Early Supported Discharge by Caregiver-Mediated Exercises and e-Health Support After Stroke

Abstract

ecreased mobility is one of the major concerns for patients who suffer a stroke.1 Demand for stroke rehabilitation exceeds supply, and because length of hospital stay is decreasing, new approaches to deliver rehabilitation are needed to improve health outcomes and promote independent living. Early Supported Discharge and Home Rehabilitation services for patients who have suffered a stroke offer an approach to managing rising demand for hospital beds and seem to achieve comparable clinical outcomes to inpatient rehabilitation.2,3 Shorter lengths of stay, however, can mean less access to therapists, potentially less recovery, and more burden to the caregiver and family; therefore, novel, more efficient approaches to augment practice with less costs are needed. 4 One way of increasing the intensity of exercise therapy is to actively involve family members in the rehabilitation process. 5,6 Training caregivers as co-therapists enables them to assist with exercise delivery and increase practice intensity without increasing staff time. However, studies examining caregiver-mediated rehabilitative exercise are scarce, and the effects on patient and caregiver outcomes are under investigation. 6Background and Purpose-This proof-of-concept trial investigated the effects of an 8-week program of caregiver-mediated exercises commenced in hospital combined with tele-rehabilitation services on patient self-reported mobility and caregiver burden. Methods-Sixty-three hospitalized stroke patients (mean age 68.7, 64% female) were randomly allocated to an 8-week caregiver-mediated exercises program with e-health support or usual care. Primary outcome was the Stroke Impact Scale mobility domain. Secondary outcomes included length of stay, other Stroke Impact Scale domains, readmissions, motor impairment, strength, walking ability, balance, mobility, (extended) activities of daily living, psychosocial functioning, self-efficacy, quality of life, and fatigue. Additionally, caregiver's self-reported fatigue, symptoms of anxiety, self-efficacy, and strain were assessed. Assessments were completed at baseline and at 8 and 12 weeks. Results-Intention-to-treat analysis showed no between-group difference in Stroke Impact Scale mobility (P=0.6); however, carers reported less fatigue (4.6, confidence interval [CI] 95% 0.3-8.8; P=0.04) and higher self-efficacy (−3.3, CI 95% −5.7 to −0.9; P=0.01) at week 12. Per-protocol analysis, examining those who were discharged home with tele-rehabilitation demonstrated a trend toward improved mobility (−9.8, CI 95% −20.1 to 0.4; P=0.06), significantly improved extended activities of daily living scores at week 8 (−3.6, CI 95% −6.3 to −0.8; P=0.01) and week 12 (3.0, CI 95% −5.8 to −0.3; P=0.03), a 9-day shorter length of stay (P=0.046), and fewer readmissions over 12 months (P<0.05). Conclusions-Caregiver-mediated exercises supported by tele-rehabilitation show promise to augment intensity of practice, resulting in improved patient-extended activities of daily living, reduced length of stay with fewer readm...

Telerehabilitation for Stroke Survivors: Systematic Review and Meta-Analysis (Preprint)

“…After a meticulous full-text screening, 15 studies (1,339 patients) were identified as eligible for our systematic review [9][10][11][12][14][15][16][17][18][19][20][21][22][23][24], 12…”

“…(1,246 patients) of which were eligible for meta-analysis [9][10][11][16][17][18][19][20][21][22][23][24]. Figure 1 shows the details of our screening process.…”

“…These studies have showed that telerehabilitation could be either equally effective [9,10] or even superior to usual rehabilitation [11,12] in improving daily activities and enhancing the psychological well-being of stroke survivors as well as caregivers.…”

Description of the CARE4STROKE programme: A caregiver‐mediated exercises intervention with e‐health support for stroke patients

“…Caregiver‐ or family‐mediated exercises (CMEs; Galvin, Cusack, O'Grady, Murphy, & Stokes, 2011; van den Berg et al, 2016; Vloothuis et al, 2015; Vloothuis et al, 2016), in which caregivers, such as partners, family members, or friends are actively involved in rehabilitation training, may be a promising and cost‐effective way to augment intensity of daily practice during inpatient stay. CME can continue after discharge to a patient's own home situation and thereby facilitate ESD.…”

“…One recent Phase II proof‐of‐concept trial tested a similar approach to C4S in Adelaide (Australia; van den Berg et al, 2016). A significant reduced level of caregiver fatigue with increased feelings of self‐efficacy was found at follow‐up.…”