Archive for category Tele/Home Rehabilitation
[ARTICLE] Preliminary Analysis of Perception, Knowledge and Attitude of Home Health Patients Using Tele Rehabilitation in Riyadh, Saudi Arabia – Full Text
Telerehabilitation is defined as delivery of rehabilitation services over telecommunication networks and the internet, which comprise of clinical assessment (the patient’s functional abilities in his or her environment) and clinical therapy.This new area of medical advancement, using state of the art technology is developing at a great speed and is definitely going to be the next milestone in health care revolution.The objective of this study was to explore the awareness, knowledge and perception of the patients for using telerehabilitation as a medium to provide physiotherapy services as a part of home healthcare services. A pretest-post test design was used where the home healthcare patients (n = 90) aged between 50 -75 years were asked to express views by given a validated modified TUQ questionnaire followed by an indepth interviewing to develop a key understanding regarding the themes. Interviews were transcribed and a qualitative thematic analysis was conducted. The awareness level regarding the telerehabilitation changed significantly from 57% to 96% post session(p<0.05). Similarly, the knowledge of the participants regarding online consultation, followup and online therapy changed significantly from 50%, 47% and 57% to 96%, 76% and 96% respectively post session of rehabilitation(p<0.05). The perception level regarding the key benefits including its usage in emergency(83%), convenience of no travel(84%), ease of getting treated at home(97%) and availability of specialist consultation (84%) were the prime ideas for excellent rating among 95% participants (p<0.05) post session. Findings are helpful to health practitioners in designing their intervention programs across the kingdom. However the actual impact could be only derived from future studies which has to conducted based on different clinical conditions.
Telerehabilitation is defined as the provision and delivery of rehabilitation health services at a distance using information and communication technologies and tools (Tan 2005; Russell 2007). Throughout the world, the health care practices is going through major transformation as it is driven through sea change because of the increased use of technology. The kingdom of Saudi Arabia too is witnessing a massive change with significant restructuring of healthcare systems with some major high-end technology driven development solutions. The increased demand is created on account of rapidly increasing saudi population including the growing elderly community, changing disease patterns, global climatic changes and financial inequity (Mahmood 2018). According to a United nations report the elderly population of Saudi Arabia those aged 60 and above is projected to increase from 3% in 2010 to 9.5% and 18.4% in 2035 and 2050, respectively (UN Report, 2018).
Similarly, comparing this phenomenon to an average life expectancy of the population in Saudi Arabia, the latest WHO data published in 2018, suggests that Saudi male and female have an average of 73.5 and female 76.5 life years with an average life expectancy of 74.8 years as against an average world life expectancy of 84 years.The increased demand in kingdom also raised because of immense economic pressure with steep fall in global oil prices in 2015-16 affecting the GDP significantly thereby been one of the key stimulus for the government to take timely corrective actions and diversify the economy from heavily oil dependent to develop other verticals for revenue generation (MoH Report, 2018).
Brian child of Crown Prince HH Mohammad Bin Salman, Vision 2030 was adopted in April 2016 and has identified its priorities across all economic sectors and serves as a roadmap for the economic development of the KSA with development of health services been one of the most important key themes. Therefore, as a part of realization of this vision the government strongly supports the partnership of private and public sectors and been seen as a strong indication of the Government’s commitment for making healthcare accessible to its citizens irrespective of the disparities available in the Saudi society (Vision 2030 Report, 2016). Access to healthcare generally relates to people’s ability to use health services when and where they are needed. Determinants of healthcare access are the types and quality of services, including the costs, time, distance (ease of travel) as well as regular interface between service users and healthcare providers. Saudi Arabia is the largest and fastest growing health care market in the region and is estimated to reach $40 billion by 2020 (NTP 2020 Report, 2016).
Moreover, the steep increase in the number of hospitals across all major cities of KSA are run by both government and private organizations which use corporate business strategies and technology driven specializations, which aim to create demand as well as attract high number patients as the facilities in majority of these hospitals are world class.Among the various strategies listed in the NTP Report 2020, one of the key components of making healthcare accessible across the kingdom is the enhanced use of telemedicine (NTP 2020 Report, 2016). In the last one decade the health services across the kingdom have taken gigantic leap jumps with private healthcare taking lead and using innovations in delivering healthcare. One of such innovations is using Home Healthcare for delivering physiotherapy and other rehabilitation based services for the patients at home (Pulse Report 2018).
Rehabilitation is a very important component in medical care and helps in propelling patient to preinjury level. It is a well known fact that in all long term cases which requires follow-ups such as in surgical cases and other debilitating disorders including Stroke, Cancer, Multiple Sclerosios, rehabilitation is time consuming and financially constraining. To add to this, patients travelling long distances for treatment, it is not only physically challenging but emotionally draining too and especially in case of geriatric patients.Therefore home tele rehabilitation programs, are winding up progressively as an elective method of service delivery. In the western countries, quite a number of research studies has been proved that the Telerehabilitation for the delivery of health services is quite effective, however the scope of using such services in the kingdom is still novice and requires a detailed study, (Hailey et al., 2010, Johansson and Wild 2011, Chang et al 2019 ).
There are scant studies to prove its efficacy in the developing countries as its successful will depends on a number of factors (Clemens et al 2018) . However, among all the variables, the two most important are the technological component and second been its implementation in real terms (Jackson and McClean 2012, Clemens et al 2018). Accordingly, these both are of extreme critical importance from the patient satisfaction point of view. The perceptions of the stakeholders, i.e. the patient and the members of the Rehabilitation team are of utmost importance for its use and wide spread application.The home healthcare services in Saudi Arabia is still in infancy stages with few delivery partners across the kingdom. The usage of telerehabilitation is even more nascent, as the perception of patients in using such a technology for delivering healthcare would be quite critical and important to understand the phenomenon which would be quite useful in framing the guidelines for its applications at a mass level, (Alaboudi et al 2016).
Therefore, this study is an attempt to study the awareness, knowledge and perceptions of the home healthcare patients in using physiotherapy services delivered via cloud based telerehabilitation. This study, to our knowledge is the first of its kind in the kingdom especially from the perspective of home healthcare patients. It aims to explore the key ideas which might work in favour or against the successful implementation of telerehabilitation used for the home healthcare delivery.
Materials and Methods
The pretest-post test study design was conducted on home healthcare patients so as to obtain an in-depth understanding of the patients’ perception about telerehabilitation services which they will receive as a part of home health services. While a few studies conducted earlier emphasized about telemedicine to be a key part in delivery of health services, however none of the studies emphasized on perception of patients to implement telerehabilitation as part of home healthcare (Clemens et al 2018, Khalil et al 2018).
Due necessary approval were taken from the ethical clearance committee of the respective organization, which is a reputed home healthcare organization based in Riyadh. In order to recruit participants for the study, sample population were selected from a pool of home healthcare patients who were undergoing treatment under one of the most prominent home healthcare organizations in the kingdom, which incidentally was the only first licensed stand-alone home healthcare services company in Riyadh province.
The study was conducted from Jan 15 to May 30, 2019. In this context, non-probability sampling method was used. Out of 113 home healthcare patients who underwent treatment for different ailments, 90 were randomly selected who also gave their consent to participate in the study out of which 57 were males and 33 were females. Those patients who suffered from orthopedic problems such as Knee pain, low back ache, disc prolapse etc. or underwent orthopedic surgeries such as knee replacement or meniscectomy etc. participated in the study. The study mainly included common geriatric patients for the study who were willing to participate but excluded the pediatric and the critical care, neurological and cardiac patients as they underwent major surgeries such as for stroke or CABG and also were unable to respond directly to answer the questions. The patients who were able respond in English or Arabic were recruited for the study.
Based on literature review and discussion with key stakeholders, a questionnaire and an the interview guide was prepared, modified from Telehealth Usability Questionnaire (TUQ) based on key themes of perceived usefulness, ease of use and learnability, Interaction quality, Reliability and Satisfaction and future use (Langbecker et al 2017) . The questionnaire was converted to Arabic version adapted from the original English version and pilot tested for the home healthcare patients using both forward and backward translation methods and achieved very acceptable score of confirmatory factor analysis of 0.78 using SPSS. It was also pilot tested for the members of the rehabilitation team. The questionnaires as given in Appendix 1 were responded by the patients and the members of the rehabilitation team followed by a semi structured individual interview from the patient as well as from the team members involved in providing home health services. The interviews were audio recorded and transcribed verbatim using Text Analysis Markup System (TAMS) Analyzer as suggested by Yin (Yin 2013).
The Tele-rehabilitation Technological solutions were a part of home health services which were delivered by the company. As a part of cloud based HIPAA compliant network, the telemedicine unit consists of a portal to track health metrics and rehabilitation treatment plan and progress by the PT specialists as well as the Case Managers. The system included case briefing, consultation by specialists as well as providing physiotherapy sessions both by Home health therapists or via health workers such as PTAs within the vicinity of home environment at patient’s ease as schematically represented in Fig. no.1.
The participants were given a pre and post session modified TUQ and asked to reflect on their entire rehabilitation experience using the Telerehabilitation platform so as to get relevant information about telemedicine services including key events such as finding out they would receive services at home by videoconference, having the internet and videoconferencing equipment installed at home and receiving services by videoconference including dealing with technical issues. Following the same detailed interview was taken using the TAMS so as to identify key ideas which can affect usage of telerehabilitation. . Statistical tests was conducted using SPSS for Pre-post differences evaluation. using paired t-tests to assess factors associated with awareness, knowledge and perception. Significance was set a priori at p < 0.05. […]
Virtual physical rehabilitation, facilitated by at-home video sessions and device-based apps, is as effective as in-person physical rehabilitation. At the end of a 12-week trial, there was also no differences between in-person and virtual physical therapy in terms of six-week knee extension, flexion, and gait speed; and in 12-week pain scores and hospital readmissions. Those who completed a virtual physical therapy (PT) trial saw a median cost reduction of $1,755 at 12 weeks post-discharge. Costs for those following a virtual rehabilitation program saw costs averaging $1,050 per person; while those . . .
[THESIS] Curo — Patient home recovery guide for stressfree and better recovery after hospitalization – Full Text
The transition from in-hospital illness management to self-management exposes patients to many risks such as inadequate training before leaving the hospital and medication errors which can lead to patient re-hospitalization. Effective care after discharge can improve patients’ health, reduce chances of re-hospitalization and decrease healthcare costs.
A patient leaves the hospital with a complex and verbose discharge summary. Once home they rely on this discharge summary to guide their recovery. Most of the printed summaries use medical jargon that informs the clinicians more than the patients. To help patients understand better, nurses go through the discharge papers with the patient and caregivers orally. Still, patients find it difficult to process and remember all this information. It becomes overwhelming. This makes them unprepared to manage their care at home. Often times the delicate mental and physical condition of the patient also contributes to the loss of information. All these factors open the opportunity for design intervention for the cause of better post-discharge patient care.
This thesis provides an auxiliary design solution that provides patients with timely, easy to follow information without overwhelming them. Patients would focus on monitoring their health alone rather than struggling to understand complex hospital instructions. The interactive system serves as a guide that helps patients on their road to recovery. Finally, this thesis endeavors to make the process of patient recovery an easy and stress-free journey.
What is Mollii?
Mollii is a suit consisting of a pair of trousers, a jacket and a detachable control unit. The Mollii garments includes 58 imbedded electrodes, positioned to stimulate 40 key muscles in the body. Through a low frequency electro-stimulation therapy, Mollii relaxes spastic, tense and aching muscles safely and simply. Programmed after each person’s needs, Mollii prevents and counteracts different forms of muscle shortening and rigidity, helps the user regain control over muscular tension, and reduces pain related to spasticity. In addition, through electro-stimulation settings, Mollii may facilitate the activation of muscles, and thereby may facilitate muscle contractions, which in turn enable movements.
Who uses Mollii?
Mollii is used by people who suffer from spasticity and spasticity-related pain, which is typically found in people with cerebral palsy, stroke, multiple sclerosis, spinal cord injury, acquired brain damages and other neurological injuries that result from or create motor disabilities, and generally induce pain. Mollii is used both by adults and children; and is available in men and women sizes starting from 104 cm. up to XXXL.
Mollii can be used in both a home and clinic environment; and is simple to use for all ages. Users dress-up with a Mollii the same way they would with an ordinary garment. There is a button for on/off and a button for play/ pause. A single push of the button starts the muscle stimulation, which proceeds automatically for 60 minutes, and has a lasting positive effect for up to 48 hours.”
How does it work?
Mollii stimulates the antagonist to the spastic muscle. If the bicep is spastic, the tricep is stimulated, which in turn makes the bicep relaxed. Relaxing the muscle enables active movements and a gradual improvement in function, while the body keeps this positive effect for up to 48 hours. The physiological mechanism is called reciprocal inhibition.
Mollii also reduces pain related to spasticity, both through the reciprocal inhibition, and via the gate control theory of pain, which asserts that non-painful input such as the electric stimulation of skin-nerves closes the nerve-gates to painful input, which prevents pain sensation from traveling to the central nervous system.
Moreover, Mollii may facilitate the sub-threshold stimulation of a muscle by preparing the muscle for contraction before generating a shortening of the muscle, thereby reducing the nerve signal-strength required by the patient to actually generate a muscle contraction.
It is a safe and simple assistive device that can increase quality of life and help recover faster motor functions. The device is used for one hour every second day. For optimum effect, Mollii should be used together with physiotherapy, training, activity and movement. The positive effect is individual and remains for up to 48 hours.
Frequently asked questions
[Abstract] Efficacy of Home-Based Telerehabilitation vs In-Clinic Therapy for Adults After Stroke: A Randomized Clinical Trial.
Many patients receive suboptimal rehabilitation therapy doses after stroke owing to limited access to therapists and difficulty with transportation, and their knowledge about stroke is often limited. Telehealth can potentially address these issues.
To determine whether treatment targeting arm movement delivered via a home-based telerehabilitation (TR) system has comparable efficacy with dose-matched, intensity-matched therapy delivered in a traditional in-clinic (IC) setting, and to examine whether this system has comparable efficacy for providing stroke education.
DESIGN, SETTING, AND PARTICIPANTS:
In this randomized, assessor-blinded, noninferiority trial across 11 US sites, 124 patients who had experienced stroke 4 to 36 weeks prior and had arm motor deficits (Fugl-Meyer [FM] score, 22-56 of 66) were enrolled between September 18, 2015, and December 28, 2017, to receive telerehabilitation therapy in the home (TR group) or therapy at an outpatient rehabilitation therapy clinic (IC group). Primary efficacy analysis used the intent-to-treat population.
Participants received 36 sessions (70 minutes each) of arm motor therapy plus stroke education, with therapy intensity, duration, and frequency matched across groups.
MAIN OUTCOMES AND MEASURES:
Change in FM score from baseline to 4 weeks after end of therapy and change in stroke knowledge from baseline to end of therapy.
A total of 124 participants (34 women and 90 men) had a mean (SD) age of 61 (14) years, a mean (SD) baseline FM score of 43 (8) points, and were enrolled a mean (SD) of 18.7 (8.9) weeks after experiencing a stroke. Among those treated, patients in the IC group were adherent to 33.6 of the 36 therapy sessions (93.3%) and patients in the TR group were adherent to 35.4 of the 36 assigned therapy sessions (98.3%). Patients in the IC group had a mean (SD) FM score change of 8.36 (7.04) points from baseline to 30 days after therapy (P < .001), while those in the TR group had a mean (SD) change of 7.86 (6.68) points (P < .001). The covariate-adjusted mean FM score change was 0.06 (95% CI, -2.14 to 2.26) points higher in the TR group (P = .96). The noninferiority margin was 2.47 and fell outside the 95% CI, indicating that TR is not inferior to IC therapy. Motor gains remained significant when patients enrolled early (<90 days) or late (≥90 days) after stroke were examined separately.
CONCLUSIONS AND RELEVANCE:
Activity-based training produced substantial gains in arm motor function regardless of whether it was provided via home-based telerehabilitation or traditional in-clinic rehabilitation. The findings of this study suggest that telerehabilitation has the potential to substantially increase access to rehabilitation therapy on a large scale.
[Abstract] Effectiveness of Post-Hospital Intensive Residential Rehabilitation after Acquired Brain Injury: Outcomes of 256 Program Completers Compared to Participants in a Residential Supported Living Program
Post-hospital residential brain injury rehabilitation outcomes research is a complicated undertaking because of the custom-tailoring of interventions needed to meet the complex and unique need of each individual. As such, there tends to be great variability across program settings, which generally limits large-scale intervention studies. Growing literature demonstrates that post-hospital residential programs are beneficial. The main criticisms of this work include the absence of randomized-controlled studies, lack of clear definition of treatment types/settings, and small sample sizes. This study is a retrospective analysis of program evaluation data for a large, multi-site, national provider of post-hospital residential brain injury rehabilitation services. Specifically, outcome of participants completing Intensive Residential Rehabilitation (IRR) were compared to participants in the Residential Supported Living (RSL) program. Results demonstrate that participants in the IRR program improve and that participants in the RSL group preserve functional ability over time, suggesting that each program is effective in achieving its intended outcome. The IRR treatment group achieved significantly better outcomes than those in the same setting not receiving the intervention. To isolate treatment effects of IRR, a subsample of participants across program types were matched on time post-injury, age, and sex. The treatment effect of IRR was strengthened in this analysis, suggesting that chronicity alone does not account for the variance between the two groups.
via Effectiveness of Post-Hospital Intensive Residential Rehabilitation after Acquired Brain Injury: Outcomes of 256 Program Completers Compared to Participants in a Residential Supported Living Program | Journal of Neurotrauma
[ARTICLE] Factors That Contribute to the Use of Stroke Self-Rehabilitation Technologies: A Review – Full Text
Background: Stroke is increasingly one of the main causes of impairment and disability. Contextual and empirical evidence demonstrate that, mainly due to service delivery constraints, but also due to a move toward personalized health care in the comfort of patients’ homes, more stroke survivors undergo rehabilitation at home with minimal or no supervision. Due to this trend toward telerehabilitation, systems for stroke patient self-rehabilitation have become increasingly popular, with many solutions recently proposed based on technological advances in sensing, machine learning, and visualization. However, by targeting generic patient profiles, these systems often do not provide adequate rehabilitation service, as they are not tailored to specific patients’ needs.
Objective: Our objective was to review state-of-the-art home rehabilitation systems and discuss their effectiveness from a patient-centric perspective. We aimed to analyze engagement enhancement of self-rehabilitation systems, as well as motivation, to identify the challenges in technology uptake.
Methods: We performed a systematic literature search with 307,550 results. Then, through a narrative review, we selected 96 sources of existing home rehabilitation systems and we conducted a critical analysis. Based on the critical analysis, we formulated new criteria to be used when designing future solutions, addressing the need for increased patient involvement and individualism. We categorized the criteria based on (1) motivation, (2) acceptance, and (3) technological aspects affecting the incorporation of the technology in practice. We categorized all reviewed systems based on whether they successfully met each of the proposed criteria.
Results: The criteria we identified were nonintrusive, nonwearable, motivation and engagement enhancing, individualized, supporting daily activities, cost-effective, simple, and transferable. We also examined the motivation method, suitability for elderly patients, and intended use as supplementary criteria. Through the detailed literature review and comparative analysis, we found no system reported in the literature that addressed all the set criteria. Most systems successfully addressed a subset of the criteria, but none successfully addressed all set goals of the ideal self-rehabilitation system for home use.
Conclusions: We identified a gap in the state-of-the-art in telerehabilitation and propose a set of criteria for a novel patient-centric system to enhance patient engagement and motivation and deliver better self-rehabilitation commitment.
Stroke has become a global problem . One new case is reported every 2 seconds, and the number of stroke patients is predicted to increase by 59% over the next 20 years [ ]. In the United Kingdom alone, more than 100,000 stroke cases are reported annually [ ], with impairment or disability affecting two-thirds of the 1.2 million stroke survivors [ ]. In the United Kingdom, only 77% of stroke survivors are taken directly to the stroke unit. Due to the high number of patients, in England, for example, the social care costs are almost £1.7 billion per annum. The social care cost varies with the age of the patient: the older the patient, the higher the cost. The cost for a person who has had a stroke was reported in 2017 to be around £22,000 per annum. Thus, cost is one of the main drives for service delivery practices. In that respect, early discharge units have been used due to better outcomes and greater success on rehabilitation. Early discharge units consist of specialized personnel who offer an intensive rehabilitation program to the patient. However, after this intensive program of relatively short duration, the patient is discharged and continues the rehabilitation at home. This is expected to reduce costs by £1600 over 5 years for every patient, according to a 2017 report [ ].
Due to increasing pressure to discharge patients early from hospital , they rely increasingly on home rehabilitation to improve their condition after discharge. As a result, the need has been increasing for home rehabilitation systems that are not dependent on specialist or clinician operators [ , , ] while providing service similar to a clinical environment. Technological advances in home rehabilitation have been mainly focused on motor control impairments due to their prevalence in the patient population (85% worldwide [ ]).
Rehabilitation in a home environment can prove more efficient than that in a clinical environment, as the home environment supports patient empowerment through self-efficacy [, ]. The presence of supportive family members and a familiarity with the space are significant contributors to motivation. Additionally, rehabilitation in cooperation or in competition with family members demonstrates higher level of engagement [ ].
Though rehabilitation in the comfort of a patient’s home seems an attractive option, home environments have limitations that can affect the use of clinical devices. The most prevalent limitations are related to space and the lack of qualified personnel to operate devices. The number of occupants; the patient’s mobility, individual personality, and mood disorders following stroke; and sound insulation, home modification requirements, and cost [, ] also contribute to limitations of home rehabilitation. Finally, different age groups react differently to technology and devices; for example, elderly survivors often do not engage with wearable devices or video games [ ]. As a result, stroke rehabilitation requires a person-centric approach that is suitable for the home environment and that does not require infrastructure change in the home.
The success of stroke rehabilitation depends heavily on personal commitment and effort. Recent studies, for example, on applied psychology in behavior change theories for stroke rehabilitation [– ], do support that the self-esteem of the patient is limited after stroke. In addition, there is an extended sedentary period due to disability and, thus, different programs of activities are set to motivate the patients. Thus, the patient’s motivation and engagement have a critical impact on the success of any routine that is to be encouraged [ ]. This is especially critical for devices used at home, since patients are usually interacting with them alone without frequent checks. Indeed, if a device does not provide a high level of engagement or motivation enhancement, it is more likely to be abandoned within 90 days [ ]. Motivation levels depend on the individual, their achievements, and their needs at each given point in time. For example, once the patients achieve their physiotherapy exercise targets, they lose motivation for further practice. There are 3 main approaches to enhancing patients’ motivation: (1) goal-setting theory, (2) self-efficacy improvement theory, and (3) possible selves theory.
This approach has been proved effective for stroke survivors. According to the goal-setting theory, the patient’s motivation can be increased through setting small goals or targets. These need to be realistic, manageable, and well defined for the individual patient. However, they also need to be sufficiently challenging for the patient to be engaged [, – ]. presents the main components contributing to motivation enhancement based on the goal-setting theory.
[Abstract] Effectiveness of home-based virtual reality on vestibular rehabilitation outcomes: a systematic review
Background: A 2015 systematic review evaluated the efficacy of utilizing virtual reality in vestibular rehabilitation programs. However, the biggest limitation with most of the included virtual reality systems was the associated cost of the equipment. In addition, home-based exercises are the preferred method of vestibular rehabilitation treatments.
Objectives: The purpose of this systematic review was to examine the effectiveness of home-based virtual reality systems on vestibular rehabilitation outcomes.
Methods: The following databases were examined: CINAHL Complete, ProQuest Medical Database, and PubMed. The following search terms were utilized: ‘video OR computer’ AND ‘vestibular’ AND ‘home’. The evidence level for all of the included articles was evaluated using the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and the methodological rigor for all of the included articles was evaluated using a 10-item tool created by Medlicott and Harris.
Results: Based on the inclusion and exclusion criteria, seven articles were selected for inclusion in this systematic review. This systematic review found that home-based virtual reality interventions were able to effectively achieve the primary objectives of vestibular rehabilitation and that the use of these interventions was equally as effective as the use of a traditional vestibular rehabilitation program. In addition, it may be most beneficial to combine virtual reality with traditional vestibular rehabilitation.
Conclusions: Clinicians should consider using a combination of virtual reality and traditional vestibular rehabilitation when treating individuals who have been diagnosed with a vestibular dysfunction.
Telerehabilitation was not inferior to in-clinic rehabilitation therapy in helping to improve arm function after stroke but could substantially increase access to therapy for those who are unable to access a rehabilitation clinic, researchers opine.
“Few patients fully recover from arm weakness after a stroke. The remainder demonstrate persistent arm impairments that are directly linked to activity limitations, participation restrictions, reduced quality of life, and decreased well-being,” Steven C. Cramer, MD, from the department of neurology at the University of California, Irvine, and colleagues write, in a study published in JAMA Neurology.
“Some rehabilitation therapies can improve these deficits, with higher doses associated with better outcomes. However, many patients do not receive high doses of rehabilitation therapy, for reasons that include cost, difficulty traveling to the location where therapy is provided, shortage of regional rehabilitation care, and poor adherence with assignments,” they continue, in a media release from Healio.
Cramer and colleagues conducted a randomized, assessor-blinded, noninferiority clinical trial to compare telerehabilitation and in-clinic rehabilitation therapy outcomes for patients who had a stroke that resulted in arm motor deficit.
Patients were enrolled in the study at 4 to 36 weeks after experiencing an ischemic stroke or intracerebral hemorrhage that resulted in arm weakness. After enrollment, participants were randomly assigned to receive intensive arm motor therapy in a rehabilitation clinic or in their home using telerehabilitation delivery services with a computer connected to the internet. Scores on the Fugl-Myer arm motor scale were measured at the baseline and after treatment to determine changes in arm motor function.
All patients received 36 treatment sessions (70 minutes) in a 6- to 8-week period, which included 18 supervised and 18 unsupervised sessions. The content of therapy was carefully matched, with each group using the same exercises and standard exercise equipment.
A total of 124 participants were included in the study. Participants had a mean age of 61 years, a mean baseline Fugl-Meyer score of 43 points and were enrolled for a mean 18.7 weeks following stroke, the release explains.
Patients in the in-clinic group were adherent to 33.6 of 36 therapy sessions (93.3%), and those who received telerehabilitation at home were adherent to 35.4 of 36 therapy sessions (98.3%).
Both groups experienced significant changes in Fugl-Meyer scores from the baseline period to 30 days after treatment, with a mean change of 8.36 points in patients who received in-clinic therapy and 7.86 points in those who received telerehabilitation therapy.
The noninferiority margin was 2.47 and fell outside the 95% confidence interval, suggesting that telerehabilitation was not inferior to in-clinic therapy.
“Our study found that a 6-week course of daily home-based [telerehabilitation] is safe, is rated favorably by patients, is associated with excellent treatment adherence, and produces substantial gains in arm function that were not inferior to dose-matched interventions delivered in the clinic,” Cramer and colleagues conclude, in the release.
[Source: Healio Primary Care]
[ARTICLE] Factors influencing the implementation of Home-Based Stroke Rehabilitation: Professionals’ perspective – Full Text
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.
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.
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.
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).
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.
Stroke is one of the major causes of mortality, loss of independence, and lower quality of life of stroke survivors and has a great impact on the social environment . Between 2010 and 2030 the absolute number of people with a stroke is expected to increase by 56% in men and 37% in women . Also, stroke is known to have major socio-economic consequences. The financial burden placed on European countries by stroke is huge. For 2010, the estimated cost of stroke in Europe was €64 billion .
Stroke rehabilitation in the Netherlands
Firstly, stroke rehabilitation can be offered as institution-based rehabilitation: organized within hospitals, rehabilitation centers and nursing homes. Within institution-based rehabilitation, care is centered around a diagnosis. Professionals are specialized in treating clients with this specific diagnosis. Also, within the institution, regular (formal and informal) inter-professional meetings take place .
Secondly, stroke rehabilitation can be offered on outpatient basis. After their transfer home (from the stroke unit or institution-based rehabilitation), stroke survivors can consult outpatient rehabilitation professionals. Stroke survivors receiving outpatient rehabilitation live at home and visit the institution to receive therapy.
Thirdly, stroke rehabilitation can be offered as Home-Based Stroke Rehabilitation (HBSR). During HBSR (Home-Based Stroke Rehabilitation) rehabilitation is offered within the home environment of the client. It includes community-based rehabilitation delivered by primary care professionals, such as occupational therapists, physical therapists, speech therapists, dieticians, social workers, nurses and general practitioners . A broad range of professionals can be involved during HBSR, because the impact of stroke is multifaceted, affecting a broad range of body functions, activities and participation patterns . In the Netherlands primary care is not nationally organized: professionals deliver care from independent private practices and from a variety of institutions. General health insurances cover a certain (predefined) amount of treatment hours for selected disciplines only. The variety in financial legislations between these selected disciplines is large. Sometimes additional treatment hours and/or disciplines are financed, depending on the severity of symptoms, personal circumstances and insurance coverage. Insurance coverage differs per person and depends on the selection of optional insurances.
Home-Based Stroke Rehabilitation (HBSR)
Healthcare professionals and organizations are challenged to provide high quality health and social care, in a client centered and cost-efficient manner. To improve the quality and efficiency of care, the location of care delivery is shifting from institution-based settings to home-based services such as HBSR.
HBSR is known for its positive impact on client outcomes. HBSR resulted in more independent clients [7, 8] who are better at performing daily activities [8, 9] and who are more satisfied with their treatment compared to clients who receive conventional (institution-based) rehabilitation [8–12]. Also, HBSR is shown to reduce the length of hospital stay and to decrease the likelihood of admittance in a long-term stay facility . Furthermore, HBSR has the benefit of treating clients within a familiar environment. According to prior studies this tends to stimulate mental and physical activity, provides more meaning to tasks [13, 14] and prevents potential problems with the transfer of learned skills from the training setting to executing daily activities .
In the Netherlands a number of reforms and new policies have been implemented over the last years to facilitate client-centered and cost-effective care. These changes include policies increasing the responsibility of the municipalities for care and welfare on the municipality and transferring more responsibilities from professional carers to civilians and local communities themselves . Despite these efforts, the client-centered and cost-effective provision of high quality care remains a challenge because guidelines, practical suggestions and organisational support seems to be missing . Consequently, both researchers as well as healthcare professionals initiate new regional projects [17–19]. According to the literature, this does not only take place in the Netherlands. Many clients do not receive appropriate care, or receive unnecessary or even harmful care .
Major difficulties can arise when implementing innovations, like HBSR, into routine practice. Even though previous studies have shown positive effects of HBSR [7–15], innovations are not always provided to those clients for whom it could be beneficial . Prior studies show that clients and caregivers experience a gap after institution-based rehabilitation (e.g. delays and discontinuity of therapy and feeling abandoned and unsupported) and poor accessibility of community services [22, 23]. In order to further implement an innovation like HBSR, context specific implementation strategies are needed at different levels [24–26].
This Dutch study explores and describes professionals’ perspectives on determinants that could influence the further implementation of HBSR. These insights can guide the selection of context specific implementation strategies. This study will not only provide insight into region specific factors influencing implementation, but also general issues playing a role in the implementation of HBSR.
- How do professionals characterize stroke rehabilitation services that are currently provided in the Netherlands?
- What are the current and potential barriers and facilitators influencing the implementation of HBSR in their daily practice, according to professionals?