The sample size will be made up of 60 patients who suffered a stroke and were discharged from the neurology unit of a second-level hospital in west Malaga (Spain), who were then referred to the rehabilitation service by the joint decision of the neurology and rehabilitation department. The patients and caregivers assigned to the experimental group were included in an early occupational therapy intervention program and compared with a control group that receives usual care.

Clinical outcomes for moderate and severe stroke survivors receiving early supported discharge: A quasi-experimental cohort study

Introduction

The aim of this study was to compare outcomes for functional independence, activities of daily living participation and balance achieved by moderate and severe stroke survivors receiving an early supported discharge model of care with those receiving standard treatment.

Method

A quasi-experimental cohort method was utilised, with a control group of convenience. Forty-one patients ( n = 28 early supported discharge group, n = 13 control group) who were medically stable post stroke, safe for discharge home, able to be treated in the home environment and requiring intensive rehabilitation from at least two disciplines participated.

Results

There was no significant difference in outcomes between early supported discharge and control groups for functional independence, activities of daily living participation or balance from baseline to 4 weeks, or 4 weeks to 8 weeks. However, patients receiving early supported discharge made further improvements across the study period, while those receiving standard care made limited improvement between 4 weeks and 8 weeks. All minimal clinically important differences on outcome measures were identified between baseline and 4 weeks.

Conclusions

Moderate and severe stroke survivors can achieve comparable outcomes when receiving early supported discharge or standard treatment. Early supported discharge models of care may also enhance ongoing improvement during the early phases of stroke recovery.

What are physiotherapists and occupational therapists doing in services that replace acute hospital admission? A systematic review

BACKGROUND

Alternatives to acute hospital admission are required to accommodate the increasing pressures on health services. Since physiotherapists and occupational therapists are integral to inpatient teams, they may also be integral to admission replacement services, and thus their roles in these services merit investigation.

AIMS

Primarily to determine the presence and roles of physiotherapists and occupational therapists in services replacing acute hospital admission. The secondary outcome is to determine the impact of therapists in such services.

METHODS

Five electronic databases were searched, with keywords related to therapy, discharge, and admission replacement. Inclusion criteria were that studies explicitly described at least one therapist role within a service replacing acute hospital admissions. Two authors independently reviewed all potentially eligible studies. Two reviewers independently assessed data extracted from included studies into a standardized data extraction form.

RESULTS

Fifteen studies (3 Hospital at Home, 12 Early Supported Discharge) were included. Both clinical (eg, exercise prescription) and non-clinical (eg, organization and study outcome assessments) therapist roles were described in different admission substitution services. Some roles were only reported among teams, not individually ascribed to therapists.

CONCLUSIONS

The roles of therapists in services that replace hospital admission are rarely described in detail, with wide variation in reported roles, including across service types and patient populations. This review could not determine the impact of individual therapists on patient or service-level outcomes. Future studies need to more clearly define therapist roles and impact.

Early supported discharge services for people with acute stroke

BACKGROUND

People with stroke conventionally receive a substantial part of their rehabilitation in hospital. Services have now been developed that offer people in hospital an early discharge with rehabilitation at home (early supported discharge: ESD).

OBJECTIVES

To establish if, in comparison with conventional care, services that offer people in hospital with stroke a policy of early discharge with rehabilitation provided in the community (ESD) can: 1) accelerate return home, 2) provide equivalent or better patient and carer outcomes, 3) be acceptable satisfactory to patients and carers, and 4) have justifiable resource implications use.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (January 2017), Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 1) in the Cochrane Library (searched January 2017), MEDLINE in Ovid (searched January 2017), Embase in Ovid (searched January 2017), CINAHL in EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to December 2016), and Web of Science (to January 2017). In an effort to identify further published, unpublished, and ongoing trials we searched six trial registries (March 2017). We also performed citation tracking of included studies, checked reference lists of relevant articles, and contacted trialists.

SELECTION CRITERIA

Randomised controlled trials (RCTs) recruiting stroke patients in hospital to receive either conventional care or any service intervention that has provided rehabilitation and support in a community setting with an aim of reducing the duration of hospital care.

DATA COLLECTION AND ANALYSIS

The primary patient outcome was the composite end-point of death or long-term dependency recorded at the end of scheduled follow-up. Two review authors scrutinised trials, categorised them on their eligibility and extracted data. Where possible we sought standardised data from the primary trialists. We analysed the results for all trials and for subgroups of patients and services, in particular whether the intervention was provided by a co-ordinated multidisciplinary team (co-ordinated ESD team) or not. We assessed risk of bias for the included trials and used GRADE to assess the quality of the body of evidence.

MAIN RESULTS

We included 17 trials, recruiting 2422 participants, for which outcome data are currently available. Participants tended to be a selected elderly group of stroke survivors with moderate disability. The ESD group showed reductions in the length of hospital stay equivalent to approximately six days (mean difference (MD) -5.5; 95% confidence interval (CI) -3 to -8 days; P < 0.0001; moderate-grade evidence). The primary outcome was available for 16 trials (2359 participants). Overall, the odds ratios (OR) for the outcome of death or dependency at the end of scheduled follow-up (median 6 months; range 3 to 12) was OR 0.80 (95% CI 0.67 to 0.95, P = 0.01, moderate-grade evidence) which equates to five fewer adverse outcomes per 100 patients receiving ESD. The results for death (16 trials; 2116 participants) and death or requiring institutional care (12 trials; 1664 participants) were OR 1.04 (95% CI 0.77 to 1.40, P = 0.81, moderate-grade evidence) and OR 0.75 (95% CI 0.59 to 0.96, P = 0.02, moderate-grade evidence), respectively. Small improvements were also seen in participants' extended activities of daily living scores (standardised mean difference (SMD) 0.14, 95% CI 0.03 to 0.25, P = 0.01, low-grade evidence) and satisfaction with services (OR 1.60, 95% CI 1.08 to 2.38, P = 0.02, low-grade evidence). We saw no clear differences in participants' activities of daily living scores, patients subjective health status or mood, or the subjective health status, mood or satisfaction with services of carers. We found low-quality evidence that the risk of readmission to hospital was similar in the ESD and conventional care group (OR 1.09, 95% CI 0.79 to 1.51, P = 0.59, low-grade evidence). The evidence for the apparent benefits were weaker at one- and five-year follow-up. Estimated costs from six individual trials ranged from 23% lower to 15% greater for the ESD group in comparison to usual care.In a series of pre-planned analyses, the greatest reductions in death or dependency were seen in the trials evaluating a co-ordinated ESD team with a suggestion of poorer results in those services without a co-ordinated team (subgroup interaction at P = 0.06). Stroke patients with mild to moderate disability at baseline showed greater reductions in death or dependency than those with more severe stroke (subgroup interaction at P = 0.04).

AUTHORS' CONCLUSIONS

Appropriately resourced ESD services with co-ordinated multidisciplinary team input provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as reducing the length of hospital stay. Results are inconclusive for services without co-ordinated multidisciplinary team input. We observed no adverse impact on the mood or subjective health status of patients or carers, nor on readmission to hospital.

Effectiveness of Goal-Setting Telephone Follow-Up on Health Behaviors of Patients with Ischemic Stroke: A Randomized Controlled Trial

BACKGROUND

Adopting healthy behaviors is critical for secondary stroke prevention, but many patients fail to follow national guidelines regarding diet, exercise, and abstinence from risk factors. Compliance often decreases with time after hospital discharge, yet few studies have examined programs promoting long-term adherence to health behaviors. Goal setting and telephone follow-up have been proven to be effective in other areas of medicine, so this study evaluated the effectiveness of a guideline-based, goal-setting telephone follow-up program for patients with ischemic stroke.

METHODS

This was a multicenter, assessor-blinded, parallel-group, randomized controlled trial. Ninety-one stroke patients were randomized to either a control group or an intervention group. Intervention consisted of predischarge education and 3 goal-setting follow-up sessions conducted by phone. Data were collected at baseline and during the third and sixth months after hospital discharge.

RESULTS

Six months after discharge, patients in the intervention group exhibited significantly higher medication adherence than patients in the control group. There were no statistically significant differences in physical activity, nutrition, low-salt diet adherence, blood pressure monitoring, smoking abstinence, unhealthy use of alcohol, and modified Rankin Scale (mRS) scores between the 2 groups.

CONCLUSIONS

Goal-setting telephone follow-up intervention for ischemic stroke patients is feasible and leads to improved medication adherence. However, the lack of group differences in other health behavior subcategories and in themRS score indicates a need for more effective intervention strategies to help patients reach guideline-recommended targets.

Patients' expectations of coming home with Very Early Supported Discharge and home rehabilitation after stroke - an interview study

BACKGROUND

An Early Supported Discharge (ESD) and rehabilitation from a coordinated team in the home environment is recommended in several high-income countries for patients with mild to moderate symptoms after stroke. Returning home from the hospital takes place very early in Sweden today (12 days post stroke), thus the term Very Early Supported Discharge (VESD) is used in the current study. The aim of this study was to describe patients' expectations of coming home very early after stroke with support and rehabilitations at home.

METHOD

This is an interview study nested within a randomized controlled trial; Gothenburg Very Early Supported Discharge (GOTVED), comparing VESD containing a home rehabilitation intervention from a coordinated team to conventional care after stroke. Ten participants (median age 69) with mild to moderate stroke symptoms (NHISS 0 to 8 points) were recruited from the intervention group in GOTVED. Interviews were conducted 0-5 days before discharge and the material was analyzed with qualitative content analysis.

RESULTS

Four main categories containing 11 subcategories were found. The VESD team was expected to provide "Support towards independency", by helping the participants to manage and feel safe at home as well as to regain earlier abilities. The very early discharge gave rise to expectations of coming home to "A new and unknown situation", causing worries not to manage at home and to leave the safe environment at the ward. A fear to suffer a recurrent stroke when being out of reach of immediate professional help was also pronounced. In contrast to these feelings of insecurity and fear, "Returning to one's own setting" described the participants longing home, where they would become autonomous and capable people again. They expected this to facilitate recovery and rehabilitation. "A new everyday life" waited for the participants at home and this was expected to be challenging. Different strategies to deal with these challenges were described.

CONCLUSIONS

The participants described mixed expectations such as insecurity and fear, and on the other hand, longing to come home. Moreover, they had a high degree of confidence in the expected support of the VESD team. The health professionals at the hospital may build on this trust to reduce the patients' insecurity for coming home. In addition, it may be beneficial to explore the patients' expectations thoroughly in front of discharge, as certain feelings and thoughts could complicate or support the home coming process. Thus, a greater attention on such expectations may facilitate the patient's transition from hospital to home after stroke.