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• W2346525768 abstract "HomeStrokeVol. 47, No. 6Stroke Rehabilitation at Home Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUBStroke Rehabilitation at HomeLessons Learned and Ways Forward Nancy E. MayoBSc(PT), MSc, PhD Nancy E. MayoNancy E. Mayo From the Division of Clinical Epidemiology, Department of Medicine, School of Physical and Occupational Therapy, Center for Outcomes Research and Evaluation, McGill University Health Center Research Institute, McGill University, Montreal, Québec, Canada. Search for more papers by this author Originally published3 May 2016https://doi.org/10.1161/STROKEAHA.116.011309Stroke. 2016;47:1685–1691Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2016: Previous Version 1 IntroductionThe modern hospital evolved from a place to care for the sick staffed by members of religious orders to a symbol of rationality and progress fostering medical innovation, professional development, science, research, and training.1 As hospitalization grew to be the norm for seriously ill patients, there was also the recognition that not all care had to be institutionalized, and in the 1960s, a practice of offering hospital care at home2 for the terminally or chronically ill emerged. By the 1990s, the hospital-at-home became an attractive option in response to demand for acute-care hospital beds.3 In 1997, hospital-at-home was tested for acute stroke patients in Italy.4 Published in 2004, 120 patients were randomized from the emergency department to be managed at home or to be managed in the hospital as usual. The results showed that functional and neurological outcomes improved similarly in both groups, but patients managed at home had lower depression scores, fewer complications, and were more likely still be at home at 6 months. With the development of effective therapies for acute stroke, hospital admission was considered best practice and stroke unit care was shown to be superior to other models of care.5,6 The hospital-at-home approach changed from a focus on avoiding hospitalization to a focus on early discharge from acute care but with support for on-going recovery by providing rehabilitation and other services in a community setting.7Home rehabilitation for stroke can now be considered under 3 broad rubrics: (1) rehabilitation at home to replace acute care—the early supported discharge (ESD) model; (2) rehabilitation at home to replace institutional rehabilitation; and (3) home exercise to prevent deterioration and promote health through physical activity. The aim of this review is to summarize what lessons have been learned from the many well-designed clinical trials evaluating the effect of providing ≥1 aspects of stroke rehabilitation in the home and identify promising avenues for implementation so that the greatest good can be achieved for the greatest number of people at the least cost. The studies that have been done are heterogeneous as to purpose, population, timing from stroke, nature of the interventions, and the type of control group. This heterogeneity provides rich learning material.Early Supported DischargeThe evidence for ESD has been systematically reviewed. The meta-analysis of individual patients’ data7 from 11 trials involving 1597 patients summarized in the Figure found a reduced risk of death or dependency for the ESD group in comparison to the usual care group (summary odds ratio, 0.79; 95% confidence interval [CI], 0.64–0.97), shortened length of hospital stay by an average of 8 days (95% CI, −4 to −11 days), and showing strongly favorable effects on extended activities of daily living (odds ratio, 0.12; 95% CI, 0.0–0.25). Table 1 summarizes the results across the different models of ESD presented by Langhorne et al.7 The effect was the greatest when the ESD was provided by a coordinated multidisciplinary team and for stroke patients with mild to moderate disability.Table 1. Summary of Outcomes From 3 Models of ESDOutcomeESD Team Coordination + InterventionESD Team CoordinationNo ESD TeamServices offeredMultidisciplinary teamMultidisciplinary teamMultidisciplinary team in hospital that ended at dischargeCoordinated discharge planning and postdischarge careCoordinated discharge planning and postdischarge careCare provided by a range of community stroke servicesRehabilitation and patient care at home by the teamRehabilitation and support at home provided by existing community-based agenciesNot planned at dischargeRegular team meetings to coordinate careNot usually coordinated or multidisciplinaryNo coordinated teamCare by trained healthcare volunteersn studies932Death*0.69 (0.44–1.07)0.95 (0.52–1.74)1.90 (0.90–3.98)Death or institutionalization*0.65 (0.45–0.93)0.75 (0.50–1.14)1.32 (0.75–2.33)Death or dependency*0.71 (0.55–0.91)0.77 (0.54–1.11)1.23 (0.79–1.91)Length of stay−6.84 (−11.20 to −2.49]−10.36 (−15.39 to −5.33)−7.0 (−8.61 to −5.39)Cost in comparison to control5 studies: −30% to −4%; 1 study: 15%1 study: −23%Not reportedESD indicates early supported discharge.*Values are odds ratios for team care vs usual care and 95% confidence interval. Values <1.0 indicate that the team approach had a lower odds of death and other poor outcomes than the usual care group; 95% confidence interval that excluded 1.0 indicates statistical significance.7Download figureDownload PowerPointFigure. The 4 Is.One of the striking features of these trials is that less than half (median, 41%) of patients with stroke were eligible for ESD (range, 13%–68%)8 because they were ill, discharge home was not realistic because of the lack of a caregiver, or the stroke was not disabling enough. The implication is that if ESD is implemented as a policy, similar eligibility criteria as the trials would need to be applied if the same benefit is to be observed. However, implementing an ESD program to a proportion of people with low disability would not necessarily be a bad thing as this group has many physical, emotional, cognitive, and participation consequences that have a negative effect on quality of life.9 These difficulties are often unrecognized during hospitalization and may only become evident after returning home. Whether and what kind of intervention people with mild stroke need is not fully understood as the trials of ESD did not provide subgroup analyses. A recent trial providing telephone support post discharge for people with mild stroke10 revealed that few availed themselves of this support service on their own and even when offered directly, there was no effect on outcomes. A more active ESD for people with low disability may be a way forward.One way of identifying the full effect of adopting a policy of ESD is to use an outcome measure that can be linked to costs. These measures fall under the rubric of utility measures,11 which are designed to create a single value across different outcome domains that are weighted by their value in terms of preference. The most widely used utility measures are generic meaning that they were developed for use in the general population to identify common health states. Several overviews of these measures have been published in different contexts,12–14 but generally, gains in 1 domain are traded off against losses in others. The best known of these generic utility measures are the Euroqol-5D,15 Short Form-6D16 derived from the Short Form-36, Health Utilities Index,12 and the Australian developed Assessment of Quality of Life.17 All have been used in stroke, some extensively. A key feature of these measures is that patients rate themselves on the domains yielding a health profile. Specific health profiles are valued by members of the general population and modeled to produce a single value representing the quality of life; when linked to life expectancy, these values yield quality-adjusted life years. With this common metric, it is possible to link outcomes to cost. A further advantage of these measures is that they would meet criteria for patient-centered outcomes defined as outcomes, beyond survival, that matter to patients, symptoms, function, and health-related quality of life.11Patel et al18 used the Euroqol-5D to compare stroke unit, stroke team, or domiciliary stroke care. Table 2, recast from this study, shows that stroke unit care was superior in terms of death/institutionalization avoided as 87% were alive and at home at follow-up, 12 months after randomization, and quality-adjusted life year gain was 0.297, larger but not significantly so than the other groups. When linked to cost, the home-care group was more advantageous, ≈£30 950 per quality-adjusted life years gained not surprising as a large proportion of stroke unit and team care is for hospital resources. A new generation of ESD trials are being designed in the context of early discharge19,20 with the inclusion of a utility measure19 to permit this type of cost-effectiveness analysis.Table 2. Selected Results at 12 Months From a Trial of 3 Models of Care for Acute Stroke From the Study by Patel et al18Stroke UnitStroke TeamHome Caren randomized148147140Alive and home*87%69%78%Gain in QALY (SD)0.297 (0.257)0.216 (0.370)0.221 (0.344))Direct costs (SD)*£11 450 (9 745)£9527 (8 664)£6840 (9 353)Cost per QALY gained£38552.19£44106.48£30950.23QALY indicates quality-adjusted life year.*P<0.05; QALY as measured by the Euroqol-5D.Given the strong evidence for ESD, the next step is implementation and a new set of research questions need to be addressed about the best way to do this. A recent review21 indicated that inconsistency in values and beliefs from professionals leads to lower implementation. Apart from a multidisciplinary expert team, success is also based on developing a collaborative approach to rehabilitation between the healthcare team and the patient and developing problem-solving skills in all, patient and provider. Specific training in these approaches may be warranted.In Canada, Ontario has been actively involved with the implementation of ESD since 2012 and through April 2015, and programs have been implemented in 5 sites.22 Ongoing research in ESD would involve methods for program evaluation, which is the evaluation of the extent to which the goals and objectives of a program have been met, including goals for processes and outcomes. This evaluation should also consider the processes and outcomes from the experiences of people receiving the program.21 The work by Nordin et al20 in summarizing the expectations of patients with respect to ESD provides information on how to move forward with implementing ESD. A key expectation was that the team would provide support, so patients could manage and feel comfortable and safe being at home. Patients had concerns about safety, particularly having another stroke out of reach of professional help. They expected the rehabilitation team to facilitate the recovery of independence and of prestroke abilities, and of course, they all hoped for full recovery. They expected to learn different strategies to deal with these challenges and to create a new everyday life. They felt being home would make them feel more capable.But the reality is that people face huge changes because of stroke, and it may be a struggle to accommodate their changed selves in an unchanged house, which may not even feel like home anymore.23 What better way of doing this than with the support of an ESD team?Rehabilitation at HomeThe second set of home rehabilitation interventions was carried out to ascertain whether rehabilitation at home could replace institutional rehabilitation, inpatient or outpatient. The main impetus for these trials is that institutional care is expensive, and if rehabilitation is needed for a period of months, prolonged institutional care will not be feasible. If some care can be equivalently carried out in patients’ homes, this would free up room in rehabilitation facilities for those who need this care venue. Other patients could recover in the comfort of their own homes, removing the need for travel to and from. However, on the negative side, the therapy team would need to spend much time on the road, taking resources away from therapy.A 2010 synthesis by Hillier and Inglis-Jassiem24 tested the hypothesis that home rehabilitation would cost less than clinic-based care but would not compromise recovery, essentially a noninferiority outcome hypothesis. Eleven trials of single discipline physical or occupational therapy, or multidisciplinary care, involving 1711 adults within 12 months of stroke were identified. Four of the trials found no difference between home and outpatient care; the remaining trials showed greater benefit for home rehabilitation in terms of cost, satisfaction, and caregiver strain. A meta-analysis of the results on the Barthel Index (scored out of 20) found that, depending on the time of assessment, the effect in favor of the home group ranged from 1 to 4 U. The effect of 1 of 20 on the Barthel Index may seem numerically small, but it is clinically relevant indicating a greater difference in independence level on 1 of the 10 activities of daily living. As this group scored initially >16 of 20 on the Barthel Index, a difference of 1 is likely to be on a high-level activities of daily living, such as walking and stairs, indicating an important benefit. The most recent trial included in the meta-analysis was published in 2004. Later results are concur.25While not designed to test a hypothesis about the effectiveness of home rehabilitation, the surprising results from the LEAPS study,26 published in 2011, contributes additional evidence that rehabilitation at home can be as, or even more effective, than institutional based care. First, the features of LEAPS study will be presented, and then some reasons why home rehabilitation is so powerful will be explored.This important study, published in the prestigious New England Journal of Medicine, was designed to test the hypothesis that, in addition to usual care (physical therapy provided according to current standards of practice), provision of a specialized locomotor-training program delivered early (2 months after stroke) or late (6 months after stroke) would be more effective in increasing the proportion of study participants who had higher functional walking levels at 1 year than provision of a control intervention that included progressive strength and balance exercises provided by a physical therapist in patients’ homes starting at 2 months after stroke. After initially screening of 4909 patients, 408 (≈8%) were eventually randomized, 139 to the early training group, 143 to the late training group, and 126 to home rehabilitation. The early training group and the home group started intervention 2 months post stroke and the late training group 6 months post stroke. Ninety-minute training sessions were scheduled for all groups, 3× per week for 12 to 16 weeks.There were many unique features of this study. The outcome was binary and not average change with 2 responder definitions: (1) for people with severe gait impairment (initial walking speed, <0.4 m/s), the critical value to leap over was 0.4 m/s or faster and (2) for people with initially moderate gait impairment (gait speed, 0.4 to <0.8 m/s), the leap was to 0.8 m/s or faster. Fifty-two percent of people achieved the targeted response with no significant differences across groups.The home rehabilitation program was offered as an active control and was not conceived of as potent with exercises targeting flexibility, range of motion, strength of arms and legs, coordination, and static and dynamic balance; participants were also encouraged to walk daily. This approach was better accepted than was intensive rehabilitation as the attrition rate was only 3% where as it was 13% and 17% for those in the early and late locomotor-training groups, respectively.The finding of a similar degree of improvement in the home rehabilitation group as with intensive locomotor-training came as a surprise to the rehabilitation community.27 However, the finding that 52% met the targeted response should be celebrated as therapy commenced on average, 64 days post stroke, outside the window of the greatest recovery. This finding supports the benefit of ongoing therapy for people with stroke, therapy of any kind. Another notable finding is that, at 6 months post intervention, the home group and the early training groups responded more favorably on all secondary outcomes than the late training group. These findings support the widespread effects of therapy and also that there is no need to wait to provide therapy for people with stroke, the earlier the better.The authors concluded that home exercise requires less expensive equipment, its implementation requires a smaller number of staff members, less training is required for physical therapists, and patients are more likely to adhere to the regimen. Another interpretation is that rehabilitation is so powerful it can be done in any venue.A way forward with implementing such a program at a population level would be to weigh the travel costs of therapy staff against the benefits and select implementation where travel would be minimized, likely in large urban centers where patients would live close to the hospital. People who could be easily treated at home should be, saving expensive hospital-based resources for those who would be more difficult for the team to access.Home Exercise ProgramsThe third form of home-based rehabilitation is providing home programs for people with stroke, so they may at least maintain, if not augment, gains made during formal rehabilitation and to reduce cardiovascular risk profile. American Heart Association recommend28 that people with stroke perform aerobic exercises 3 to 7 days per week, as well as strengthening, flexibility, and neuromuscular exercise 2 to 3 days a week, for their life time. Clearly institutionalizing this ongoing intervention is not feasible, and home-based programs, if successful, would be a solution.Olney et al29 tested this by comparing the outcomes achieved by 2 groups of people with chronic stroke, 1 with 10 weeks of supervised training (n=38) and 1 group with 1 week of supervised training to learn the program followed by 9 weeks of unsupervised training carried out at home (n=36). Both groups made equally modest gains on indicators of motor impairment (gait speed, >6 minutes; muscle strength) and cardiovascular risk (weekly physical activity, physiological cost of walking) and on physical and mental health. Gains in some outcomes were maintained for 1 year. The authors concluded that a brief period of exercise instruction followed by home exercise produced changes in physical function that are retained >1 year as similar to a supervised program. The home program is much more feasible.In a study published in 2004, Salbach et al30 found that 6 weeks of supervised walking training resulted in greater gains in the distance walked in 6 minutes (40 m) than did an attention controlled intervention involving exercise for the upper extremity (5 m). However, further analyses (published as abstract31) found that, on average, differences post intervention were lost by 6 months with only 1 of 3 of people who improved during the walking intervention maintaining these gains to 6 months. A major limitation to this type of intervention is that many people eligible for this trial (251/344, 73%) opted out of participating because they were not interested or too tired to attend the clinical setting for therapy.To address this, Mayo et al32 subsequently designed a trial of home-based therapy testing 2 types of interventions: a task-oriented exercise and walking program (exercise group; n=44) and a cycling regimen (cycle group; n=43) for a 1-year period. Although the programs were not supervised directly, both groups were provided with instruction, the program was progressed, and all equipment was supplied. All were visited at home 13× for the 12 months and had regular telephone monitoring. Both groups had elements of repetitive training, but the cycling regimen was simpler with more opportunity for continuous repetitive training, the cycle was a visual reminder to exercise, and removed the dependence on optimal weather conditions. The hypothesis was that, for a 1-year period, walking capacity would improve in both groups, but the cycle group would experience greater increases in walking ability, secondarily to developing better exercise habits, and, consequently, greater gains in participation and health-related quality of life. The premise was that no exercise is beneficial if it is not done and adherence to the cycling regimen might be greater because of its simplicity. Of the 607 people eligible, only 87 agreed to enter the trial claiming lack of interest in exercise as the primary reason. The trial was stopped early because of difficulty recruiting and futility. Of those who did enter, retention was poor with 28 of 43 (65%) randomized to the cycle group available for the 1-year assessment and 37 of 44 (84%) in the exercise group, necessitating data imputation for the analysis.There were no remarkable differences between groups on the primary outcome measure, distance walked in 6 minutes, with both groups showing no change, on average. However, there was a tendency for the exercise group to have a larger proportion of responders, people making a change in the distance walked in 6 minutes of >20 m: ≈40% versus ≈23%, for exercise and cycle groups, respectively. Secondary outcomes were analyzed using a global response method. For global physical function, estimated across 5 measures, the odds of response disfavored the cycle group but not significantly so (odds ratio, 0.65; 95% CI, 0.40–0.1.08); for global participation, across 4 measures, the odds of response also significantly disfavored the cycle group (odds ratio, 0.51; 95% CI, 0.27–0.95).Adherence was measured as best it can using diaries and personal interviews, and there were no differences between groups in the proportion with high adherence (36% versus 33% for exercise versus cycle). Depression affected adherence. There was a tendency for greater adherence to result in greater change in the distance walked in 6 minutes, most marked in the exercise group. The study concluded that the 2 programs were equally effective in maintaining walking capacity or equally ineffective in improving it, depending on whether the view is of a glass half full or half empty.This study indicates that providing unsupervised home rehabilitation is difficult, but at least a proportion of people, ≈1/3, will adhere and benefit. It remains to identify early on after stroke those most likely to adhere and to benefit and to ensure that they are offered programs. A challenge will be to engage the approximately 2/3 of people who cannot easily adhere to home rehabilitation.These challenges also become opportunities to develop successful implementation strategies. For those who will likely do well, provide them with the tools to do well: (1) clearly written instructions for continued home exercise progression; (2) regular follow-up at clinic where progress is actively measured and communicated back to the patient and family; (3) provision of self-management tools (4) referral to community based-programs that provide opportunities for physical, social, and personal development. There is emerging evidence for these tools.33–36For those with limited capacity to adhere to home rehabilitation, professional team input to a home-care team could be an option. At the least, support, regular follow-up, and perhaps a booster rehabilitation program could keep this group independent enough to remain at home. The costs of admission to long-term care could offset the additional expense of keeping in touch with this difficult to manage group.Why Does Rehabilitation at Home Work or Not?What could contribute to this powerful effect of home rehabilitation? Even in a research context with therapy as an established protocol, providing therapy in the home environment supports continuity of care, establishes a relationship that the therapist and patient are making a journey together, provides an authentic environment for the experiences of functioning, and encourages patients to develop problem-solving skill.37,38 Jensen39 observed that physical therapists use a great deal of skilled communication grounded in observation, active listening, and thoughtful questions. It is likely that these skills contribute to a successful read of the patient.This read is likely to motivate the patients and also facilitate developing problem-solving skills in a realistic and relevant setting, the home. Problem solving is emerging as a component of developing healthy coping strategies for people post stroke.40Why else might home rehabilitation work? Siemonsma et al21 systematically reviewed the determinants of successful of implementation of home-based rehabilitation for people who experienced a recent stroke. The home environment enables a more client-centered approach, encourages patients’ involvement in the rehabilitation process, and calls on problem-solving skills. In my study of ESD in Montreal,41 the qualitative information volunteered by subjects, family members, and service providers strongly supported that the ESD intervention empowered the subject and his or her family to take charge of the care, and this involved active decision making and concrete action plans.A qualitative study by Olofsson et al42 summed up the importance of home post stroke: “If only I manage to get home I’ll get better.” Although in hospital, the patient with acute stroke felt that they became a depersonalized object for caring measures. However, Tamm43 argues that home rehabilitation can also be perceived as negative as essentially the public sector moves into private space such that the home now has to function as a public workplace, and patients have to ensure a good working environment.Perhaps the greatest barrier to successful home rehabilitation is the lack of motivation. In a rehabilitation facility, an unmotivated patient will still receive therapy and is likely to be swept along with the crowd for other activities. At home, they will not. A recent systematic review of apathy post stroke44 estimated a prevalence in the postacute phase of ≈34%. Mayo et al45 in a longitudinal study of apathy post stroke found that any degree of apathy had a strong effect on participation in meaningful activities and life’s roles likely explaining in part why 50% of people 6 months post stroke lack for meaningful activity.46 Apathy poststroke is under studied, poorly measured, and largely ignored in the rehabilitation process.ConclusionsAmong the lessons learned are that ESD is effective. Another valuable lesson is that rehabilitation for stroke is so powerful that it can be offered in any setting without sophisticated equipment or technology. We also learned that without supervision only ≈1 of 3 of people with stroke will be able to follow or benefit from a home rehabilitation program.The ways to move forward are to implement what we do know and to develop optimal implementation strategies and policies. We also need to implement home or community-based rehabilitation programs to those who can and will engage and benefit. We need to identify this group early and provide resources, so they can optimize their outcomes. We need to develop solutions for the challenging patients, which may mean institution-based, not home-based rehabilitation, or closer follow-up with home care. We need to address apathy post stroke and to use advancing knowledge on neuroscience to develop interventions. Those that show promise, an emphasis on goal setting, and the development of problem-solving skills could be achieved through self-management programs, which are now delivered through media. We have information, we can interpret this information at the individual and population level, and we have effective interventions; we are still lacking appropriate and focused implementation strategies. I suggest that the 4Is—information, interpretation, intervention, and implementation—as shown in the Figure are the lessons learned and the ways forward.DisclosuresNone.FootnotesCorrespondence to Nancy E. Mayo, BSc(PT), MSc, PhD, Division of Clinical Epidemiology, Department of Medicine, School of Physical and Occupational Therapy, Center for Outcomes Research and Evaluation, McGill University Health Center Research Institute, McGill University, Royal Victoria Hospital Site, Ross Pavilion R4.29, 687 Pine Ave W, Montreal, Québec, H3A 1A1, Canada. E-mail [email protected]References1. Risse G. Mending Bodies, Saving Souls: A History of Hospitals. New York, NY: Oxford University Press Inc; 1999:3–13.Google Scholar2. Morris DE. Santé Service Bayonne: a French approach to home care.Age Ageing. 1983; 12:323–328.CrossrefMedlineGoogle Scholar3. Shepperd S, Iliffe S. Hospital at home.BMJ. 1996; 312:923–924.CrossrefMedlineGoogle Scholar4. Ricauda NA, Bo M, Molaschi M, Massaia M, Salerno D, Amati D, et al.. Home hospitalization service for acute uncomplicated first ischemic stroke in elderly patients: a randomized trial.J Am Geriatr Soc. 2004; 52:278–283.CrossrefMedlineGoogle Scholar5. Kalra L, Evans A, Perez I, Knapp M, Donaldson N, Swift CG. Alternative strategies for stroke care: a prospective randomised controlled trial.Lancet. 2000; 356:894–899. doi: 10.1016/S0140-6736(00)02679-9.CrossrefMedlineGoogle Scholar6. Langhorne P, Dennis MS, Kalra L, Shepperd S, Wade DT, Wolfe CD. Services for helping acute stroke patients avoid hospital admission.Cochrane Database Syst Rev2000;(2): CD000444.Google Scholar7. Langh" @default.
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