The RT program was prescribed using form, including pictures and a written adults, those at greatest risk of stroke
t greatest risk of stroke and
acombination of hand-held dumbbells,
Dyna-Bands (with wrist and ankle
attachments), and thepatient’s body weight
for resistance. These types of RT exercise
allow for independent limb actions and
weight prescription. When possible, the
exercises were task specifi c, incorporating
muscle actions that are performed during
activities of daily living that emphasize
retraining of balance and coordination, body
weight support, and weight shifting and
incorporate multi-joint rather than single-
joint movements. Patients were prescribed a
weight load equivalent to 50% to 80% of 1
repetition maximum on the nonaffected
limb. Aweight load that would yield a rating
of perceived exertion value of less than 15
on the Borg 6 to 20Scale28 was chosen for
the stroke-affected limb. We advocate
prescription of 1 to 2 sets of 7 to 10
exercises, 10 to 15 repetitions, 2 to 3 times
per
week. The RT program typically takes 30 to
40
minutes to complete.
overground walking was used primarily for
participants who not only were capable of
independent ambulation but also could
sustain
high enough speeds and durations to achieve
aerobic benefi t.
All exercise information was provided in
written
A major component of rehabilitation after
stroke is exercise
therapy that serves to minimise the effects
of brain cell damage
and optimise motor re-learning.1
Physiotherapists have traditionally
been the mediators of post-stroke exercise
therapy, but it has
Stroke is a major cause of functional
limitation in older adults. Although patients
with stroke improve in functional ability
through spontaneous recovery and
rehabilitation,recovery in most patients
plateaus approximately 6 months after
onset.1,2 Studies have shown that
approximately 35%of patients with chronic
stroke require assistance in performing
daily activities.3-5 Patients with stroke in a
community-living setting reported
dissatisfaction with functionalrecovery 1
year after onset because of hindered
participationin life events.5-7 Although 60%
of community-living patients with stroke
can visit places of interest (eg,
shoppingmalls) after being discharged from
hospital, approximatelyone-third cannot
leave home unattended.8Because of high
costs, many patients with stroke
oftendepend on outpatient care for
rehabilitation after being discharged
description
of RT exercises. The AT walking route was
mapped
for patients either around their home or in a
nearby
shopping mall. Caregivers were encouraged
to attend each class to facilitate home
exercise and risk factor modifi cation.To be
admitted to the program, patients had tobe at
least 3 months post stroke, with a hedoke-
McMaster Stroke Assessment leg
impairment scoreof 3 to 6,30 and able to
ambulate at least 10 m (33 ft)without
physical assistance with no signifi cant
limitations due to pain or signifi cant
cognitive
impairments that would preclude safe
exercise.
Higher functioning patients were integrated
into
the regular cardiac rehabilitation program
Improved
overall health, improved functional abilities,
enhanced confi dence, reduced
musculoskeletal
issues, family support, body weight
maintenance,
and improved appearance were identifi ed
by at least 50% of all participants in the
study as providing motivation to complete
their homeworkouts.
Familysupport has also been shown to
motivate older
been suggested that the amount of therapy
that is delivered is not
optimal.2 While the evidence for novel
exercise interventions to
promote motor recovery after stroke is
growing, the involvement of family and
carers in a structured program of exercise
delivery
after stroke has remained largely
unexamined.3
from hospitals.9 However, compliance with
rehabilitationprograms is frequently
compromised because offinancial strain or
logistical difficulties or for social
andpsychological reasons.10 Thus, home-
based programs haveemerged as an
attractive alternative for stroke
rehabilitation.
Numerous studies have shown that home-
based rehabilitationprograms can improve
the mobility and functional performanceof
patients with acute or subacute stroke and
reduce health care costs.11-15 Anderson et
al11 observed thatearly hospital discharge,
coupled with a home-based
rehabilitationscheme, was less costly than
conventional hospital care. Widen
Holmqvist et al12 found that early
supported dischargewith continually
provided home-based rehabilitation
services for patients with stroke in the first 3
months after anacute stroke was no less
beneficial than routine rehabilitation. Home-
cardiovascular disease, to exercise.34
Although
previously reported that stroke19 and
cardiac21
patients, as well as the elderly,34 were more
likely to exercise if it was recommended by
their physician, none of the patients studied
here suggested physician support as a reason
they exercised.
First, educating the families of stroke
patients about
the stroke-specific benefits of exercise and
maximizing their involvement from the
beginning
of the rehabilitation process may be an
important
aspect of program design, given that family
support was identifi ed as a motivating
factor and
family obligations were identifi ed as a
barrier to
exercise. Second, to improve adherence,
program
staff should emphasize benefits that
motivate
patients, such as improved overall health,
improved
functional abilities, enhanced confi dence,
reduced
musculoskeletal issues, body weight
maintenance,
and improved appearance.
ADHERENCE JURKIEWICS 2011
The approach to exercise delivery by Wang
and colleagues
builds on the concept that people with stroke
and their caregivers
take responsibility for the bulk of exercise
therapy. COMMENT CAREGIVER
WANG 2015
based rehabilitation programs were
observed to reduce initial hospitalization
significantly and had no
adverse effect on mortality or the number of
falls. Thesestudies suggest that home-based
rehabilitation programs area viable option in
certain health care systems.13However, the
cost of services provided by a
homebasedrehabilitation team, even a
physical therapist, mightstill be prohibitive
for many patients with stroke or
theirfamilies.9 Thus, additional cost-
effective and flexible
rehabilitation models for patients with
chronic stoke needto be developed.Patients
with chronic stroke rely on caregivers to
perform
daily activities.14,15 Current clinical
practice guidelines recommend
that family caregivers of stroke patients
become
active members of their rehabilitation teams
by participating
in goal setting and decision making to
facilitate functionalrecovery and community
reintegration.16,17 Family members
are often the closest persons to, and the most
vital environmentalcomponent for, patients
with stroke.18,19Familymediatedexercise
therapy has been shown to be effective
inimproving the functional recovery of
patients with acute
stroke,20 and a family-mediated and home-
based programsupervised once a week by a
physical therapist was as effectiveas
outpatient or day hospital therapy.21
Caregiver training has been demonstrated to
be cost-effective in improving the physical
functioning of patients with stroke in
rehabilitation
settings.22 The International Classification
of Functioning,Disability, and Health (ICF)
conceptual framework of theWorld Health
Organization was recently applied to a
rehabilitation strategy.23,24 It asserts that
functioning encompasses
“body functions and structures and activities
and participation”and is viewed in relation
to the health condition as wellas personal
factors (patients with stroke) and
environmentalfactors (family members and
life situation). The modelenables patients
with stroke conditions to achieve and
maintainoptimal functioning in interacting
at home and in a
community environment. However, to our
knowledge, theeffectiveness of a caregiver-
mediated, home-based intervention(CHI)
based on the ICF conceptual framework has
notbeen examined in patients with chronic
stroke in community living settings.(1)
experienced a single ischemic or
hemorrhagic stroke in the cerebral
hemisphere, as determined through
computed tomographyor magnetic
resonance imaging; (2) were > 6 months
postonset;(3) exhibited mild to moderate
disability (Brunnstromrecovery stages III-
V); (4) were undergoing
rehabilitationactivities 2 or fewer times per
week; (5) were home dwelling;(6) had
family members, friends, or paid workers as
caregivers; and (7) still required assistance
to accomplish everyday activities. Patients
were excluded if they required
use of a nasogastric feeding, urine, or
tracheal tube or exhibited 1 of the following
conditions: recurring stroke, dementia(based
on medical records), global or receptive
aphasia,severe orthopedic disability, or an
unstable medical condition(eg, severe acute
myocardial infarction). We defined the
caregiver as a person who was most
responsible for patient’sdaily care and who
lived with the patient. Caregivers
wereexcluded if they were in poor physical
health, had mental orbehavioral disorders
(eg, alcohol abuse, severe orthopedic
disability, uncontrolled diabetes, and
hypertension), or were unable to provide to
the patient at least two 60- to 90-minute
sessions of rehabilitation training per week.
The program was roughly divided into 3
phases:
phase 1 (weeks 1-4), to improve patients’
body functionsand structural components;
phase 2 (weeks 5-8), to improvepatients’
ability to undertake everyday activities
within their living environments using task-
specific restorative andcompensatory
training methods; and phase 3 (weeks 9-
12),to help the patients reintegrate into the
society by participating in restorative
outdoor leisure activities (Figure 2)
Berg Balance Scale, the 10-Meter Walk
Test, and the 6-Minute Walk Test (6MWT)
in a hospital setting and the Stroke Impact
Scale (SIS) and the Barthel Index at
participants’ homes. The SIS 3.0 contains
59 items measuring 8 domains: strength,
hand function, activities of dailyl
iving/instrumental activities of daily living
(ADL/IADL),mobility, communication,
emotion, memory/thinking, andsocial
participation. Factor analysis of the SIS
revealed that 4 domains (strength, hand
function, mobility, and ADL/
IADL) could be combined to create a
composite physical dimension score. The
other domains (emotion, communication,
memory, and social participation) were
scored individually,
and a single item was used to assess the
perceived
general recovery of patients with stroke.
Each item was assessed with a 5-point scale
(5, not difficult at all; 1, extremely difficult
or cannot do at all). A summed score was
generated for each domain (score range, 0-
100), and a high total score indicated
satisfactory functional recovery. The Berg
Balance Scale evaluated the patients’
balance
control based on 14 common tasks
performed in everydaylife. Each task was
rated 0 to 4 points, with a maximal score of
56. The scale was determined to provide a
valid and reliable measurement of balance
control ability.31 The original 0- to 100-
point Barthel Index was used to measure
performance in daily activities. A high score
suggested a greater
ability to live independently at home.32 For
the 10-Meter Walk Test, the free (habitual)
and maximal walking velocities of each
patient were measured 3 times on 2
occasions ina 10-m corridor; mean speeds
on each occasion were analyzed. 33 The
6MWT was used to measure functional
walkingcapacity. Each patient was asked to
walk along a 25-m corridor for 6 minutes,
and the total distance walked was recorded.
This measure was found to be a reliable
submaximal
test of the cardiovascular fitness of patients
with
stroke.34
Previous studies have demonstrated
that patients with
chronic stroke can achieve and maintain
physical functional improvement through
outpatient or home-based rehabilitation after
hospital discharge.17 The home
environment drastically differs from the
hospital environment. The hospital
environment has minimal barriers and
readily available professionals and therapies
to protect patients with stroke from
injuries and to provide assistance when
needed.40 Yet, the home environment is
typically filled with obstacles and
barriers,11 particularly in Taiwan, where
rooms in traditional
homes are divided by raised doorsteps
approximately 10 to 20 cm high. Thus, once
returning home, most patients lackthe ability
and support to manage this “new”
environment,41 and the caregiver, most
often a spouse or close relative, is generally
not well trained to solve these problems.
Thus,patients’ mobility is often hindered by
their physical impairmentsand inability to
manage barriers in the home.42,43 In this
study, repeating daily activities in the home
environment seemed to have resulted in
marked improvements in patients’ mobility,
balance, and self-care ability. A key
contributing factor in
this regard was likely the adherence to the
ICF conceptual framework,24 which
emphasizes family involvement, repetitive
task training, and reintegration into the
society. Several
clinical reports have suggested that the most
effective
approach to learn an activity is to practice it.
Repetitive-task training can be effective in
facilitating physical functional
improvement in patients with stroke.45,46
CHI enabled the patients to repetitively
practice specific daily tasks at home.Most
caregivers were the patients’ spouses or
close relativesand thus lived in the same
environment and likely had the
same living patterns. As such, they were
most likely toserve as facilitators for the
patients, providing the mostneeded care and
rehabilitation skills. Patients’
physicalfunctioning can therefore be more
effectively maintained orenhanced with
improvement of the caregivers’ ability
toadminister care, coupled with their high
accessibilitySecond, the program was home
based andpatient centered. Thus, the patient
and the caregiver canpractice the
rehabilitating skills in a familiar and
comfortablehome environment. Third,
implementing CHI eliminatedthe need for
patients to commute for rehabilitation.
Transportation is often a major problem for
these patients.Frequent trips are time-
consuming and may not be affordable for
many of them. Fourth, the patients learned
the exactskills that are needed in their
everyday lives. Finally, the
training program emphasized social
participation to facilitate
patients’ reintegration into the society.
EKSKLUSI Patients with stroke of
Brunnstrom
recovery stage I or II may have muscle tone
or spasticity but not voluntary movement
control.
NEED MORE ADVANCED
CAREGIVER
the control group received a home visit or
Stroke is a serious, common, and disabling
global health care
problem.1–3 It is not uncommon for the
stroke survivors to
have some limitations in managing daily
activities, such as walking, dressing,
feeding, and showering.4,5 Evidence
suggests that after stroke, individualized
physical activity and exercise prescription,
including neurodevelopment treatment,
motor relearning program, neuromuscular
electrical stimulation,
and biofeedback therapy, can be effective in
reducing
the adverse outcomes, such as joint
contracture, shoulder joint
subluxation, shoulder-hand syndrome, and
drop foot.6 This is usually performed in a
hospital or rehabilitation unit by
professionals. 7 However, the hospital care
resources are limited in most regions. In
addition, costly rehabilitation programs and
inconvenient transportation may restrict
stroke survivors to receive professional
supervised rehabilitation, which may delay
the best rehabilitation time.8,9 Thus, there is
an urgent need
for new outpatient rehabilitation and
recovery training strategies
that meet the specific needs of stroke
survivors and
their caregivers.10
The study was conducted in Shanghai 5th
People’s Hospital
Affiliated to Fudan University, Shanghai,
China. Inclusion
and exclusion criteria shown as follows
were used for enrollment of participants.
Inclusion criteria are the following:
(1) aged 35 to 85 years old, men or women;
(2) first diagnosis
was ischemic or hemorrhagic stroke or
recurrent stroke but
without hemiplegia symptoms before; (3)
have a symptom of
hemiplegia, left or right; (4) 14 to 90 days
from stroke onset;
(5) National Institute of Health Stroke Scale
scores from 2 to
20 and modified Rankin Scale (MRS) scores
from 1 to 5;
(6) have not previously received any
rehabilitation intervention
since this stroke onset. Exclusion criteria are
the following:
(1) Glasgow Coma Scale scores under 15,
have been confirmed
as having dementia based on MiniMental
State Examination
assessment, with mental disorders and
unable to
telephone call by a therapist to balance the
therapistpatient
contact time. Although no intervention was
involved, the visit/call might have a slight
effect on therecovery of the control patients.
However, the exact effect could not be
easily determined.
cooperatewith examination, treatment or
follow-up; (2) disability not induced by
stroke or disability induced by historical
stroke; (3) associated severe primary disease
of heart, liver, kidney, or hematological
system; (4) cognitive disorder, history of
psychosis, substance abuse, or alcoholism;
(5) skin infections in the areas of surface
electrodes attached; (6) metal implants
in the body, including cardiac pacemaker,
metal stent,
or steel plate; (7) in the gestation or
lactation period or have
a fertility plan; (8) associated malignant
tumor or severe progressive
disease in any other system; (9) have been
recruited
by any other clinical trial in the preceding
90 days; (10) unable
to complete the basic course of treatment,
with poor treatment
adherence or inability to follow up. In our
study, hemiplegic
stroke patients were included as subjects.
For one thing, the
subjects were required to do rehabilitation
exercises merely
by themselves, which meant they must have
some motor functions to accomplish the
training tasks. For another, to determine
the muscular contraction intensity of the
patients, we
need to measure the root mean square
(RMS) value of the investigated
muscle, which should be in paralysis
needing a rehabilitation
process.
The principle of the Bobath19 and
proprioceptive neuromuscular
facilitation20 concept underlay physical
exercises
programs, with occupational therapy as a
complementary training
method. Specific training methods included
the following:
(1) at the supine position, the paralyzed
upper limb of stroke
survivors was passively stretched out and
externally rotated in the painless range, with
the palm up. Then, the upper limb was
swung back to the anterior inferior part of
the trunk, with the shoulder adducted and
intorted, the elbow slightly flexed and the
palm down; (2) first, the paralyzed limbs
were exercised based on motor imagery
therapy, namely, by using will to control the
nerve impulses, making the paralyzed
muscles
Stucki G, Cieza A, Melvin J. The
International Classification of
Functioning, Disability and Health (ICF):
a unifying model for the conceptual
description of the rehabilitation strategy.
J
Rehabil Med. 2007;39:279-285.
ASLI CAREGIVER WANG 2015
contract; then, the paralyzed limbs did
assisted movement
and, lastly, exercised actively; (3) stood up
and did some standing balance training; and
(4) walking training. Once the survivors
recovered to a point where the patients were
evaluatedwhether they had the capacity to
complete occupation
therapy tasks,
Participants in the COR group received
rehabilitation
therapy in the outpatient rehabilitation
department. Participants adopted the same
equipment models for ETNS and
physiological
data collection. Therapeutic strategy was the
same
as the tele–supervising rehabilitation group,
but it was carriedout face-to-face with
trained therapists rather than via theTR
system.
Modified Barthel Index (MBI) to measure
disability and activities of daily living.22
TheMBI consists of 10 items: urinary
incontinence,
fecal incontinence, help needed with
grooming, toilet use, feeding, walking,
transfers, climbing stairs, bathing,
and dressing. The score ranges from 0 to
100, with high scores
demonstrating less severity of stroke.23
Loewen SC, Anderson BA: Predictors of
stroke
outcome using objective measurement
scales.
Stroke 1990;21:78–81
The Berg Balance Scale (BBS) was used to
assess balance,
which records participants’ ability to
perform14 activities, each of which is rated
on a 5-point Likert scale.24,25 The MRS is
a7-level scale (0–6) for assessing global
disability. Grades 0 or1, 2 or 3, and 4 or 5
are considered as no or minimal
disability,moderate disability, and severe
disability, respectively.26,27
Govan L, Langhorne P, Weir CJ:
Categorizing stroke
prognosis using different stroke
scales.Stroke 2009;40:3396–9
Outcomes Assessment
Baseline data were collected before
randomization allocation.
The information included sociodemographic
variables
(including age, sex, and educational level),
comorbid conditions, duration of hospital
stay, level of cognition byMiniMental State
Examination30 (anxiety and depression by
Hospital
Anxiety and Depression scores),31 stroke
severity by National Institute of Health
Stroke Scale score,32,33 others including
CSI, MBI score, BBS, MRS, and RMS
For stroke survivors, the purpose of the
rehabilitation is to
improve their ability of daily life and even
some social activity
in an economical way, by which the stress
of the caregivers
could be alleviated. Compared with
traditional hospital rehabilitation,
an efficient home-based rehabilitation in
real-life environment would be more helpful
in achieving that goal. In
literature, it has been proved that neither the
“natural progression”
of improvements nor merely the home life
environment
could play a pivotal role in the patients’
recovery after stroke,
but it is the rehabilitation program that
worked.6,7
In our study, to ensure the rehabilitation
training of patients
in the HTR group smoothly, what the
caregivers in
HTR group were required to do was a
challenge for them because although the
caregivers in the HTR group did not need
to transport the survivors to outpatient
facilities as the caregivers did in the COR
group, they had to supervise and assist the
survivors with rehabilitation training during
the therapy, and regularly logged. Such a
long-term task of assisting the patient
treatment might affect the caregivers’
physical health, social interaction,
employments, and time demands There
were several potential reasons for the
consequence. To begin with, rehabilitation
at home saved commute time forthe cares.
Besides, more opportunities to be closer to
their families contributed to the cares’
mental health. Finally, active control
of rehabilitation training helped to ease the
burden.
Chumbler et al.13 described that TR was a
useful supplement to conventional
poststroke rehabilitation for stroke survivors
living at
home by home visits and telephone calls. In
a trial studied by Redzuan et al.,16 a self-
instructional video-based therapy program
was used as intervention method for stroke
survivors at
home. This study concluded that the home-
based rehabilitation
therapy was safe and was not stressful for
the caregivers.16
Stroke survivors exercised by playing 3D
interactive games
installed in a bidirectional and multiuser TR
system.12 The
study reported that the use of the TR system
was feasible for
improving self-care functions in chronic
stroke survivors living
in long-term care facility. It also indicated
that thecommunication
between therapists and stroke survivors
could bemuch satisfactory through the
system.12 These may help explain the
findings of the present study that TR therapy
is as effective as conventional rehabilitation
and could ease the burden of the caregivers
as conventional rehabilitation.
12Lin K, Chen C, Chen Y, et al:
Bidirectional and multi-user
telerehabilitation system: clinical effect
on balance, functional activity, and
satisfaction in patients with chronic
stroke living in long-term care facilities.
Sensors (Basel) 2014;14:12451–66
13. Chumbler NR, Quigley P, Li X, et al:
Effects of telerehabilitation on physical
function and disability for stroke
patients: a randomized, controlled trial.
Stroke 2012;43:2168–74
16Redzuan NS, Engkasan JP, Mazlan M,
et al: Effectiveness of a video-based
therapy program
at home after acute stroke: a randomized
controlled trial. Arch Phys Med Rehabil
2012;93:2177–83
This type of intervention may provide more
opportunities
to access to a real-life environment and
social circumstances, which may drive the
positive consequences of
improved physical abilities. The
intervention of the present
study was a home-based rehabilitation
program that consisted of unified specific
training method and individualized family
activity exercises. Therefore, in the whole
rehabilitation process,
not only the training method played a
significant role,
the individualized family activities exercise
(eg, daily routines and personal social
contact) also contributed to the final
outcome. 38 Conventional rehabilitation
requires the therapists
and individuals after stroke in the same
setting, andmost stroke
survivors have challenges traveling to a
facility for rehabilitation as either they are
difficult to move or their main caregivers do
not have extra time to take the stroke
survivors to the hospitals.
Home-based TR programs, like home-based
tele–supervising
rehabilitation could be an important way to
overcome
the barriers and may be particularly useful
for stroke survivors,who live in a rural area
or at low level of economic status. Although
the cost-effectiveness of TR has not been
delivered so far,39 it is likely to reduce cost
of rehabilitation delivery by reducing
round trip time and travel-related expenses
for stroke
survivors and the caregivers.
is effective in improving
functional recovery in stroke survivors with
hemiplegia and
could ease the burden of caregivers as
conventional outpatient rehabilitation. It
might be a promising rehabilitation strategy
for stroke survivors at home EFFECT
HOMEBASED TELEREHAB CHEN
2016

Stroke is a significant health
care problem and a major cause
of long-term disability.1
Receiving rehabilitation in a
hospital
poststroke onset allows the
patient rapid access to
immediate
multidisciplinary care.2
However, acute hospital lengths
of stay
have been significantly
reduced.3 After early discharge
from the
hospital, rehabilitation therapy
can still further improve the
patient’s function.4,5
Accordingly, the number of
stroke patients
who need continued
rehabilitation and the provision
of homebased
rehabilitation is increasing.6
Home-based rehabilitation
allows practice of functionally
embedded activities in the
patient’s real environment,
which may
be more beneficial than practice
within standardized settings.7
The
programs can be tailored to
match the patient’s needs and
then practiced in a natural
environment, which makes
client-centered
therapy more practicable.8
However, studies of home-based
rehabilitation for the recovery of
upper-limb function have
shown promising but
inconsistent results. No
conclusive effects of
home-based rehabilitation can
be drawn, mainly because of
insufficient study designs and
the varied types of treatment
protocols, such as exercise
programs, home visits,
telerehabilitation,
constraint-induced therapy, and
specific upper-limb
training programs.3,6,9-14
Further research to more
comprehensively
investigate the efficacy of home-
based rehabilitation using a
controlled trial design is still
warranted.15
Approximately 70% to 80% of
stroke patients have upper
extremity (UE) motor deficts.5
Mirror therapy has emerged as a
novel UE rehabilitation
approach, and current evidence
shows that
stroke patients benefit from this
therapy.16-19 A case study
found
that mirror therapy can be
successfully administered at the
patient’s home environment.10
Another study showed the
bilateral
movement practice and motor
imagery in mirror therapy can be
regarded as a type of priming
technique which can facilitate
subsequent motor learning.20
Task-specific training, another
recommended training for
stroke rehabilitation,21
emphasizes adding active,
repetitive
practice of functional activities
to the treatment.22 Its treatment
principles include providing
challenging, functional, and
goaldirected
activities; feedback; variability
in practice conditions;
and promoting engagement,
which contribute to successful
outcomes.
22 Research supports that task-
specific training is critical
for enhancing motor and
functional recovery and for
producing
neuroplastic changes
poststroke.23-25
During each period, participants
received 12 intervention
sessions
for 4 weeks. They were
randomly assigned to receive
home-based
rehabilitation first versus clinic-
based rehabilitation first. After a
4-week washout period, the
group that received home-based
rehabilitation first received the
clinic-based rehabilitation, and
vice versa.
(1) diagnosed as having had a
stroke,
within 1 month to 5 years post
onset; (2) able to follow study
instructions; (3) modified
Rankin scale score of 2 to 4,
indicating
moderately severe to slight
disability;26 (4) Fugl-Meyer
Assessment
score of 18 to 62, indicating
moderately severe to mild motor
impairments;27,28 and (5) no
severe muscle spasticity in the
affected arm (modified
Ashworth scale _3). The
exclusion criteria
were (1) cerebellum stroke; (2)
other neurologic diseases; (3)
serious pain, inflammation, or
swelling in the affected arm; and
(4)
global or receptive aphasia or
other major medical problems
Home-based rehabilitation
This group received 30 to 45
minutes of mirror therapy,
followed
by 45 to 60 minutes of
functional task training, at each
session.
The intervention took place in
the participant’s home
environment.
During the mirror practice, the
patient was instructed to
watch the image of his or her
nonaffected UE on the mirror
and
was encouraged to actively
move the paretic UE
concurrently with
the mirror reflection of the
movement of the nonparetic UE
as
much as possible. Mirror
therapy treatment activities
included
active range of motion exercise,
object manipulation, functional
tasks with objects, and sensory
stimulation.10
After mirror therapy, the
participants received functional
task
training. The functional
treatment activities were
selected
according to each patient’s level
of motor deficits and individual
needs. Repetitive task training
for improving UE motor
function,
daily activities, mobility, or
walking ability was applied.
During
treatment, the therapist gave the
patient clear instructions,
feedback,
and encouragement. Examples
of tasks were opening
drawers, pouring water, picking
up a phone, opening a door,
twisting a towel, folding clothes,
cooking activities, laundry
activities, transfer techniques,
and indoor walking in the home
environment. The use of familiar
everyday objects and items
within the person’s daily routine
was emphasized.
Clinic-based rehabilitation
The clinic-based rehabilitation
group also received 30 to 45
minutes
of mirror therapy, followed by
45 to 60 minutes of functional
task training, at each session.
The intervention took place in
the hospital
clinics. Most of the treatment
principles and instructions were
the
same as those in the home-based
group. However, the major
differences
between the home-based and
clinic-based rehabilitations
were different modes of
treatment delivery, treatment
contexts
The Motor Activity Log (MAL)
is a self-report scale that was
used
to evaluate the amount of use
(AOU) and quality of movement
of
the affected UE. It assesses 30
common daily tasks, and the
score
of each task ranges from 0 to
5.38
Functional walking and the
ability to stand after sitting in a
chair are critical factors of
independent living in the
community. Previous
studies showed that upper-limb
rehabilitation interventions led
to positive and additional
benefits on mobility,
ambulation, or gait
performance of stroke
patients.39-41 In addition, the
functional tasks
provided in this study included
transfer, mobility activities, and
indoor walking to decrease
dependence of patients. The 10-
meter
walk test42,43 and sit-to-stand
test44,45 were thus used.
During the sit-to-stand test, the
participant was encouraged to
complete as many full stands as
possible from the chair within
30 seconds. The sit-to-stand test
procedure was the same for the
2 treatment groups, except that 2
different chairs with similar
height
were used during the study
period.
The COPM is a client-reported
questionnaire to assess an
individual’s
perceived performance in self-
care, productivity, and
leisure activities.29 The
participants were asked to
identify the 5
most important
problems/activities that they
wanted to improve
and to rate their own level of
performance and satisfaction
with
performance (1-10) for each
identified problem. Its reliability
and
validity have been validated.46
The EuroQoL-5D (EQ-5D)
Questionnaire is a measure for
valuing health, with good
psychometric properties.47,48
The ratings
on the 5 dimensions can be
converted to a single index
value, the
EQ-Index.49 Patients also rated
their overall health on the day of
the
interview with the EQ-VAS, a
vertical 0 to 100 visual analog
scale.
Home-based rehabilitation has
the advantage of promoting
context-dependent learning, and
the objects of relevance to the
participants are frequently
incorporated into
treatment.54,55 Participants
who practiced in a familiar
home environment were perhaps
more likely to transfer the skills
they had learned to realworld
activities.56 This may have
contributed to greater
improvement and generalization
of using the affected UE in daily
activities by self-report than in
the hospital contexts. Previous
studies also showed that home-
based constraint-induced
therapy
and virtual reality enhanced the
daily use of patient’s affected
UE
Regarding the impairment level
of outcomes, the possible
explanation for the
nonsignificant differences
between the 2
groups may be that the clinic-
based rehabilitation can provide
a variety of modalities according
to each participant’s level of
impairment, whereas the home-
based rehabilitation uses objects
and tasks familiar and relevant
to the participant’s daily life for
practice. Each practice setting
has its own advantages to
improve
the participants’ sensorimotor
impairments, leading to
nonsignificant
between-group differences. The
findings are similar to the
previous studies in which they
also found no significant
differences
in improvements of patients’ UE
motor function between
home-based rehabilitation and
control interventions
14 Turton AJ, Cunningham P,
van Wijck F, et al. Home-
based reach-tograsp
training for people after
stroke is feasible: a pilot
randomised
controlled trial. Clin Rehabil
2017;31:891-903
Study limitations
First, because the optimal
treatment duration and
frequency of
home-based stroke rehabilitation
have not been established, we
adopted a relatively intensive
schedule. The therapist
delivered
one-on-one treatment 3 times
weekly, which may be
impractical
for home-based rehabilitation.
The integration of home-based
with
clinic-based intervention,
including the treatment
frequency and
mode of delivery, to optimize
stroke rehabilitation outcomes
warrants further consideration.
Second, the study did not
estimate
the costs of home-based
rehabilitation (eg, intervention
expenses
or transportation costs). It is
important to assess the
costeffectiveness
of home-based rehabilitation for
further applications.
CONCLUSION The
implementation of a home-based
stroke rehabilitation intervention
with patient- oriented goals
resulted in mixed outcomes.The
home-based rehabilitation
demonstrated better
improvements
in the amount the affected UE
was used in daily tasks and in
lower extremity force, whereas
the clinic-based rehabilitation
enhanced self-perceived health
status. Further studies are
suggested to investigate how to
integrate home-based and clinic-
based interventions in patients
with different stroke phases,
including the treatment
frequency and mode of delivery,
to optimize rehabilitation
outcomes.
EFFECT OF HOMEBASED
VS CLINIC BASED
COMBINING MIRROR AND
TASK SPESIFIC ON
STROKE(RCT) HSIEH 2018
To our knowledge, no study has combined
all 3 components
(strength, balance, and endurance) into 1
intervention
for individuals with stroke. We developed
an intensive
home-based exercise program based on
evidence from prior
exercise interventions for elderly individuals
and stroke
survivors. Our intervention targeted
individuals who had
experienced mild and moderate strokes
because they often
retain significant deficits that may not have
received specific
interventions and they are likely to have
secondary deconditioning.
The purposes of this pilot study were to (1)
develop
an exercise intervention based on principles
of exercise
physiology and motor learning and to
deliver it in the home
to individuals with mild or moderate
strokes, (2) evaluate the
feasibility of the intervention and the ability
to recruit and
retain stroke subjects, and (3) assess the
effects of the
interventions
Research Design
In this randomized controlled pilot study, 20
individuals with mild to
moderate strokes who had completed acute
rehabilitation and who
were 30 to 90 days after onset were
randomized to a 12-week
(8-week therapist-supervised program and
4-week independent program)
home-based intervention
(experimental group) to improve
strength, balance, and endurance or to usual
care (control group).
Specific inclusion criteria for participation
in this pilot study were (1) 30 to 90 days
after stroke; (2)
minimal or moderately impaired
sensorimotor function (Fugl-Meyer
Motor Score 40 to 90,20 Orpington
Prognostic Scale score 2.0 to
5.221); (3) ambulatory with supervision
and/or assistive device; (4)
living at home; and (5) living within 50
miles of the University of
Kansas Medical Center.
Exclusion criteria were (1) a medical
condition that interfered with
outcome assessments or limited
participation in submaximal exercise
program, (2) a Mini-Mental State score
,18,22 or (3) receptive
aphasia that interfered with the ability to
follow a 3-step command.
As part of the enrollment, medical records
from the Kansas City
Stroke Study Registry were reviewed to
determine each subject’s
demographics, stroke onset, and stroke type.
Barthel Index Activities of Daily Living
The Barthel Index Activities of Daily Living
(ADL)23 is a weighted scale of 10 items of
basic ADL including feeding, bathing,
grooming,
dressing, bladder and bowel control,
chair/bed transfer, ambulation,
and stair climbing. The highest possible
score of the Barthel
Index is 100.
10-Meter Walk
The 10-meter walk is a measure of gait
velocity. Individuals were
given a 3-m warm-up distance. The time it
took to traverse 10 m at
the subject’s usual pace was recorded. Two
trials were averaged to
determine gait velocity.
2056 Home-Based Exercise Program
After Stroke
Downloaded from http://ahajournals.org by
on November 6, 2019
6-Minute Walk
The 6-Minute Walk26 is a measure that was
originally developed to
assess cardiopulmonary function. In this
test, subjects were given 6
minutes to walk as far as they could at their
usual pace. The distance
they covered in 6 minutes was recorded.
Subjects were allowed to
stop and rest as they deemed necessary.
Berg Balance Scale
The Berg Balance Scale27 consists of 14
items that require subjects to
maintain positions of varying difficulty and
perform specific tasks
such as rising from a chair and timed
stepping. Each item is graded
from 0 to 4. The maximum possible score
on the Berg Balance Scale
is 56 points.
Intervention
The exercise program was designed to
improve strength, balance,
and endurance and to encourage more use of
the affected extremity.
The experimental group did not receive any
physical or occupational
therapy other than that provided by the
study. If an experimental
group subject required speech therapy, the
subject was treated by
usual care providers. The experimental
exercise intervention was
initiated within 5 days of baseline testing. It
was a home-based
exercise program provided by a physical
therapist. The study
principal investigator (a physical therapist)
and coinvestigator (an
occupational therapist) observed at least 1
therapy session for each
subject to ensure standard application of
interventions. The program
included 3 visits a week for 8 weeks, and
the patients were instructed
to continue the exercise program on their
own for 4 additional weeks.
Each exercise session lasted '1.5 hours.
Exercise sessions were
divided into 4 blocks preceded by a 10-
minute warm-up session of
stretching and flexibility exercise. The first
block included assistive
and resistive exercises using Proprioceptive
Neuromuscular Facilitation
Patterns (PNF)29 or Theraband exercise
(see below) to the
major muscle groups of the upper and lower
extremities. PNF
exercises include upper and lower extremity
patterns. The movement
patterns included (1) flexion, abduction, and
external rotation of
shoulder with the elbow extended and with
wrist and finger extension;
(2) extension, adduction, and internal
rotation of shoulder with
elbow extended and with finger and wrist
flexion; (3) flexion,
adduction, external rotation of hips with
knee flexion, and ankle
dorsiflexion; and (4) extension, abduction,
internal rotation of hips
with knee extension, and ankle plantar
flexion.
Therabands are elastic bands of varying
elasticity used as a means
to provide resistance. Functional exercises
in which body weight was
used for resistance were also included.
Assistive-resistive exercises
that included PNF patterns were used only if
the patient was too
weak to use the elastic bands. Resistance
progression was based on
a protocol in which when subjects could
complete 2 sets of 10
repetitions through the available range of
motion, resistance was
increased by progression of Theraband
elasticity (levels of resistance)
or by increased manual resistance in PNF
exercises. The
second block included 15 minutes of
balance exercises, which were
progressively ordered by difficulty. In the
third block, participants
were encouraged to use the affected upper
extremity in functional
activities. The final session included a
progressive walking program
or progressive exercise on a bicycle
ergometer. The detailed protocol
of the intervention used is available from
the authors.

Subjects in the control group received usual
care as prescribed by
their physicians. Participants in this group
were visited by a research
assistant every 2 weeks to assess the
patients’ exercise and activity
level. The clinicians providing therapeutic
interventions to the usual
care group were asked to complete an
intervention log to capture
type of exercises and frequency and
duration of therapy visits during
treatment or in a home exercise program.
The study coordinator met
with the treating therapists at least twice to
discuss the therapy logs
and intervention programs.
Experimental Therapy
Each member of the experimental group
received 23 visits by
a physical therapist for 90 minutes in
duration. The experimental
group was treated for 8 weeks and
instructed to
continue exercise interventions at home for
an additional 4
weeks. All subjects completed the
intervention program and
were retested. One experimental group
subject took 12 weeks
to complete therapist-directed sessions.
RANDOMIZED PILOT STUDY OF
HOME BASED EXC 1999
Stroke is a major cause of death and Papua New Guinea, Pakistan, and Mongolia south,9 with double the incidence along the
disability in many countries. (low in Vietnam, stroke belt.41 In India,
It was reported that, in 2013, globally, there Timor Leste, and DPR Korea); on the contrary, the incidence is higher in
were nearly hypercholesterolemia in Japan, rural areas.7 In
25.7 million stroke survivors, 6.5 million Thailand, the stroke prevalence is highest in
deaths due to stroke, Hypertension the cities, and
113 million disability-adjusted life-years (SBP>140 mmHg then, in a decreasing fashion, in the central,
(DALYs) lost because and DBP>90 mmHg) south, north, and
of stroke, and 10.3 million new cases of (2015) northeast regions of the country.23
strokes.1 A majority of 18+ years (%) Similarly, stroke prevalence
the stroke burden was observed in Diabetes mellitus was found to be higher in cities and urban
developing countries, accounting (FBS>7.0 mmol/L or areas than in rural
for 75.2% of all stroke-related deaths and on medication) regions, in Indonesia.20 These differences
81.0% of (2014) 18+ years (%) have been attributed
the associated DALYs lost. Hypercholesterolemia to the differences in the risk factors between
Stroke is an especially serious problem in (TC>6.2 mmol/L) various regions in
Asia, which has (2008) 25+ years (%) the same country. However, there is no
more than 60% of the world’s population, Insufficient physical difference in the
and many of its activity (2010) age-standardized stroke mortality between
countries are “developing” economies. 18+ years (%) the metropolitan
Stroke mortality is higher Obesity (BMI>30) cities of Korea and the other regions in the
in Asia than in Western Europe, the (2014) 18+ years (%) country.12
Americas or Australasia, Smoking (2015)
except in the case of some countries such as >15 years (%) Comparative epidemiology
Japan.2 The epidemiology Heart disease and stroke are competing
of stroke in East Asia and South Asia has HT, hypertension; DM, diabetes mellitus; causes of mortality.
been previously HL, hyperlipidemia; AF, atrial fibrillation; Generally, stroke-associated mortality, as a
reviewed pS, previous stroke; TIA, transient ischemic percent of total
Vascular factors attack; CAD, coronary artery disease; mortality, is lower than ischemic heart
Increasing age, sex (male), and genetics are SM, smoking. disease-related mortality,
non-modifiable risk in most parts of the world.42 This has been
factors for stroke. The modifiable stroke risk In general, hypertension, diabetes mellitus attributed to the
factors are shown and higher prevalence of diabetes mellitus and
in Table 2, based on data from the tobacco smoking tend to be more prevalent higher mean serum
WHO.6,24 These were derived among men, cholesterol levels among those with
from community-based cross-sectional whereas hypercholesterolemia, inactivity ischemic heart disease,
surveys. Similar criteria and obesity tend to
were used for diagnosis, which makes the be more prevalent among women. than stroke patients. However, in some
studies comparable. countries, the converse
Hypertension remains the most common In general, ischemic stroke occurs more is true, wherein the stroke-related mortality
medical risk factor commonly exceeds the mortality
for stroke, whereas current smoking and than hemorrhagic stroke, except in India and caused by ischemic heart disease (in China
inactivity are the most Vietnam, by 11.9%, Korea
predominant among lifestyle-related risk where the converse is observed. by 9.9%, Mongolia by 8.0%, Thailand by
factors. In most Subarachnoid hemorrhage is 6.6%, etc.). Yet,
countries, high or low frequencies of uncommon. Cerebral venous sinus the stroke mortality in Asia is higher than in
occurrence are observed thrombosis may also cause North America or
consistently across all risk factors for that stroke, especially among young women.4,6 Europe.43
country, compared Likewise, globally, the disease burden—as
to other countries. There is a range of Variations in stroke epidemiology have been measured by the
frequencies within each found within DALYs lost—associated with stroke is
region. A high prevalence of hypertension is many countries. Studies in China have lower than that associated
seen in Mongolia shown that the stroke with ischemic heart disease.42 However, in
and Pakistan (low in Korea and Singapore); incidence is higher in the northern regions terms of mortality,
diabetes mellitus in compared to the the stroke burden exceeds the ischemic heart
disease burden
in the same countries in which an excess
stroke mortality
is observed—China, Mongolia, and
Thailand.
As in much of the world, ischemic stroke
occurs more frequently
than hemorrhagic stroke (Table 4).
However, the 15–
40% incidence of stroke due to hemorrhage,
in Asia, is much
higher than the 15% observed in most
developed countries in
North America and Western Europe. The
incidence of hemorrhagic
stroke is highest in East Asia, notably in
China, compared
to North America and Western Europe.44
Trends
Globally, between 1990 and 2013, there was
a rise in the number
of deaths, survivors, and events associated
with stroke.
However, the significant increase in the
associated deaths and
DALYs lost were not significantly different
between developing
and developed countries.1
Stroke-related mortality has been decreasing
in East-Asian
countries such as Japan, Korea, Taiwan, and
the urbanized areas
of China.43 This may be due to the better
risk factor control
and stroke care in these countries. However,
the age-standard
ized stroke incidence, in general, has
remained relatively constant.
Dealing with the social and economical
burden resulting
from the high number of stroke survivors
with permanent
disability represents a major challenge for
modern
societies. The challenge becomes yet higher
taking into
account the enduring aging of the population
worldwide
[1] that will consequently result in the
increase of the
number of individuals with age related
diseases such as
The GDB study showed a reduction in age-
standardized
stroke incidence in Japan, Singapore, and
Korea, between 1990
and 2010;2 in fact, the substantial decline in
the age-adjusted
stroke incidence in Japan began in the
1960s, due to a decrease
in severe hypertension and current
smoking.45 Impressive
falls in the DALYs lost were observed in
Japan, Singapore,
Korea, and Taiwan (Table 5).2 The decrease
in high mortality,
incidence and morbidity, observed
predominantly in high-income
countries, reflects the significant impact of
the economic
status of a country on health. This pattern of
high incidence
and falling mortality is likely to raise the
prevalence of stroke
in those countries. This problem may be
compounded by the
presence of fewer caregivers, as these
countries also have low
birth rates.
In South-Asian counties such as India,
Pakistan, and Bangladesh,
and in developing countries in South-East
Asia, such as
Cambodia, Indonesia, Lao PDR, and
Malaysia, with the better
control of infectious diseases, life
expectancy will be prolonged.
With the economic transition of these
countries, towards
achieving “developed country” status, risk
factors such as hypertension,
stroke. For the particular case of the USA,
estimates
indicate that by 2030, ~4 % of the population
will have
experienced a stroke, with related costs
expected to rise
from $71.55 billion to $183.13 billion
between 2012 and
2030 [2]. New strategies have to be found to
face this
upcoming scenario, otherwise it will
represent a large
burden on healthcare systems and caregivers.
One approach relies on home-based
rehabilitation, so
diabetes mellitus, hypercholesterolemia,
obesity,
and cigarette smoking will become more
prevalent, raising the
incidence of stroke. However, due to
insufficient healthcare facilities
in these developing countries, the mortality
will be high,
and the number of disabled survivors will
also rise.
Conclusions
Stroke is a major healthcare problem in
South, East, and
South-East Asia. With a majority of the
world’s population living
in the developing countries of these regions,
the the global
burden of stroke will have the largest
contribution from Asia.
In these countries, there are disparities in the
healthcare provisions,
and this will continue to pose a challenge to
disease
control. Governments and healthcare
workers need to work together,
with an informed public, to stem this
growing epidemic.
As life expectancy increases, with the aging
of Asian populations
and reduction in mortality due to infectious
diseases, and
the rise in the prevalence of vascular risk
factors among econ
STROKE EPIDEMIOLOGY 2017
VENKETASUBRAMANIAN
that stroke survivors can continue their
rehabilitation
program after hospital discharge with
minimal supervision.
Home-based stroke rehabilitation has been
increasingly
addressed during the last years, and while
showing
promising results in terms of feasibility and
impact on
recovery[3, 4] it also poses a number of
technical and
human challenges.
Laver KE, Schoene D, Crotty M, George S,
Lannin NA, Sherrington C.
Telerehabilitation services for stroke.
Cochrane Database Systematic
Reviews. 2013;(12). Art. No.: CD010255.
4. Fearon P, Langhorne P. Early Supported
Discharge Trialists. Services for
reducing duration of hospital care for acute
stroke patients. Cochrane
Database of Systematic Reviews 2012, Issue
9. Art. No.: CD000443.
One challenge relates to
the definition of rehabilitation approaches
that are
adequate for a home environment. What is
the most
effective strategy to support users when they
have to use
these systems on their own or with minimum
supervision?
Self-managed computerized rehabilitation
should
be straightforward to use, tailor exercises to
the profile
of users, address function, set goals, improve
selfefficacy,
provide instantaneous feedback on
performance
and be engaging [7–9]. A second challenge in
homebased
approaches in general is long-term treatment
adherence. It has been observed that
compliance tends
to decrease over time below recommended
levels for
reasons such as insufficient familiarity with
technology,
competing commitments, or simply lack of
motivation
[10–12]. Hence, it is important to investigate
what
characteristics should be included in such
systems so
that stroke survivors feel more engaged and
motivated to
use these tools in a systematic way over long
periods
of time.
Two paradigms show promise for engaging
users and
promoting long-term usage of home-based
rehabilitation
technology: coaching and gaming. The first
approach relates
to the use of coaching strategies for
suggesting exercises,
supervising performance, providing
appropriate
feedback and encouragement for training
compliance,
and ultimately leading to sustained behavior
change. The
worth of telephone- or web-based coaching
has been
shown for encouraging physical activity in
overweight
adults [13] and cardiac patients [14], walking
in persons
with Parkison’s Disease [15], or adherence in
a treatment
of depression [16]. One key aspect of
coaching in stroke
rehabilitation is the existence of a patient-
therapist type
of interaction. An association between a
positive therapeutic
alliance and better treatment outcomes and/or
treatment adherence has been reported in
neurological
rehabilitation [17–19]. Such an alliance has
also been
observed between clients and relational
artificial agents
[15, 20] suggesting the feasibility of using
virtual coaches
as a valid alternative to face-to-face patient-
therapist
interaction.
Coaching: mode based on the delivery of
positive
feedback and encouragement during training.
The
system has a total of 41 prerecorded feedback
sentences, each of them associated to a score
range.
The categorization of the feedback sentences
was
done based on the ratings of 10 naive healthy
volunteers who were asked to imagine that
they
were exercising in a gym and that a coach
was
giving them feedback on their performance.
For
each feedback sentence, the volunteers rated
their
perceived performance in a 10-point Likert
scale (1 -
I performed very poorly; 10 - I performed
very well).
These ratings were used to allocate the
feedback
sentences to specific scores. After each
movement
sequence, and based on the achieved score,
audio
and written encouragement feedback is given
to the
user concerning the performance of the
movement
(Fig. 1b). For example, feedback sentences
such as
"That was fantastic!" or "That was
awesome!" are
associated to very high scores (≥8); on the
opposite
side, feedback sentences such as “Let’s try
again. I
know you can do better.” Or “That was
close!”
correspond to lower scores (≤2).
When dealing with home-based self-managed
rehabilitation,
one of the main problems is the use rate
decrease
over time for reasons such as frustration in
the use of
the affected limb, lack of motivation to
exercise, or simply
difficulty in implementing a systematic
training
routine [10, 12]
In humans, stroke survivors that performed
protocols with
hundreds of movement repetitions displayed
cortical
plasticity and better functional improvements
than controls
with lower doses of treatment [43, 44].
Hence, any
rehabilitation program should promote the
execution of
an adequate number of movement repetitions
to optimize
recovery. Unfortunately, current movement
practice during
stroke rehabilitation tends to be insufficient particular perceived deficits and personal
[45, 46]. preferences Conclusions
For example, Lang et al. observed 312 (tai-chi, baseball, etc. …). This suggests that In this paper we compared two promising
conventional therapy for increasing approaches
stroke rehabilitation sessions and reported usage and adherence in home based for home-based stroke rehabilitation,
that on an rehabilitation coaching and gaming,
average 36 min session, patients executed 54 systems, tasks should be individualized and and aimed at identifying key characteristics
active directed towards of each
movement sequences of the upper extremity the specific perceived deficits and needs of mode that should be taken into account for
[45]. Extrapolating each future development
our results from 5 stroke survivors to a 36 user, and, when possible, in the context of and deployment. For healthy participants, the
min activities that gaming mode was considered more
session and assuming one fourth of rest stroke survivors enjoy. enjoyable, a key
period, it would The results of this preliminary study allowed factor for improving treatment adherence.
be possible to achieve about 196 repetitions us to observe However, the
during gaming that choices on specific features of computer activity level was affected by the game
and 422 repetitions during coaching, with based dynamics, and
coaching rehabilitation approaches should be carefully hence participants were more active during
being more than two times more efficient weighed depending the coaching
than gaming in on the profile and goal of end-users. mode because it was fully self-paced. Stroke
terms of repetitions. This means that we Coaching is survivors
could reach satisfactory thought to provide support strategies to help showed a similar trend. Data on movement
movement practice with the coaching mode, achieving an execution
but internally driven behavioral change, whereas during gaming on healthy participants has
would fall short with the current interactive gaming, as however been
game, shown in our results, can be used as an shown to lead to increased movement quality,
although reaching much better activity levels external driver. possibly
than those Hence, this does not mean that therapists and because the focus of attention is on
reported in the literature for conventional patients movement effects
therapy. Nevertheless, necessarily have to choose one over the other. and not on movement patterns. Yet, this
dosing depends on three key parameters: (1) In fact, we might be influenced
training believe that an optimal approach would be by the impairment level when used by
duration, (2) frequency with which the one that extracts patients.
individual the most beneficial features of these
performs training, and (3) number of approaches and Finally, both training modes have shown high
repetitions performed combines them into a single paradigm. Such a acceptance
during training broader approach in both healthy participants and stroke
could then be customized for targeting survivors, although
On the other hand, animal studies suggest patients healthy participants rated significantly higher
that the mere repetition of movements with different profiles, needs and preferences. the perceived
involving little or Stroke patients in an acute stage will in usefulness of the feedback in coaching.
no learning, does not induce plastic changes principle benefit more from a solution that We showed that the choice of the training
in motor promotes paradigm in
maps [6, 48]. For this reason, rehabilitation more repetitions that can lead to faster to computer based approaches influences
training higher levels performance and
should be task-specific and always pose of recovery. Hence, we speculate that a we discussed the potential implications for
motor challenges coaching approach stroke rehabilitation.
for post-stroke subjects would be more adequate. However, for long- As follow-up work, it is now important to
term evaluate the specific performance effects of
Finally, home based treatment past the acute stage of gaming and
when stroke survivors were asked about stroke coaching in a large sample of stroke
particular exercises aimed at fitness and maintenance, a gaming survivors, and also
they would like to perform with such system, approach the impact of recovery through a controlled
there could be more adequate and lead to more clinical trial.
was a trend towards selecting exercises assiduous Further, an assessment at the home of
directed to their training. participants is required
to evaluate long term use and adherence.
Physical function reaches its peak at around 6
months
poststroke and begins to decline as soon as 1
year after
stroke1; this suggests that increasing use of
rehabilitation
postdischarge is likely to result in better
functional recovery.
Indeed, supervised stroke rehabilitation in the
community for
up to 1 year postdischarge was associated
with faster recovery
and better functional status at 1 year than
with unsupervised
therapy.2 The main barriers cited by patients
to participating
in supervised rehabilitation postdischarge
were
getting to the rehabilitation clinic and
inconvenience.2 Providing
rehabilitation in the home is limited by high
costs and
rehabilitation provider availability,
particularly in rural ar-eas.3
Thus, stroke survivors could benefit from a
system that
enables therapists to deliver rehabilitation in
the patient’s
home from a remote location.4
Participants were eligible for the study if they
experienced an
ischemic or hemorrhagic stroke within the
previous 24 months.
Other inclusion criteria included age 45 to 90
years, having been
discharged to the community, not cognitively
impaired (no more
than 4 errors on the Short Portable Mental
Status Questionnaire),
able to follow a 3-step command, discharge
motor Functional
Independence Measure (FIM) score of 18 to
88 (ie, maximal
assistance on no more than 4 motor activities
of daily living as the
most severe stroke included, and modified
independence on at least
2 motor activities of daily living as the least
severe), approval by the
Coaching or gaming? Implications of
strategy choice for home based stroke
rehabilitation Mónica S. Cameirão1,2 2016
patient’s physician, and signed medical media
release form.6 The
FIM measures physical and cognitive
disability with reference to
burden of care. It has been employed to check
patient progress and
to measure rehabilitation outcomes.7
The STeleR intervention focused on
improving functional mobility. The
intervention lasted 3 months and
included the following 3 components: 3 1-
hour home visits (televisits)
by a trained assistant to assess physical
performance and help
communicate the instruction of exercises and
use of assistive
technology and/or adaptive techniques
recommended by a licensed
physical therapist or occupational therapist
(teletherapist); participants’
daily use of an in-home messaging device
(IHMD) that was
monitored weekly by the teletherapist; and 5
telephone intervention
calls between the teletherapist and the
participant. During this
3-month period, all participants (intervention stepping on a
and UC) received
routine VA care as directed by their
providers.
Home-based telerehabilitation (TR) is defined Thus, providing home-based, exercise-
as use by a
clinician of telecommunication devices (eg,
telephone, videophone)
to provide evaluation and distance support of demonstrated that a telehealth program that
disabled persons living at home.4 Many
standardized instruments
have been validated and recommended for
use by
occupational therapy/physical therapy via
high-quality videoconferencing
system when an in-person assessment is
impractical.
4 A 2011 systematic review of TR
interventions in
stroke care identified 9 studies; only 4 of
these were randomized
controlled trials (RCTs), the quality of which for communitydwelling
indicated
that methodological improvement is needed.5
Most of the TR
studies focused on upper extremity function.
Lacking from
stroke TR studies were interventions directed
toward broader
functional goals using traditional
rehabilitation interventions
(eg, exercise, adaptive strategies).
Motor weakness in the lower extremities
adversely affects
functional mobility, including sit-to-stand
ability and the
ability to walk,15 and thereby affects
mobility-related daily
tasks and social roles. Exercise and use of
adaptive strategies,
such as assistive technology (eg, gait aids,
bathroom aids) and
environmental modifications (eg, rails), have
been found to
improve physical functioning; these are the
main focus of
traditional physical rehabilitation. In fact,
locomotor training,
including the use of body-weight support in
treadmill, was not shown to be superior to
physical therapistsupervised
progressive exercise for stroke patients at
home.20
oriented interventions
is very efficacious. Dovetailing with this
literature, we
taught stroke
patients how to perform functionally based
exercises and
improve the interface with their environment
resulted in
greater improvements in the ability to
perform both self-care
and social role tasks than did UC alone. To
our knowledge,
this is the largest RCT to date employing
telerehabilitation
technology to improve functional outcomes
individuals who experienced a stroke within
the past
2 years.
STeleR has potential
to be a useful supplement to traditional
poststroke rehabilitation,
given the limited resources available for in-
home
rehabilitation for stroke survivors. Many
individuals with
stroke have serious challenges traveling to a
facility for their
care because either they cannot drive or their
informal
caregiver cannot take extended time off work
to travel to the
main hospital.24 Telehealth-based programs
similar to STeleR
could be an important way to overcome these
access barriers
Mobility is essential for an active and healthy
lifestyle.1 It can reduce rates of
chronic disease in individuals and is
considered to be central to regular healthy
living and aging.2,3 Consequently, mobility
limitations (i.e., the inability to move
from place to place or limitations in
independent
physical movement) are often associated with
both
disease and health complications, including
obesity
and cardiovascular disease.4 Individuals who
experience
limited mobility often report poor mental
and cognitive health, which negatively affects
quality
of life, increasing morbidity and mortality
rates.5
This issue of mobility limitations is more
pronounced
in stroke survivors. An estimated 800,000
people have a stroke each year,6 with more
than 75%
of individuals losing their ability to walk.7,8
Kelly-
Hayes et al.9 observed 5,209 stroke survivors
6 mos
after their stroke and reported that 30% could
not
walk without assistive devices, 26% were
dependent
and may be particularly useful for reaching
vulnerable patient
groups, such as individuals from a lower
socioeconomic
status and those who live in a rural area.
STeleR may also be
more readily integrated into clinical practice
than are faceto-
face programs. Findings from this study
could lead to
improved methods for functional assessment
and more effective
and efficient rehabilitation strategies, and
could support
the implementation of more efficient and
effective approaches
to coordination of care when transitioning
from
hospital to home. Even though our novel
intervention employed
research staff for the home visits, we believe
that it
for activities of daily living, and 26% were
institutionalized
in a nursing home because of physical
limitations. In addition, elderly individuals
(965 yrs)
who had a stroke have a 63% lower
probability
of maintaining independence 3 mos after
being
discharged from the hospital.10 Given these
staggering
numbers, it is important to explore
interventions
that can improve, maintain, or prevent
further declines in mobility and independence
among
long-term stroke survivors.
Physical activity interventions have been
successful in enhancing physical function in
older
adults11Y14 and tend to confer a protective
effect
for functional limitations, including mobility,
disability,15Y17 and fall prevention.18Y20
Researchers
have similarly examined the effectiveness of
various
physical activity and exercise regimens for
stroke
patients in an effort to improve functional
outcomes
in this population. Wevers et al.8 conducted a
has ready application to real-world scenarios.
For example,
home health personnel already in the home,
such as skilled
nurses or even certified nurse aids, might use
the technology
to communicate efficiently with centrally
located rehabilitation
personnel. Within the Veterans Health
Administration,
telehealth technologists are now employed in
peripheral
clinics to facilitate telehealth clinics. In
addition, the telehealth
technologists may be able to facilitate home
telehealth
visits.
EFEK TELEREHAB ON PHYSICAL
FUNCTION AND DISABILITY STROKE
PATIENTS 2012
systematic review assessing the effects of
taskoriented
circuit class training on walking after
stroke. They concluded that circuit-training
classes,
including gait-related tasks, are effective in
improving
subjects_ walking capacity after a stroke.
An and Shaughnessy21 conducted a
systematic review
assessing the effects of exercise-based
rehabilitation
on balance and gait for stroke patients.
The authors concluded that initiating early
rehabilitation
after a stroke can improve balance and
walking capacity. Pang et al.14 conducted a
metaanalysis
that examined the impact of aerobic exercise
on aerobic capacity in stroke survivors. The
authors concluded that aerobic exercise
improves
cardiovascular fitness in stroke survivors. In
addition,
Stoller et al.22 conducted a systematic review
and meta-analysis assessing the effects of
cardiovascular
exercise early (e6mos) after a stroke. They
inferred that stroke survivors might benefit
from
cardiovascular exercise during the acute and
subacute
phases of rehabilitation. However, each of
these reviews (1) examined participants who improvements since stationary biking limits
were the
either in the acute or subacute phases after need for postural control and balance, two
their components
stroke and (2) primarily involved stationary that are important for mobility. However,
biking, it remains to be determined whether such
which is a seated mode of aerobic exercise. exercise
The interventions can significantly improve
authors also acknowledged that other modes mobility
of and physical function among long-term
aerobic exercise might lead to greater survivors,
mobility after this subacute phase (96 mos since
stroke).
CONCLUSION
The findings of this study provide further
evidence
that aerobic exercise may improve mobility
long after a stroke. When combined with
rehabilitative
physiotherapy, aerobic exercise improves
walking capacity and gait speed.
#Effect Aerobic on Mobility
Stroke_kendall2016

Proper care of stroke survivors is essential as (Schneiders et al., 1998). Adherence or non- neurology outpatient clinic for the first time;
stroke can adherence can (b) have a
lead to neurological deficits that in turn lead be measured using an exercise diary or caregiver present for therapy sessions; (c)
to functional logbook. This can be above the age of
impairments. Functional recovery in a stroke accompanied by a standardised functional 18 years. Participants were excluded if: (a)
survivor begins outcome measure they had been
with rehabilitation. It has been found that or questionnaire (Bassett & Petrie, 1999; dependent in activities of daily living before
supervised Schneiders they had
rehabilitation in an institution or at home et al.; Schoo, Morris, & Bui, 2005). stroke; (b) they had any physical impairments
improves a patient’s pre-stroke;
quality of life and fitness (Touillet, Guesdon, Methods (c) this was not their first stroke. Once
Bosser, A randomised controlled trial was used to informed consent to
Beis, & Paysant, 2010). However, it may not compare adherence participate in the study was obtained, patients
be feasible for to a 4-week home exercise programme in were
therapists to supervise all rehabilitation, patients randomly allocated to either the control or
especially in a with stroke. Patients received a home intervention
home environment. Therefore, adherence to exercise programme group. The investigator was blinded to the
home exercise with verbal instructions or a home exercise group allocation.
programmes is important (Taylor, Dodda, programme A research assistant randomised the
McBurney, & with verbal instructions and a written and participants and concealed
Graham, 2004), and would allow for potential pictorial home their allocation using an envelope
savings in exercise prescription added on. Adherence
treatment cost and help to avoid morbidity was defined as Stroke type and severity were not considered
and unwanted “the extent to which a client completes the in the inclusion
side effects (Schneiders, Zusman, & Singer, active element and exclusion criteria because the aim of the
1998). It also of treatment effectively following advice and study
has a positive effect on functional outcome instructions was not to create a homogeneous group of
(Duncan et al., and comprises a wide variety of behaviours stroke survivors.
2002). including
entering into and continuing a treatment All patients had a full assessment done by the
In 2008, Howard and Gosling defined programme, researcher
adherence as the attending therapy appointments and during their first appointment. This included
ability to continue with an activity once it has performing homebased demographic
been initiated. exercises” (Taylor et al., 2004, p. 57e58) information, history-taking and functional
There are two ways to look at adherence: assessment using
first, as an Stroke survivors were recruited from a the MRMI and BI. This was followed by
attitude, in which case the willingness to hospital-based treatment using
follow prescribed neurology outpatient clinic. Those who met functional activities and exercise therapy and
instructions is assessed, and second, as a the following a home exercise
behaviour, which criteria were included in the study: (a) programme with verbal instructions. This is
then relates to the actual carrying out of the attending the standard
prescription
practice at the hospital where this study was
conducted.
The intervention group was prescribed the
standard
home exercise programme described above,
but with an
additional written and pictorial prescription
of the home
exercises to optimise the patients’ functional
status. The
home exercise programmes are drawn up
according to patients’
clinical presentations and the patients’ as well
as
caregivers’ main concerns. The programmes
are tailored to
the functional ability and home circumstances
of each
stroke survivor. However, the individual
exercises are
selected from a compilation of exercises (of
which a selection
is presented in Appendix I) so as to maintain
some
level of control. The compilation was
developed based on
common exercises that are prescribed for
stroke rehabilitation
with reference to the current literature and,
for
content validation, in consultation with
therapists who
work in the field of stroke rehabilitation. To
prevent the
exercises from being too complex to
understand, each exercise
had a name, an accompanying picture(s) and
a basic
set of instructions (Schoo et al., 2005).
Both control and intervention groups were
given an exercise
logbook with instructions to document their
adherence
to the home exercise programme. The
logbook
Introduction
Rehabilitation therapy is important for stroke
patients.
The Centers for Medicare and Medicaid
Services (CMS)
reported that stroke patients need to receive a
minimum
spanned a 4-week period with the specific
dates and days
for daily recording of the prescribed
exercises. There were
columns next to each exercise for the patient
and caregiver
to sign off a completed exercise. There were
also columns
for the times that the exercise was started and
ended so as
to log the time it took the patient to complete
the home
exercise programme.
All participants were followed-up after 4
weeks. At the
follow-up appointment, the investigator
retrieved the
completed exercise logbook and administered
the MRMI and
BI again for a follow-up score.
The caregiver played an active role in both
control and
intervention groups and was educated and
sensitised to
the importance of exercises by the researcher.
Emotional/physical support from family
members or
caregivers is deemed to be one of the most
important
factors in improving adherence to home
exercise programmes
(Taylor et al., 2004). Therefore, the role that
the caregiver played in both groups may
explain the
similar adherence rates.
_ All participants were given an exercise
logbook to
document their adherence. Taylor et al.
(2004) reported
that the log sheet that needs to be filled out
regarding
the completion of each exercise serves as a
reminder
and a motivational track record for the patient
and assists
patients in improving their adherence.
of 3 hours of therapy for at least 5 days or a
minimum of
15 hours over 7 days.1 No study has yet been
published
that provides evidence to support the CMS 3-
hour rule
requirement. In Japan, convalescent
rehabilitation wards
_ The exercise programme that was
prescribed to all the
participants in both control and intervention
groups
consisted of three short personalised
exercises, which
may have played a positive role towards
adherence
(Schneiders et al., 1998).
Conclusion
Based on the study results of similar
adherence rates in the
control and intervention groups, it appears
that the addition
of a written and pictorial home exercise
prescription
does not lead to better adherence to a home
exercise
programme compared to having no written
and pictorial
instructions. Possible reasons for this finding,
apart from
the actual intervention of the written and
pictorial home
exercise programme, may be that patients had
caregivers
as a support system, the exercise logbook
served as a
reminder and motivational track record for
patients, and
the exercise programme was short and
personalised. There
also does not appear to be a relationship
between functional
ability and level of adherence, which may be
due to
the study participants being within the
optimal time frame
for spontaneous functional recovery of 6
months. Further
study at different time frames in stroke
rehabilitation in
different contexts is recommended.
#Effect OF written &pictorial Home EXc
on Adherence_2016
are the main system providing inpatient
rehabilitation
facilities covered by the medical insurance
system.
Patients who still need assistance in activities
of daily living,
after acute treatment, are transferred to these
rehabilitation
wards.2 The maximum length of stay (LOS) methods, is a feasible alternative to a increased FIM gain.
and randomized controlled
amount of exercise with therapists covered by trial. We examined the associations of the
insurance amount Many studies have showed the positive
are limited. In the Japanese medical insurance of rehabilitation with functional gains in association
system, elderly stroke between a longer rehabilitation treatment
the maximum LOS for stroke patients is 180 patients at the convalescent rehabilitation time per day
days and the ward using the and functional gains of stroke patients.7,11
maximum rehabilitation time for stroke PS analysis methods and the Japan Wang et al12
patients is 3 hours Rehabilitation Database. showed that the daily treatment time of
of rehabilitation per day, including weekends physical therapy,
(21 hours The intensive rehabilitation therapy (IRT) occupational therapy, and speech and
per week). Previous studies have group was language therapy
demonstrated that the defined as the stroke patients who received was also significantly associated with
amount of therapy a patient receives is related more than functional gains.
to outcomes 15 hours of rehabilitation therapy per week Jette et al13 reported that longer daily
such as independence in ambulation and (315 hours) treatment durations
ambulation by physical therapist, occupational therapist, of physical and occupational therapy were
distance,3 independence in activities,4 and and/or associated
chances of speech therapists. The subjects of the usual with increased FIM score and mobility
discharge to home.5 Several recent studies rehabilitation function of
reported the (UR) group received less than 15 hours of patients who had suffered a stroke and that
positive effects of daily rehabilitation rehabilitation longer daily
treatment time on therapy per week (<15 hours). The Japanese treatment durations of OT and SLT were
functional improvement of patients, who public health associated with
suffered a insurance system reimburses rehabilitation better improvement of cognitive function of
stroke, at an inpatient rehabilitation performed by patients who
hospital.6-8 physical, occupational, or speech therapists had experienced stroke, in skilled nursing
when the facilities.
However, the determination of the amount of patient receives rehabilitation therapy for 7
rehabilitation days a week CMS reported that stroke
is left to the discretion of the physician and/or patients are required to receive a minimum of
the Outcome Measurements 3 hours of
therapist. For example, patients with a low The primary clinical outcome was the FIM therapy for at least 5 days or a minimum of
capacity of gain (discharge 15 hours over
activities for daily living are more likely to FIM - admission FIM). The FIM is a reliable, 7 days.1 In the UK guidelines for stroke, it is
have a validated recommended
decreased amount of rehabilitation and such indicator of activities of daily living that has that people with stroke should accumulate at
patients are 13 items least 45 minutes of each appropriate therapy
also more likely to have decreased functional regarding motor function and 5 items every day.17
gain. Thus, regarding cognitive In the Australian guidelines for stroke, it is
the selection treatment is confounded by function.10 Each item is given 1-7 points, recommended
patient factors from “total assistance” that rehabilitation therapy should be provided
that are also related to outcomes. Most of the to “complete independence”. Total scores to stroke
studies cited range survivors for a minimum of 3 hours per day,
were not able to adjust comprehensively for from 18 to 126, with higher scores indicating with at least
the variety of greater independence. 2 hours of active task practice.18 Our results
factors that influence the amount of The secondary clinical outcomes were supported
rehabilitation. It discharge the importance of the CMS 3-hour rule at
appears difficult in practice to conduct a rate to home and FIM efficiency (FIM convalescent
randomized controlled gain/LOS). rehabilitation wards.
trial to examine the effects of increasing the Previous studies have demonstrated that
amount of rehabilitation; instead, a large- The result based on the database we used inpatient
scale retrospective showed that . stroke rehabilitation has been shown to
cohort study, using the propensity score longer rehabilitation time per week was positively affect
(PS)analysis associated with
the probability of home discharge.19,20 The
clinical importance
of rehabilitation therapy for stroke has been
wellestablished,
but the debate on the most appropriate time
of rehabilitation therapy per week continues
to date.
Suzanne et al21 reported a consistent dose-
response to
rehabilitation therapies across discharge.
However, the
high intensity group was defined as patients
who received
therapy intensities of at least 60 minutes per
day in this
There is a growing body of evidence that
suggests
a positive relationship between motor
recovery after
stroke and the dose of therapy provided
(Kwakkel et al,
2004; Lohse, Lang, and Boyd, 2014;
Schneider, Lannin,
Ada, and Schmidt, 2016; Veerbeek et al,
2014). Findings
from meta-analyses and trials suggest that to
maximize
recovery of movement of the upper limb,
therapists
should provide intensive, repetitive task-
specific training
(Langhorne, Coupar, and Pollock, 2009; Van
Peppen
et al, 2004; Veerbeek et al, 2014). However,
there are
significant challenges faced when delivering
high-dose
upper limb therapy (Kaur, English, and
Hillier, 2012;
Kwakkel, 2006), and to address these,
therapists may
also need to encourage practice outside of
therapy
times (Schneider, Lannin, Ada, and Schmidt,
2016).
The use of home-based therapy as one
component of
a motor training program potentially enables
an even
greater dose of motor training to be provided
after stroke
(Brown et al, 2015; Coupar et al, 2011).
study. Similarity, Jette et al22 showed that
patients in
skilled nursing facilities were 1.22 and 2.02
times more
likely to be discharged to the community
when therapy
averaged 1-1.5 hours per day and more than
1.5 hours per
day, respectively, as compared with less than
1 hour per
day. Wodchis et al23 also reported a greater
likelihood for
community discharge was present as dose
increased. In
External work and amount of time dedicated
to practice. An observational study by
Connell et al. (2014) looked at
time, repetitions and accelerometry as
measures of intensity
during a structured upper limb exercise
program in
a group of stroke patients. They concluded
that time may
not be the most accurate measure of intensity
and that
counting repetitions was feasible when using
a structured
exercise program, such as used in the
InTENSE trial. In
the present study, the mean exercise time was
50.3 min
(SD 16.04) and the median number of
repetitions was
134.0. In the study by Connell et al. (2014),
themean time
was 48.5 min (SD 7.8 min), and median
purposeful repetitions
was 251. The lower number of repetitions in
the
present study can be explained by a greater
level of
impairment of participants in this study
population in
comparison to the participants in the study by
Connell
et al. (2014) that is, the severity of stroke will
influence the
ability to self-practice.
The role the therapist plays in enhancing
adherence in
clinical practice is important to consider.
While this was
the present study, the discharge rate to home
in the IRT
group was higher than the UR group before
and after
IPW adjustment. Our result suggests that IRT
is associated
with higher discharge rate to home in elderly
stroke
patients at convalescent rehabilitation wards.
Effectiveness of Intensive Rehabilitation
Therapy on Functional
Outcomes After Stroke: A Propensity
Score Analysis Based on
Japan Rehabilitation Database 2019
not formally assessed in this study, three
participants commented
to the investigator that they were conscious of
the
fact that the investigator may have monitored
their
practice. This may be seen as a form of
therapist ‘supervision’,
and there is extensive research that suggests
motivation
and compliance can be enhanced through
supervision of exercise programs (Picorelli et
al, 2014;
Schutzer and Graves, 2004).
The importance of the role of social support
on health
has been extensively reported in the literature
(Brenner and
Marsella, 2008; DiMatteo, 2004; McAuley et
al, 2003). The
precise means by which social support
improves health
outcomes is not completely understood but
may include
benefits such as buffering stress, influencing
the ability to
adjust and supporting adherence to treatment
(DiMatteo,
2004). The findings from our study, where all
participants
who had less reliable social supports were
amongst those
who practiced less, are in line with other
works suggesting
higher levels of social support are associated
with better
adherence to exercise (Essery, Geraghty, adherence to exercise recommendations. In participants. This finding suggests that future
Kirby, and our study, an trials of
Yardley, 2017), and it has been suggested exploration of individual case studies upper limb home exercise program efficacy
that caregivers revealed that the should stratify
are under-utilized in assisting during participants who had less social support were for baseline activity ability and also for the
rehabilitation amongst availability of
(Galvin, Cusack, and Stokes, 2009). Visser those who exercised less. The support from support from family.
Brychta, Chen, family as VIALIBILITY 2019
and Koster (2014) found older people with reported by the Social Support and Exercise
low levels of Scale was
social support were also more likely to more important than that from friends in this
misperceive their group of

Introduction financial and social barriers.8 The latter the patient on how to use the tele-
Stroke is a leading cause of long-term include rehabilitation system
disability in mobility and transportation problems, as well and how to perform the physical
Singapore, contributing to 6.8% of total as the rehabilitation and exercises.
disabilityadjusted cost of treatment.8 Similar barriers were These aim to improve physical function such
life years and 4.7% of years lost to reported in a as
disability.1 recent study that documented unmet needs for strength, mobility and balance.14,15 In
poststroke addition, telerehabilitation
Stroke survivors rehabilitation services in India.9 can enable therapists to work with and
often experience physical limitations (such as evaluate their patients remotely and the
loss of Given the modifiable barriers to continuing patients to perform
balance, mobility and dexterity)3 and require rehabilitation rehabilitation in the comfort of their own
rehabilitation after hospital discharge,8 home-based tele- home
to regain their functional independence rehabilitation and at their own convenience.16,17
during may be an alternative to centre-based
and after hospitalisation. (conventional) rehabilitation for stroke The inclusion criteria for the trial were: (a)
Rehabilitation may be defined as a process survivors in age _40
where Singapore. Systematic reviews have shown years, (b) recent stroke (within four weeks
individuals with disability, such as stroke that stroke prior to
survivors, patients who completed home-based tele- recruitment), (c) able to sit unsupported for
receive assistance from health-care rehabilitation 30 seconds,
professionals to achieved outcomes equal or greater to those (d) able to stand on the non-paretic leg for
regain functional independence through of centrebased more than
various types patients in terms of physical function and four seconds, (e) able to walk at least two
of therapies (e.g. physical, occupational and participation metres with a
cognitive), in social activities.10–12 Additionally, those maximum of one person assisting, (f) able to
and this plays a key role in recovery.4 who experienced tele-rehabilitation reported follow a
Adhering to higher two-step command, (g) living in the
rehabilitation at both inpatient and outpatient levels of satisfaction with tele-rehabilitation community before
settings services13 the stroke and expected to be discharged
can facilitate these individuals to achieve compared to those who completed centre- home and (h)
their goals of based having a caregiver when the patient was
regaining and/or maintaining functional rehabilitation. doing the exercises
independence5 Home-based tele-rehabilitation programmes for safety reasons.
and potentially lower long-term health-care often The exclusion criteria were: (a) a pacemaker
costs.6,7 consist of education, exercise and social in situ,
A local study, however, reported that a support components (b) unable to ambulate at least 45 metres prior
significant delivered through a video-conferencing to stroke
number of participants chose not to continue system.14 or intermittent claudication while walking
their A therapist or therapy-aide initially provides less than
rehabilitation after hospital discharge due to training to 200 metres, (c) serious cardiac conditions, (d)
functional, history
of serious chronic obstructive pulmonary
disease or
oxygen dependence, (e) severe weight-
bearing pain,
(f) pre-existing neurological disorders, (g)
history of
major head trauma with severe residual
deficits,
(h) lower extremity amputation, (i) legal
blindness or
severe visual impairment, (j) severe
uncontrolled psychiatric
illness, (k) life expectancy of less than three
months, (l) severe arthritis or orthopaedic
problems
that limit passive ranges of motion of lower
extremity,
(m) history of sustained alcoholism or drug
abuse in
the last six months or (n) hypertensive crisis.
Details
can be found in the published protocol by
Koh et al.15
The primary outcome was self-reported
disability,
which was measured by the disability
component of
the Late-Life Function and Disability
Instrument
(LLFDI).20 The instrument evaluates self-
reported frequency
of participating in 16 major life tasks and
limitation
Supervised therapy is an important factor in
determining
post-stroke functional recovery. In a 1-year
cohort
study on local post-stroke patients in the
community,
only a third of the subjects undergo
supervised
rehabilitation one month after discharge into
the
community [1]. Those who performed
supervised
therapy >25 % of the recommended amount
of time
recovered faster than those who performed a
lesser
amount of supervised therapy <25 % at 1-
and 6-
months. Performing therapy at outpatient
rehabilitation
centre at 1- and 6-months post-stroke is also
in performing such activities. A five-point
scale
was used for all LLFDI items. Raw LLFDI
scores are
transformed into a scale ranging from 0 to
100. Higher
scores indicate more participation and less
limitation.
The frequency component of the LLFDI was
reported
to correlate highly with the physical
functioning subscale
of the Medical Outcomes Study 36-item
Short-
Form Health Survey, while its limitation
component
was reported to correlate moderately with the
London Handicap Scale.21,22
The secondary outcomes of this study
included: (a)
the timed five-metre walk test,23 (b) two-
minute walking
distance,24 (c) the modified Barthel Index
(BI),25 (d)
the Activities-Specific Balance (ABC)
scale26 and (e)
the EuroQoL (EQ-5D).27 The details of these
measurements
are summarised in the published protocol.15
Potential cost savings
Llorens et al. reported a lower cost of
telerehabilitation
of US$654 for stroke survivors in Spain
independently predictive of better Barthel
Index (BI)
scores at 1 year (72.4 vs. 62.7 at 1 month and
74.7 vs.
59.4 at 6 months). Greater functional
independence is
associated with reduced caregiver burden,
better patient
health-related quality of life and potentially
lower
cost of care [2–5].
Solutions to addressing non-adherence to
rehabilitation
include the use of transportation and mobility
systems
such as stair-lifts for stroke survivors living
in
apartments on floors without access to an
elevator. Paid
compared to centre-based rehabilitation due
to the
reduced hours of supervision by physical
therapists.6
It was found that in-clinic intervention
required 8.3
physical therapist hours, whereas home-based
telerehabilitation
programme required 1.6 hours.6 Besides
savings due to reduced physical therapist
hours, savings
in travel expenses, which represent 88% of
the
total costs of in-clinic intervention, also
contributed
to the reduced cost of home-based tele-
rehabilitation.6
Similarly, Thaker et al. reported reduced
costs of
transportation for therapists to make home
visits to
provide in-person rehabilitation with the use
of telerehabilitation.
32 Consequently, tele-rehabilitation in
Singapore has the potential to reduce some of
the operating
costs such as travel time and transportation,
while optimising post-stroke rehabilitation
participation
after hospital discharge.
TELE REHAB +IMPACT ON SELF
REPORT FUCNTIONAL
OUTCOMES_SINGAPORE_ASANO2019
handicap-fitted transport services to ferry
stroke survivors
to and back from outpatient rehabilitation
centers
can also overcome physical barriers.
Providing paid caregivers
for social support and subsidies for outpatient
rehabilitation
may reduce financial and social barriers.
Nevertheless, all such services and/or
equipment are expensive;
moreover, caregivers are in short supply
around
the world [5].
Given the heavy cost and inconvenience
incurred in
transporting stroke survivors to outpatient
rehabilitation
centers, home rehabilitation seems to be a
viable option
in the delivery of post-stroke recovery. Even
through
home rehabilitation was shown to be equally
effective as
inpatient rehabilitation [6, 7], it is less cost-
efficient than
outpatient rehabilitation center [5]. Gladman
et al.
randomized 327 patients to receive
domiciliary or routine
(hospital-based) care. Over a 14-month time
frame,
mean per patient costs for hospital-based
services were
less than domiciliary services [8]. Indeed, the
cost of
home rehabilitation is at least two times more
expensive
than therapy at an outpatient rehabilitation
center (in
Singapore, the norm cost of one hour of home
rehabilitation
is S$125 per hour and one hour of centre-
based
rehabilitation is S$50 per hour [5]). The
relatively higher
cost for home rehabilitation can be attributed
to the
greater economies of scale in outpatient
rehabilitation as
compared to home rehabilitation [8]. For
instance, home
therapists can only see one patient at a time
whereas
centre-based therapists can directly supervise
the treatment
of more than one patient at a time.
Recent studies focus on the use of home-
based telehealth
technologies to provide support and guidance
by
rehabilitation therapists at a distance,
representing a novel
potential approach for addressing the access
to post-acute
rehabilitation care problem for stroke
survivors [9]. Telerehabilitation
provides greater convenience to patients
and families and encourages rehabilitation
within the
patient’s home. A study by Sanford et al.
showed the feasibility
of providing a multi-factorial,
multidisciplinary individualized,
home-based tele-rehabilitation intervention,
demonstrating improved self-efficacy in
mobility-impaired
adults (n = 16) to the same degree as those
who received
supervised rehabilitation with
physiotherapists and occupational
therapists at outpatient rehabilitation centers
(n = 16) [10]. These findings were
corroborated and
extended in two subsequent randomized
clinical trials,
with differing populations (stroke survivors
and intensive
care survivors) [11–13]. However, the
intervention
still require home visits and video-recordings
by a therapy
aide. Moreover, as video-recordings do not
allow
the collection of physical and sensor
information frompatients,
this approach to tele-rehabilitation limits the
therapists’ assessment of patient performance
Inclusion and exclusion criteria
Stroke diagnosis
Participants are individuals with recent onset
of ischemic
or hemorrhagic stroke. For purposes of
inclusion in this
study, a stroke is defined, according to the
World Health
Organization definition, as “a rapid onset
event of vascular
origin reflecting a focal disturbance of
cerebral function,
excluding isolated impairments of higher
function
and persisting longer than 24 h [16]”. Stroke
diagnosis
will be made by a clinician and/or supported
by brain
imaging.
Inclusion criteria
The inclusion criteria for the trial are as
follows: (1)
age ≥ 40 years, (2) recent stroke (defined as
stroke diagnosis
occurring within 4 weeks prior to admission
into
inpatient rehabilitation unit or hospital), (3)
able to sit
unsupported for 30 s, (4) able to stand on the
nonparetic
leg for >4 s, (5) able to walk at least 2 m with
maximum of 1 person assisting, (6) able to
follow a 2-
step command, (7) living in the community
before
stroke and expected to be discharged home,
(8) has a
caregiver when the patient is doing the
exercises for
safety reasons, as the tele-therapist is not
present when
the patient is doing the exercise and a
caregiver is
needed to catch the patient if he/she should
fall.
Exclusion criteria
The exclusion criteria for the trial are as
follows: (1) has
a pacemaker in-situ (because of possible
interference of
pacemakers by wireless electronic signals),
(2) unable to
ambulate at least 45 meters (150 feet) prior to
stroke, or
intermittent claudication while walking less
than 200
meters (656 feet), (3) serious cardiac
conditions (e.g.
hospitalization for myocardial infarction or
heart surgery
within 3 months, history of severe congestive
heart failure,
serious and unstable cardiac arrhythmias,
hypertrophic
cardiomyopathy, severe aortic stenosis,
angina or
dyspnea at rest or during activities of daily
living), (4)
history of serious chronic obstructive
pulmonary disease
or oxygen dependence, (5) severe weight
bearing pain, (6)
pre-existing neurological disorders such as
Parkinson’s
disease, amyotrophic lateral sclerosis,
multiple sclerosis or
severe dementia, (7) history of major head
trauma with severe
residual deficits, (8) lower extremity
amputation, (9)
legal blindness or severe visual impairment,
(10) severe
uncontrolled psychiatric illness such as
psychosis, schizophrenia
or medication refractory depression (11) life
expectancy less than three months, (12)
severe arthritis or
orthopedic problems that limit passive ranges for each exercise prescribed is determined by can be used but would be kept consistent and
of motion the teletherapist will be
of lower extremity (e.g. knee flexion who will assess and inform the patient of the documented from test to test.
contracture of > 10°, change before increasing the difficulty level.
knee flexion ROM < 90°, hip flexion Usual care Balance confidence
contracture > 25°, Stroke patients in Singapore typically receive The 16-items Activities-Specific Balance
and ankle plantar flexion contracture > 15°), acute (ABC) Scale
(13) stroke care in an acute hospital, which usually will be used to assess self-perceived efficacy
history of sustained alcoholism or drug abuse has a dedicated in maintaining
in the stroke unit. balance while performing a number of
last six months, (14) hypertension with activities
systolic blood Gait speed common in community-dwelling older adults
pressure greater than 200 mmHg and diastolic Gait speed is related to the severity of such as
blood impairment in the bending, reaching, and walking both inside
pressure greater than 110 mmHg at rest, that home and the community and has been used and outside
cannot in many the home [26]. This measure has good
be medically controlled into the resting range studies [21]. Gait speed will be measured reliability and
of using the internal consistency. Participants have to
180/100 mmHg. timed 5-meter walk test. The individual walks indicate their
without level of confidence in doing the activity
The Mini-Mental State Examination (MMSE) assistance for 5 meters (16.4 feet) and the without losing
is the time is measured their balance or becoming unsteady from
most commonly used screening tool for for the intermediate 3 meters (9.8 feet) to choosing one
cognitive allow of the percentage points on the scale with 0 %
impairment and dementia worldwide. A for acceleration and deceleration. Timing is representing
number of started when no confidence and 100 % representing
studies have examined the accuracy of the the toes of the leading foot crosses the 1- complete
MMSE in meter mark confidence. The total rating is calculated and
the detection of dementia. In Singapore, the and it is stopped when the toes of the leading divided
localised foot by 16 to obtain the overall ABC score. Based
MMSE version discriminated well between crosses the 4-meter mark. Assistive devices on the
elderly with can be used score, participants can be classified into three
and without dementia (cut-off 23/24, but would be kept consistent and documented categories:
sensitivity 97.5 %, from test < 50 % representing low level of physical
specificity 75.6 %) [17]. to test. Three trials are done and the average functioning,
will be recorded 50-80 % representing moderate level of
The tele-rehabilitation intervention group will for each session. The participant will be physical
receive a assessed functioning and >80 % representing high
standardized rehabilitation programme for when they are walking at normal comfortable level of functioning
three months, speed and [26].
which was based on the rehabilitation at maximum speed.
programme for the 2-minute walk distance Shah-modified BI will be used to assess and
control group in a randomized controlled trial In addition to the gait speed, the distance a compare the
on weightsupported person can improvements in the performance of ADL
locomotion by Duncan et al. [21]. The types walk and the amount of daily walking that a between the
of person is intervention and control groups. The Shah-
exercises are summarized in Table 2. The able and willing to do are strong indicators of modified BI
programme his or her is considered to be a valid measurement of
comprises of both physiotherapy (Category I health and condition [21]. Hence, the two- ADL, as it is
to IV) and minute walk an empirically derived scale with proven
occupational therapy components (Category test will also be conducted. Individuals walk inter-observer
V). Each at their and test-retest reliability and validity which
tele-session may cover up to all five usual speed as far as they can without measures the
categories of exercises. assistance for patient’s functional ability [25]. It involves
The difficulty level and minimum range of 2 min and the distance is measured. Assistive the assessment
motion desired devices
of 10-items, which include personal hygiene, and chair/bed transfer. Five response options and the higher the score, the more
bathing with independent the
self, feeding, toilet, stair climbing, dressing, their score are provided for each item and a subject i
bowel total score PROTOKOL TELE REHAB +IMPACT ON
control, bladder control, ambulation, will be calculated. The score can range from SELF REPORT FUCNTIONAL
wheelchair ambulation zero to 100 OUTCOMES_SINGAPORE_ASANO2019

Inclusion Criteria cardiac arrhythmias, hypertrophic problems that limit passive ranges of motion
Inclusion criteria for the trial include (1) age cardiomyopathy, of lower
≥ 18, (2) severe aortic stenosis, angina or dyspnea at extremity (knee flexion contracture of > 10°,
stroke within 30 days, (3) residual paresis in rest or during knee flexion
the lower activities of daily living). Anyone meeting ROM < 90°, hip flexion contracture > 25°,
extremity (Fugl-Meyer lower extremity score New York Heart and ankle
< 34), (4) Association criteria for Class 3 or Class 4 plantar flexion contracture > 15°, (15)
ability to sit unsupported for 30 seconds, (5) heart disease is History of sustained
ability to excluded. Those who have undergone alcoholism or drug abuse in the last six
walk at least 10 feet with maximum 1 person coronary artery months,
assist, (6) bypass grafts (CABG) or have had mitral and (16) major post-stroke depression as
ability to follow a three-step command, (7) valve replacements indicated by a
physician within the last 3 months are excluded if their Patient Health Questionnaire (PHQ)-9 score
approval for patient participation, (8) participation of greater
provision of is not approved by 2 physicians. One of the than 10 in the absence of documented
informed consent, (9) self-selected 10 meter physicians making the determination must be management of the
gait speed a cardiothoracic depression by a health care provider (either
less than 0.8 m/s at the 2 month assessment, surgeon and the other must be either a anti-depressant
(10) successful cardiologist medication or psychotherapy), (17) History of
completion of the bicycle ergometer exercise or the participant's primary care physician. pulmonary
tolerance Additional exclusion criteria include: (4) embolism within 6 months, (18)
test at the 2 month assessment (see below) History of serious Uncontrollable
and, (11) living chronic obstructive pulmonary disease or diabetes with recent weight loss, diabetic
in the community at 2 months post-stroke or oxygen coma, or frequent
if they dependence, (5) Severe weight bearing pain, insulin reactions, (19) Severe hypertension
are living in a nursing home they are (6) Preexisting with
expected to be discharged neurological disorders such as Parkinson's systolic blood pressure greater than 200
to home and will be able to travel to the disease, mmHg and
intervention Amyotrophic Lateral Sclerosis (ALS), diastolic blood pressure greater than 110
site to participate in the LTP program or will Multiple Sclerosis mmHg at rest,
be able (MS), dementia, or previous stroke with that can not be medically controlled into the
to receive the HEP program in the nursing residual motor resting range
home facility. deficits, (7) History of major head trauma, (8) of 180/100 mmHg, (20) Previous or current
Exclusion Criteria Lower enrollment
Exclusion criteria for participation in this extremity amputation, (9) Non-healing ulcers in a clinical trial to enhance stroke motor
study include: of a lower recovery, (21)
(1) Lived in nursing home prior to stroke, (2) extremity, (10) Renal dialysis or end stage Residence more than 50 miles from the
Unable to liver disease, training sites, (22)
ambulate at least 150 feet prior to stroke, or (11) Legal blindness or severe visual Inability to travel 3 times per week for
intermittent impairment, (12) A outpatient training
claudication while walking less than 200 history of significant psychiatric illness programs; and (23) Intracranial hemorrhage
meters, and (3) defined by diagnosis related to
Serious cardiac conditions (hospitalization for of bipolar affective disorder, psychosis, aneurysmal rupture or an arteriovenous
myocardial schizophrenia malformation
infarction or heart surgery within 3 months, or medication refractory depression, (13) Life (hemorrhagic infarctions will not be
history of expectancy excluded).
congestive heart failure, documented serious less than one year, (14) Severe arthritis or
and unstable orthopedic Stroke Diagnosis
Participants are individuals with recent onset
of ischemic
or hemorrhagic stroke. For purposes of
inclusion in this
study, a stroke is defined according to the
World Health
Organization definition as, "a rapid onset
event of vascular
origin reflecting a focal disturbance of
cerebral function,
excluding isolated impairments of higher
function
and persisting longer than 24 hours [21]."
Stroke diagnosis
is confirmed by CT or MRI scan or, if scan is
not available,
by clinical criteria.
Interventions
Participants are randomized to 1 of three
intervention
groups, each receiving 3 treatment sessions
per week for
12 to 16 weeks (36 total sessions):
1. Early Locomotor training (LTP-early) –
High intensity
locomotor training program that includes
both walking
training on a treadmill with partial body
weight support
and overground provided 2 months after
stroke.
2. Late Locomotor training (LTP-late) – High
intensity
locomotor training program that includes
both walking
training on a treadmill with partial body
weight support
and overground provided 6 months after
stroke.
3. Home-based exercise (HEP-early) -, Low-
intensity exercise
program focused on strength, balance and
coordination
provided in the home 2 months after stroke.
Home Exercise Program
An exercise intervention designed to improve
upper and
lower extremity strength, sitting and standing
balance,
and coordination was designed for the home
exercise
group, incorporating techniques used in
previous lowintensity
and gait preparatory exercise programs (see
Figure 4) [12-14]. The purposes of the home activities. At the end of each session,
exercise program participants are
are to provide (1) an exercise-based encouraged to walk every day. Each
intervention participant is individually
that is expected to have little or no effect on progressed according to their ability within
the primary each
outcome, gait speed, (2) an equal number of phase. Table 4 outlines examples of
interactions progression of exercises/
and time spent with a physical therapist to activities. To ensure that all groups receive
minimize any the same
potential for bias due to differential exposure advice regarding the use of assistive devices
and minimize for walking,
the risk for differential loss to follow-up, and the home exercise group participants are
(3) a evaluated for
credible training program so that the assistive device needs after the 12th, 24th,
participants would and 36th
consider themselves involved in meaningful session.
therapy Vital Sign Monitoring for LTP and HEP
activity. To match the LTP group, the home Interventions
exercise group Blood pressure (BP) and heart rate (HR) are
receives 36 therapy visits (3 times per week monitored
for 12 weeks) prior to a session, during a session, and at the
with length of HEP and LTP training sessions completion
the same. of each session. BP and HR must be within
Cardiovascular response monitoring during normal range
exercise is for the participant prior to initiating each
identical to that done in the LTP groups. In training session.
these ways, the HR must be less than 100 bpm to begin the
HEP intervention will plausibly control for training
Hawthorne session. Participants' resting diastolic BP
effect but exclusively through interventions must be less than
that have 100 and systolic BP less than 180 to begin the
been shown to have little or no impact on gait training session
speed. [56]. During the 20–30 minute training
The exercise program is divided into three 4- sessions, BP,
week phases HR, blood oxygen saturation, and the Borg
to provide the participants with a sense of scale Rate of
progression. Perceived Exertion are monitored every 5
The first phase consists of upper extremity minutes initially
resistance to assure that they remain within acceptable
exercise, lower extremity active exercises limits.
against no resistance, The criteria for termination of a training
and sitting balance tasks. Each major joint of session include
the complaints of light-headedness or moderate
upper and lower extremities is addressed. The or severe dyspnea,
second or the development of paleness and excessive
phase adds minimal resistance to the lower sweating
extremity, or confusion; complaints of feeling ill; onset
strengthening exercises, coordination tasks of
and static angina; pressure changes (systolic BP greater
standing balance exercises. The third phase than 200
adds low repetitions mm Hg, diastolic BP greater than 110 mm
of sit-to-stand practice and dynamic standing Hg), drop in
balance systolic BP greater than 20 mmHG and
inappropriate
balance
 bradycardia (drop in heart rate greater than 10 BP and HR are monitored and training will of consciousness occurs, or cardiac arrest,
beats per resume only emergency medical
minute). In addition, should the participant's when vital signs have returned to within an services through 911 are called immediately.
HR exceed acceptable All trainers
80% of the predicted maximum HR (220 – range and excessive dyspnea or chest pain are CPR certified and aware of signs of
age) or have resolved. cardiac
the participant report a Borg exertion rate of If any of these conditions persist after rest, complications. All trainers and assistants are
greater than the patient's trained in
12–13, then the training ceases. Should primary physician is called and the patient procedures to afford quick and safe removal
training be halted, referred for of a patient
the participant is asked to rest (sitting or evaluation. If the patient complains of angina from the BWST system in the case of an
standing) while at rest, loss emerge
Protocol for the Locomotor Experience Applied Post-stroke
(LEAPS) trial: a randomized controlled trial 2007

1]. An estimated 20% of people
with stroke in developing countries have had
a prior
stroke, reflecting insufficient secondary
prevention [2].
International clinical stroke guidelines
strongly recommend
therapeutic exercises to optimise recovery of
function and
continuance of physical activity to prevent
further stroke [3,4].
In a low resource setting like India, stroke
units and
rehabilitation facilities are virtually absent in
the Government
sector, and those in the private sector are
inaccessible for
the semi-urban and rural population [2,5].
Therefore, homebased
rehabilitation is a feasible and economical
alternative,
which has been shown to be equally effective
as centrebased
rehabilitation to promote function and quality
of life
in stroke survivors [6–8]. A recent large trial
showed that
cost-shifting rehabilitation to being family-
led is not feasible
or effective in the Indian context [9].
Adherence to prescribed
treatment is essential for successful
implementation
of the intervention, [10] but many stroke
survivors find it difficult
to adhere to home-based exercises
programmes
[11,12]. Therefore, it is important to address
the reasons for
non-adherence and thereby improve exercise
adherence
among stroke survivors.
Intervention Mapping (IM) is an iterative
approach which
provides the step by step guide in the
development of health
behaviour interventions [13].
we included participants in their acute and
chronic stage of stroke as well as from
different socio-economic
strata. Most of the women were unemployed
and
stayed at home. Data were obtained from
both mildly
affected to majorly disabled adults with
stroke to understand
the array of challenges in continuing home-
based exercises.
Discussions between all the investigators and
thorough
reviewing of analysed data established the
credibility of
the results.
Factors influencing adherence to home-
based Exercises in india 2019

To accelerate home discharge and
rehabilitation of
hospitalized stroke patients investigators have
found that early supported discharge
improved
functional outcome, increased quality of life,
and
reduced both risk of re-admission and referral
to
nursing home or death.1–5
The following inclusion criteria were
implemented
for patient selection: acute stroke patients ⩾
18 years
of age; premorbid Modified Rankin Score7 of
0 to 3;
premorbid ability to live in own home;
patients hospitalized
in our stroke unit for more than three days
with focal neurological deficits; and patients
or caretakers
providing informed consent. Patients were
excluded if they were terminal; premorbidly
unable
to understand or speak the Danish language;
previously
included in this investigation; living in or
discharged
to nursing homes; unable to take care of
themselves in their own home with or without
assistance;
relocated to other hospital departments after
being admitted to the stroke unit; unable to
participate
in home-based rehabilitation; had severe
memory
impairments causing them to fail to
understand
and act upon instructions; or a baseline
modified
Barthel-100 ADL Index8 score of 91 or
better.
Three months after stroke, patients being
subjected
to training at home during ongoing
hospitalization
were less disabled and experienced a higher
quality
of life than patients receiving standard care.
In
detail, inpatients trained at home achieved
better
modified Rankin Scale and EuroQol-5D™
scores,
and their improvement scores in Motor
Assessment
Scale and BMI were also better than among
control
patients. Additionally, three months after
stroke the
total amount of home-based training in
minutes
positively correlated with modified Barthel
ADL
index, Motor Assessment Scale and EuroQol-
5D™
scores, and negatively correlated with the
modified
Rankin Scale scores. The chosen home-based
rehabilitation
scheme was more effective than the existing
rehabilitation services and did not increase
rehabilitation costs.
Overall our results suggest that the early
supported
discharge team should start acting before
discharge by training inpatients at home.
How does home-rehabilitation work?
There is limited knowledge about the
mechanisms
behind home-based rehabilitation facilitating
improved functional outcomes compared to
standard
Functional declines are reported several years
after stroke, and
impairments in mobility are the most
frequently reported problems
(58%).[1,2] Problems such as reduced
balance and reduced
cardiorespiratory capacity as well as their
psychological consequences,
such as depression, a reduced health-related
quality of
treatments.30–31 However, it is known that
stroke survivors consider coming home to be
an
important part of recovery and rehabilitation,
including the process of regaining control
over his
Downloaded from cre.sagepub.com at
FUDAN UNIV LIB on May 16, 2015
Rasmussen et al. 11
or her life, striving for re-personalisation and
autonomy, and possibly no longer feeling as a
depersonalized object for caring
procedures.32
Future investigations may provide better
answers,
although it can be speculated that prolonged
institutionalization
limits patient autonomy and experienced
quality of life, reduces motivation for daily
activities and thereby could explain our
current
findings, while patients rehabilitated at home
experienced
both increased quality of life and improved
functional outcomes.
Clinical messages
•• Training stroke inpatients at home, taking
them home and back again, improved quality
of life and reduced disability compared
to patients receiving standard care.
•• Outcomes among patients correlated with
the
amount of received home-based training.
•• Home-based rehabilitation of inpatients
was not more expensive than standard care.
home-based rehabilitation within the first
three
months accelerated recovery compared to
usual
care. After three months, benefits of home-
based
life and low self-confidence, can persist for
years after stroke.[3]
Together, such changes can lead to activity
limitations, including
walking and difficulties in the activities of
daily living.[3]
Physical activity (including exercise) has
multiple benefits and
effects that likely target the top-10 research
priorities after
treatment slightly improved and reached a
plateau
after one year.5 In another investigation,
these
investigators found long lasting benefits of
six
months of home-based rehabilitation.16 Thus
in our
study, there may have been further positive
results
of home-based treatments continued for at
least a
year after stroke onset. Even five years after
stroke
onset, early supported discharge has resulted
in
reduced death, institutionalization and
resource use
as well as improved perceived health status
and
independency in activities of daily living.2,
17-19
In a recent investigation in Japan, it was
found
that involving family members instead of
professional
personnel shortened lengths of hospital
admissions and improved the rate of home
discharge,
although there was no effect upon functional
outcome.20 Involving family members may
therefore provide additional benefits to
homebased
rehabilitation.
Our results tentatively indicated that 20 to 70
minutes of daily training at home increased
modified
Barthel ADL index scores.
$Stroke home rehab_b4 and after
discharge improve QoL_brasmussen2015
stroke.[4] Higher levels of physical activity
are associated with better
balance, walking ability and physical fitness
even in high-functioning
stroke survivors; however, individuals are
often sedentary
after stroke.[4,5] As such, these individuals
have a higher risk of
developing both serious health problems and
psychosocial problems,
such as depression and reduced health-related
quality of
life.[2,6] Therefore, strategies for increasing
physical activity following
stroke are important issues and need to be
explored further.[5]
Becoming more physically active may affect
thoughts and emotions
and subsequently improve patients’ short-
term and longterm
psychological status.[7] Strategies to support
such changes
should focus on self-management and be
problem-focused.[8] The
current evidence supports exercising in a
group setting with other
individuals post-stroke.[4] A recently updated
Cochrane review that
examined the effects of exercise concluded
that insufficient evidence
exists to support the use of resistance training
for poststroke
individuals.[3] In the Cochrane review,
resistance training
did not produce better gait performance or
balance.[3] In contrast,
the latest recommendation for stroke
survivors supports the use of
both aerobic and resistance training.[9]
These results indicate that the effects of
resistance exercise that
is performed in a group setting need to be
further explored, but a
different approach might be necessary.
Motivation, goals and
beliefs about one’s capability have been
found to be among the
strongest variables associated with physical
activity maintenance.[
10] Motivating individuals with stroke to
perform and maintain
physical activity is challenging; thus,
effective strategies need
to be developed.[9] Furthermore, studies
should be performed to
evaluate the effects of resistance training
interventions on psychological
factors, such as health-related quality of life
and depression.[
3] Increasing physical activity and long-term
follow-up
evaluations should be included when
evaluating these benefits.[3]
The inclusion criteria
were as follows: verified stroke of any type
within the previous
1–3 years, ability to walk a minimum of 10 m
and either a lack of
outdoor walking for at least 5 days per week
(derived from the
Physical Activity Scale for the Elderly
(PASE)),[12] low fall-related
self-efficacy (Falls Efficacy Scale-Swedish
version (FES(S))<115
points),[13] balance difficulties (Berg
Balance Scale (BBS)_52
points) [14] or repeated falls within the past
year. The exclusion
criteria were cognitive deficits (Short
Portable Mental Status
Questionnaire<7 points),[15] dementia
diagnosis, severe communication
problems (assessed through medical records
or revealed
during examination) or a systolic blood
pressure>180 mmHg. All
of the individuals were assessed for
contraindications to the proposed
exercise according to the American Heart
Association guidelines.[
16] The medical conditions of all of the
participating
individuals were considered stable by their
general practitioner. All
of the individuals provided written consent.
The study complied
with the Helsinki Declaration. Ethical
approval was obtained from
the Regional Ethical Review Board of
Uppsala University Hospital.
A total of 67 individuals were randomized
and have baseline data.
A flow-chart of the recruitment and retention
process can be
found in Figure 1.
Intervention
Training was performed in circuit classes that
were conducted
twice weekly over a 3-month period and
consisted of different
work stations with functional exercises that
involved the major
muscle groups (particularly lower extremity
function; Table 1).
According to the American Heart
Association/American Stroke
Association,[9] there are currently no
recommendations about the
duration of strength training for individuals
with stroke. Two to
three days/week are recommended for novice
individuals, and a 3-
month period was chosen to achieve neural
adaptation and the
effects on physical function and strength. The
intervention
included the following sessions: a warm-up
that consisted of stationary
cycling or walking (10 minutes), a circuit
class (approximately
45 minutes) and a motivational session that
included
discussions about issues and personal goals
that are related to
physical activity (20 minutes). The exercises
were retrieved from
the high-intensity functional exercises (HIFE)
program [17]. Medical
reasons for cessation were recorded along
with the exercise fidelity
(e.g. attendance and weight progression). The
intensity
throughout the training was regulated with
the assistance of the
Borg Rating of Perceived Exertion Scale.[18]
Compared with the
HIFE program, the resistance exercises that
were used in this study
were performed at a low (>15 repetitions) to
moderate (10–15
repetitions) intensity and were intended to
improve strength and
muscular endurance.[16] As several of the
participants had
experienced heart failure and were previously
defined as sedentary,
at least 10 repetitions of each exercise were
performed in
accordance with statements by the American
College of Sports
Medicine/American Heart
Association.[16,19] The intensity was further
defined as high as follows: the balance
exercises were close
to the balance maximum and challenged the
support base, and
the individuals did not rest more than
necessary; they worked in
intervals at their own highest possible
intensity for 2 min followed
by 1 min of rest.[17] During the training, all
of the individuals wore
a belt around their waist that could be loaded
with individual
weights that ranged from 1 to 12 kg. Two
exercises (squats in a
parallel stance or forward lunges) were used
to evaluate the suitable
loads for each individual. The maximum
weight was determined
by the participants’ subjective perceived
exertion as
reported to the physiotherapist when
performing the exercises.
The exercises were standardized and included
individual adjustments
to match each participant’s functional status.
The exercise
progression included increasing the weights
according to the perceived
exertion or adjusting the exercise
performance (e.g. deeper
knee bends) or balance challenge (decreased
support base) to
increase the exercise demand.[17] The first
seven exercises in the
circuit were static and dynamic-balance
exercises in combination
with lower-limb strength exercises. The next
seven were dynamicbalance
exercises that were performed while walking.
The ratio of
the trainers (one physiotherapist and one
assistant) to participants
was two to seven. One individually tailored
at-home exercise to be
performed daily was also provided to each group were more thorough investigations of
participant to implement their physical and
in their daily life and support the progressive psychological functions over a longer period
resistance and of time than usual.
balance exercise program. The physical activity and exercise levels of
Since exercise recommendations for stroke the control group during
survivors highlight the intervention period were recorded for the
both effective and lasting behavioral and assessments at
medical interventions, 3, 6 and 15 months.
motivational group discussions after each
training session were Discussions
used as a complement to the exercise The three-month progressive resistance and
program.[9,20] This balance exercise program
approach included discussions with the effectively improved the balance and walking
physiotherapist for 20 min speed of individuals
about physical activity behavior and risk with chronic stroke directly after program
factor modifications with completion.
targeted questions about the barriers and Furthermore, the effects on walking speed
facilitators to physical persisted at six months.
activity (Table 1). A follow-up that targeted Mobility, psychological factors and physical
the compliance of the activity levels were not
one daily at-home exercise was also included Affected
in the discussions.
The individuals who were allocated to the Short-term and long-term effects of a
control group were progressive
encouraged to continue their regular activities resistance and balance exercise program in
and were not individuals with chronic stroke: a
restricted from participating in ordinary randomized
physical activities and controlled trial 2016
rehabilitation programs.
The potential benefits of participating in the
study for the control

Introduction
In the United States, approximately 610,000
people per year experience
stroke for the first time.1 While the impact of
stroke varies
across individuals, hemiparesis occurs in
approximately 80% of
persons post-stroke.2 Furthermore, upper
extremity hemiparesis
has been shown to persist, with up to 65% of
stroke survivors
continuing to report this impairment at six
months post-stroke.3
In addition, upper extremity motor recovery
has been identified
as important to individuals post-stroke and
the amount of recovery
has been found to impact several quality of
life domains.4,5
Over the past two decades, advancements
related to neural
plasticity have increased our understanding of
upper extremity
recovery post-stroke.6 These advancements
have led to the development
of interventions that can be implemented to
support
motor recovery.7−10 However, the
translation of these intervention
techniques into rehabilitation practice has
been slow.11,12 For
example, while it is known that task specific
repetitive practice
has demonstrated efficacy in this
population,11,13 when typical
outpatient therapy sessions have been
observed the number
of repetitions in a session fell short of the
anticipated number
needed to support change in motor
function.14 Proffitt found a
similar shortfall in the reported dosage of
practice that occupational
therapists prescribed in home exercise
programs for adults
with neurological conditions.12
Another factor that may contribute to the
limited translation
of research-based methods into the clinic is
the mismatch
between the amount of services offered in
research studies vs. the
amount of services available to most stroke
survivors. Systematic
reviews report that persons in these studies
receive direct services
that can vary from 10 visits across 2 weeks to
33 visits across
12–14 weeks.9,15 This is in contrast to other
literature which
focused on health service usage, where in an
integrated delivery
system (e.g. Kaiser Permenante) the median
number of rehabilitation
visits in the first year after stroke was 6 with
a range from 1 to
21 visits.16 Furthermore, data from a United
States health survey
found that only 30.7% of stroke survivors
receive outpatient services,
this is below the anticipated 50% or more
based on stroke
guidelines.17 In order to bridge the gap
between the amount of
direct services available to a client in the
clinic and the need for
additional practice, clinicians often create
home programs.
Home programs are a set of exercises or
activities provided
by a rehabilitation professional for a client to
complete at home
without the therapist present.18 Research
suggests that between
89 and 94% of stroke survivors receive home
programs as a part
of or at the end of a rehabilitation
program.12,19 Yet, adherence to
home programs is often low.19,20 A recent
study found that only
65% of persons attending a post-stroke
support group reported
regularly completing at least some
components of their home
exercise program.19 This is also consistent
with a recent trial completed
by Emmerson, Harding, and Taylor
evaluating adherence
via different methods of education in which
regardless of education
method, self-reported adherence was
approximately 60% for
both groups.20 Barriers to home program
participation reported
by individuals post-stroke include: fatigue,
pain, low motivation,
cognitive impairments and
frustration.19,21,22 Conversely, factors
The discovery of and increasing knowledge
about
the plasticity of the adult brain following
stroke
opened up new perspectives on stroke
rehabilitation
(2 – 4). Although the major functional
improvement is
that have been reported by clients to facilitate 32 respondents reporting using them always.
adherence to home Visual demonstration
programs focusing on general exercise (n = 48, 63%), direct training with return
include participation in a demonstration
group, level of motivation to improve overall (n = 49, 64%), and discussion of home
health and a desire program routines (n = 46,
to reduce musculoskeletal issues.22 61%) were reported as used always by a
Given the importance of upper extremity majority of the sample.
recovery to individuals Strategies that used video (n = 32, 43%) or
post-stroke and the limited amount of electronic handouts
services that they (n = 37, 49%) were reported as never being
receive, understanding how clinicians create, used by almost half
implement and of the participants.
track home programs is valuable to When asked to report the frequency of using
understand prior to creation technology in
of a home program-based intervention. The home programs the piece of technology with
information the most frequently
gained through this type of study could be reported use was home exercise handout
used to develop new creation software with
strategies that may improve outcomes and 37 respondents (48%) reporting use of this
potentially reduce type of technology
health care costs. greater than 70% of the time. Conversely,
While information regarding practice patterns technological devices
for persons like activity trackers (85%), robotic devices
with neurological conditions has been (87%), or video conferencing
gathered, a focus on (91%) were reported as never being used by a
understanding clinical practice patterns large
specifically with individuals majority of the sample. While still being
post-stroke is necessary as stroke survivors reported as being never
are likely used by over a third of the sample the
to have additional cognitive, visual perceptual incorporation of mobile
and language applications, gaming devices, and electrical
impairments that can impact the designs and stimulation paired
implementation with an orthotic was more frequent with 38–
of upper extremity home programs. 53% of respondents
Furthermore, these clients reporting using these tools from 1 to 29% of
tend to be older, which also has an impact on the time. See Table 3
both recovery and for more details.
implementation of some treatment modalities Home programs for upper extremity
recovery
Clinicians in the sample reported that paper post-stroke: a survey of occupational
handouts were used therapy
by 65 of the respondents (89%) greater than practitioners 2017
70% of the time with
seen in the fi rst 6 months following a stroke, phase (3,5). Stroke rehabilitation will
studies therefore be
have shown that stroke survivors can needed for years following the incident, both
experience to
functional improvement for years following produce further improvement and to maintain
the stroke function
incident, as the disease moves into a more and general physical fi tness (6,7).
chronic Physiotherapists
have a central role in the process of stroke
rehabilitation. Norwegian communities are
bound by
a number of laws and regulations specifying
the need
to provide patients with ongoing
rehabilitation. An
important factor for successful stroke
rehabilitation is
the establishment of multidisciplinary teams
where
patients participate in therapy guided by
health professionals
who have special training in stroke
management.
Patients in need of long-term rehabilitation
from a multidisciplinary team have the right
to an
individual rehabilitation plan.
After patients are discharged from inpatient
rehabilitation,
the number of physiotherapy sessions is
severely decreased and some stroke patients
never
see a physiotherapist after discharge (8).
Because of
the high demand for rehabilitation,
physiotherapists
often depend on patients to take an active part
in the
process. Patients may be left to manage a
home exercise
programme on their own (9) and are expected
to do exercises regularly when not seen by
the physiotherapist.
A recent review indicates that supervised
home-exercise programmes were superior to
standard
care to restore function (10).
Adherence is a term used to describe how
well a
patient adopts and follows recommendations
decided
in co-operation with health professionals
(11). There
seems to be a low level of adherence to
physiotherapy
home exercises and this decreases following
discharge
from rehabilitation (12,13). Adherence to
therapy is
seen as being of greater importance than
improved
medical treatments. Although medical
advances are
necessary, they are insuffi cient on their own
and patients
will not realize their potential if adherence is
not
addressed (11). Non-adherence infl uences
the effectiveness
of treatment, affecting patients ’ quality of
life
and the costs of health care, and it is
considered a waste
of resources (14). Interventions aimed at
improving
adherence will provide a signifi cant positive
return on
investment in the long run (11). However, the
challenge
to physiotherapists is to fi nd ways of
encouraging realistic
expectations and adjustment to disability
(15).
Between 30% and 50% of stroke patients stop
adhering to exercise programmes within the fi
rst
year, and between 45% and 80% within about
2 challenges
years (12). Up to 42% of stroke survivors
report
that they perform activities less than once a
week,
contributing to a loss of functional benefi ts
achieved
during rehabilitation. Between 21% and 43%
experience
decreased mobility (16). Most studies of
adherence to physiotherapy home exercises
focus on
acute diseases and injuries among younger
patients.
It is also common knowledge that non-
adherence to
exercise programmes is widespread among
the
healthy population. The theory of
phenomenology
by Merleau-Ponty (17) emphasizes that we
experience
through the body and focuses on the body
both
as a subject and an object. Diseases such as
stroke
give rise to the experience of bodily
strangeness,
making experience through the body diffi
cult. This
being the reality, the challenge is how health
professionals
can deal with adherence for elderly people
with chronic diseases such as stroke who are
expected to do home exercises over a long
period,
maybe for life.
In 1986, the Ottawa Charter (18) presented
the
concept of empowerment in rehabilitation as
a way
of preparing patients to take control of their
own
health. The concept builds on the Universal
Declaration
of Human Rights (19), which states that
all persons have a democratic right to
participation.
The concept of empowering patients arose
from
increasing criticism of the paternalistic
approach
used by health professionals, and patients
who were
passive and non-participatory. Empowerment
this approach; it makes use of patients ’ own
experiences, knowledge and insight to
mobilize
independence and participation (20).
Empowerment
in the rehabilitation process has a twofold
meaning. While it gives patients several
rights , it
also gives them responsibilities in the
process. To
empower patients, health professionals are
committed
to facilitate patients ’ participation and
independence
through guidance and knowledge. The
patient, on the other hand, has an obligation
to
participate actively and implement the
rehabilitation
goals to be met. Thus, the increase in the
demands for accountability in stroke
rehabilitation
acknowledges the importance of joint
decision
making (21,22)
the following inclusion criteria
to be enrolled in the study:
• elderly, 67 years of age or over;
• diagnosed with stroke;
• living at home;
• discharged from community rehabilitation ’ s personal feelings, experiences, history, care between all health professionals
for a adherence involved (7).
minimum of 6 months; and compliance are all important factors However, only one of the participants in this
• having a physiotherapy home exercise represented in the body and the awareness of study
programme; the had an individual rehabilitation plan.
• able to understand written and spoken body (17).The body of the stroke patient Although such
language; becomes a a plan was developed, it seemed for the
and hindrance to learning, perception and participant
• no specifi c criteria with reference to side activities. Perception, only to be words on a piece of paper, as he
and consciousness and movement are shared:
severity of paralysis. fundamental “ I participated in setting goals when I had
dimensions allowing experience, participation the stroke.
Focus in physiotherapy is the body, and in a and action (31). Several studies have also The health personnel did all the work
broader perspective, the awareness of the revealed producing this
body of bodily changes that are diffi cult to adjust to plan for me. ”
each individual forms the starting point and and that Rehabilitation takes place throughout the day,
suitable last for at least 2 years following a stroke not
approaches (30). The presence of varied (31). only during the physiotherapy sessions. It
perceptual The degree of participation in rehabilitation needs to
defi cits and motor bodily dysfunctions are by be integrated into the activities of daily living
well the participants in this study varied. Some (34).
known outcomes of a stroke. Merleau-Ponty ’ participants Stroke management necessitates a
s theory were passive, with neither desire nor multidisciplinary
of the phenomenology of perception (17) intention team that is in possession of extensive
emphasizes to participate. knowledge
the experience of the body as a whole, as both concerning stroke rehabilitation (7,34).
a An individual rehabilitation plan is of great The elderly stroke patient ’ s long-term
subject and object, breaking away from the importance in the rehabilitation of stroke adherence to physiotherapy
previous patients to home exercises 2014
dualistic view of the body. This means that establish goals, evaluate progress and co-
the individual ordinate

Introduction healthy volunteers.5 Low levels of used once-weekly center-based supervised

The cardiorespiratory fitness of stroke
survivors is low1,2
with peak oxygen consumption (VO2peak)
values ranging
from 26% to 87% of those of healthy age-
and gendermatched
individuals.2 It has been estimated that over
three
quarters of people after stroke have low
levels of physical
activity or are sedentary.3 Stroke survivors
spend a
large proportion of their day (median = 19.5
hours, 81%)
in sedentary behaviors, often accumulated via
prolonged
bouts of inactivity (median = 1.7 hours).4
Stroke
survivors spend 4 hours more per day in
sedentary behavior
than age-, sex-, and body mass index-
matched
cardiorespiratory fitness
and physical activity and high levels of
sedentary time
can reduce the ability to perform activities of
daily living
and may contribute to an increased risk for
recurrent stroke
and other cardiometabolic diseases.6
Exercise programs that include an aerobic
component
have been shown to improve
cardiorespiratory fitness,1,7-9
walking speed8,9 and walking endurance.8-
10 Even modest
amounts of aerobic training can improve
cardiorespiratory
fitness by 10%-15%.1 Of the 28 studies
included in
a recent systematic review, 25 used multiple
sessions of
center-based supervised training each week1;
2 studies
sessions in conjunction
with a home program; and 1 study used a
oneon-
one therapist-supervised home program.1 For
safety
reasons supervised cardiorespiratory fitness
training programs
may be required for stroke survivors with
significant
impairments or multiple comorbidities.
people might have minimal mobility issues,
they may
benefit from ongoing interventions to
maintain or improve
their cardiorespiratory fitness and to reduce
their sedentary
behavior. The need for studies of home-based
programs with intermittent supervision has
been recognized
in a recent review, particularly to provide
evidence
for therapies that may help stroke survivors
who live away
from major centers
Introduction
Clinical practice guidelines indicate that for
the
best outcome, rehabilitation should be
structured to
provide as much practice as possible within
the
first six months after stroke,1,2 and that
patients
should be encouraged to continue to practice
skills
they learn in therapy sessions throughout the
remainder of the day.1,2 Consistent with
these
guidelines, allied health professionals
working in
rehabilitation frequently prescribe home
exercise
programmes for patients to practice
independently
between therapy sessions.3,4
Patients who most closely follow their
treatment
recommendations experience better treatment
outcomes.
5 However, patients who are older, in poor
health, or experiencing anxiety, depression,
or
mental health problems, typically have low
adherence
to home exercise programmes.6 Poor
adherence
to home exercise programmes has been
identified as a factor that may contribute to
disability
in patients after stroke.7
Traditionally, written notes and/or pictures
have
been provided as reminders to clients when
prescribing
home exercises. However, these paperbased
programmes are sometimes difficult to
follow for patients.8 The mode of delivery of
information
can make a difference to recall and
compliance,
with visual information appearing to be more
beneficial than verbal information alone.9–12
The
format of home exercise programme may be
a significant
Home and Comnity Based Phys Activity
improve Cardiorespiratory fitness and
walking capacity 2016
factor in determining adherence and therefore
functional outcomes.
Participants were eligible for inclusion if they
had a diagnosis of stroke resulting in any
degree of
impairment to upper limb function, and had
been
referred for occupational therapy. They were
excluded if they had visual or cognitive
deficits
that would prevent use of the technology; or
no
carer or family member was available to
provide
daily assistance (where necessary).
Participants allocated to the intervention
group were provided with an iPad tablet for
use
during the trial and were instructed in the use
of
the tablet (Appendix 1, available online).
During
the first therapy session, a home exercise
programme
was developed by the occupational therapist
with the participant, according to usual
practice. The tablet was used to video the
participant
performing their home exercise programme
with commentary from the therapist. A
reminder/
alarm was also set up to provide both a visual
and
audio daily exercise cue. Videos were
updated
throughout the programme upon review with
the
treating occupational therapist.
Participants in the control group were given
instructions for their home exercise
programme in
a written format, often including diagrams,
during
their first therapy session. The therapist
supervised
the participant as they practised their
programme,
and exercises were updated throughout the
programme
upon review with the treating clinician.
Participants in the control group who owned
or had
easy access to a touch-screen tablet were
asked not
to use video or reminder functions on their
device
as part of therapy programmes. However,
these
participants were offered a video home
exercise
programme at the end of the trial.
Participants were asked to complete their
home
exercise programmes for a period of four
weeks.
After this time, follow-up outcome measures
were
collected by an assessor blinded to group
allocation.
The content of both the video and paper-
based
home exercise programmes was based on the
recommendations
from the National Stroke
Foundation Clinical Guidelines,1 including
techniques
such as constraint-induced movement
therapy,
repetitive task-specific training, mirror
therapy, and bilateral training. Content varied
depending on individual deficits. The number
of
exercises within a programme varied, as did
the
number of recommended sessions per day.
Home
programmes were typically recommended to
be
completed once to twice per day. Three
general categories
of exercise were prescribed: stretching/
range of movement; strengthening; and fine
motor/
coordination exercises (Table 1). All
participants
completed their usual individual therapy and
group
programmes throughout the trial period.
Discussion
Among participants with upper limb
impairment
post-stroke, there were no group differences
in
exercise adherence, upper limb function, or
satisfaction
with use of an electronic tablet to support
completion of home exercise when compared
with
standard, paper-based home exercise
provision.
The use of this smart technology device,
including
the alarm function, was not superior to
paperbased
methods of prescribing home exercise
programmes.
There may be no additional functional benefit
in prescribing home exercise programmes on
electronic tablets when compared with
standard
practice for patients receiving rehabilitation
for
upper limb deficit following stroke.
Reintegration into the community is the
primary
aim of stroke rehabilitation. Coming home
after discharge
makes one realise the consequences of
thestroke and also encourages one to seek
solutions to
future challenges (Olofsson et al. 2005).
Reintegration
is a slow process: it takes time to regain one’s
physical
functions, to re-establish one’s independence,
to
readjust one’s expectations and finally, to get
one’s
life back on track (Wood et al. 2010). Persons
recovering
from stroke need both internal and external
resources in rebuilding their lives. According
to Reed
et al. (2010), participating in stroke-specific
groups
that combine the elements of physical
activity, goal
setting, informal support and knowledge
acquisition
There may be time benefits for the clinician.
Although not measured in the current trial, it
appears that when prescribing written home
exercise
programmes, clinicians need to go away with
the client’s upper limb assessment, and utilise
a was not examined. However given the
computer program (such as Visual Health
Information software) to develop a home
exercise
program. By using a tablet, the clinician can
commence
videoing a home exercise programme
within the session, and alter it as needed
within
subsequent therapy sessions. This means that
the
patient receives their home exercise
programme
earlier, and less non-clinical time is required
of the
clinician. Future studies could evaluate this
factor
as part of a broader health economic analysis
of
can support stroke survivors in rebuilding
their lives
and in strengthening their confidence and
sense of
purpose.
Home-based rehabilitation interventions
make it
easier for therapists to construct services
based on the
clients’ own goals (von Koch et al. 2000) and
to support
continuity in life (Wohlin Wottrich et al.
2007).
Clients need support in returning to their
social roles,
in resuming meaningful activities and in
finding social
networks after stroke (Cott et al. 2007).
Successful reintegration
requires giving space for clients’ active
participation
and for their own decision-making as soon
as possible (Proot et al. 2007). Client-centred
goal setting,
equal partnership and encouraging
discussions
about the goals of life are needed to reach a
shared
understanding about the aims of rehabilitation
(Bendz
this intervention.
Other potential benefits of using smart
technology
to prescribe exercises include accuracy
of movement and feedback. Accuracy of
movement
visual feedback provided to patients via the
video, this may be evaluated in future studies.
Though this was not recorded, the videos
have
the potential to assist carers in knowing how
to
help, and enable them to review exercises as
needed. A more in-depth qualitative analysis
could explore these ideas further, both from
the
client/carer perspective and from the
clinician’s
perspective.
Home exercise programmes supported by
video and automated reminders compared
with standard paper-based home exercise
programmes in patients with stroke: A
randomized controlled trial 2016
2003, Rosewilliam et al. 2011).
Returning home after a stroke is a demanding
process
for both clients and their carers. Clients may
feel
that they do not get enough support during
this process
(e.g. Ellis-Hill et al. 2009) or that they are
controlled
by the therapist or that they are given too
passive a role in the therapy (Jones et al.
2008). The
client perspective is still an under-examined
area in
neurological rehabilitation (Dixon et al.
2007), and
according to Jones et al. (2008), more
research is
needed on interventions which focus on
increasing
stroke survivors’ control over their recovery.
Learning new coping strategies
According to the interviews, the clients had
learnt
new ways of coping in many kinds of
activities at
home and in the community. Many
participants had
an active role in setting goals for meaningful
tasks
and evaluating their performance and
progress.
The participants said that they had had
difficulties
in carrying out daily activities at the time of
discharge,
but they had learnt concrete strategies for
coping with them in the familiar home
environment
Before discharge, some of them had visited
their
home with professionals to evaluate whether
they
can use the stairs or reach the kitchen
cupboard or
whether they need aids at home. Some had
learnt
practical strategies for managing at home:
how to
push doors open, to use a mobile phone for
safety, or
to use other aids:
The therapist advised me to push the door
with my back,
then I was able to get out. The door of an old-
fashioned elevator
is very heavy. (Bertha, 83)
The physiotherapist’s advice in a concrete
situation
provided Bertha with a practical strategy for
opening the elevator door. This achievement
had a
special meaning for Bertha. She once had to
stay
inside the elevator for a long time and wait
for help
because she was not able to open the door by
herself.
Jonathan pointed out that it was easier to set
goals
for practising and to evaluate progress in a
familiar
context. In the home environment, he found it
possible
to face the challenge of coping with daily
tasks in
a realistic way:
We tried to walk. Yesterday, we walked
around here in the
kitchen by using a stick and taking support
from the wall. I felt
I made the best progress while she
(physiotherapist) was here.
Q (question): Why did you find it best?
A (answer): I suppose at home it was easy for
me to notice
what was important to practice. well as numbers two and four. Although I try
(Jonathan, 79) hard to push
During home-based rehabilitation, the number three, it turns up as five. (Anita, 48)
participants For Anita, learning to cope with these tasks
also learnt strategies for coping in the seemed
community. to be a meaningful step towards returning to
When going out together with professionals, her role
they as the head of the family. The responsibility
practised skills they needed in shopping, of being
visiting offices the sole provider for her school-age children
or managing at a cash point: was an
First we went out for a walk and then to the important motivator on her way towards
cash point, so recovery.
I could pay my bill. I asked (the James had been jogging for years and was
physiotherapist) for us to able to
go there, and, what a miracle it was, I did continue running after coming home. During
remember my the
identification number . . . I was afraid to go home-based rehabilitation, he followed the
there alone, so I guidelines
found it very helpful. (Ann, 80) he had adopted during his stay at the
The physiotherapist and occupational rehabilitation
therapist started to centre. He noticed the importance of
visit here . . . Sometimes we went to the city . stretching as a
. . Now I can way to avoid muscle stiffness after jogging.
manage at the cash point by myself, it has got He also
better seemed to appreciate the guidance and
. . . and when I go shopping during the rush feedback
hour, I given by the therapist when trying to improve
must hurry up, and it has been good practice . his
. . My selfconfidence running technique:
is better now. (Anita, 48) She (the physiotherapist) has been observing
Both Ann and Anita described situations in if I make mistakes
which while walking and jogging . . . yes, it is
support given by the rehabilitation important, so
professionals had I can correct my mistakes. (James, 51)
improved their cognitive and instrumental A training diary was often used as a tool for
functions enhancing the motivation to exercise. Patrick
and strengthened their self-efficacy. Visiting had
offices kept a training diary after discharge to
and shops in the city centre accompanied by a monitor his
therapist progress. His goal was to return to his leisure
seemed to encourage Anita to face activities
demanding at his summer cottage:
situations, and later she was able to function Q: How did you find it to keep a training
alone or diary?
with her school-age children. She was able to A: I suppose it also has psychological value.
evaluate With my
her performance and regard the difficult therapist, I always checked which things had
situations got better,
as learning challenges: and they were . . . and it was a great thing for
Yesterday, or was it day before yesterday, I me to see
was at a cash it, too, as I had already noticed myself that it
point paying a bill by myself and it took me IS getting
three tries to better.
make it. Somehow, I always mix numbers (Patrick, 70)
three and five as
Alice had set herself a goal to continue with
her
dancing hobby. After shared planning with
the therapist,
she had started to work towards that goal by
practicing balance. She found the individual
coaching,
given by her therapist, and especially at
home,
meaningful because it was based on her
wishes:
Q: Did the practice really help your coping at
home?
A: Yes, it did, I suppose the most important
thing was the
therapist’s visits here at home.
Q: What did you practice at home?
A: I tried to exercise balance and walking. It
was like more
personal, as I was already able to walk. We
used a
mirror to search for the midline of the body. I
have
been attending a dancing group for years and
we used
it as a basis for exercises with the therapist.
(Alice, 66)
The exercise coaching included sharing
useful
information and encouraging the clients to
carry out
exercises on their own initiative. However,
there were
also those who thought that the rehabilitation
focused
too much on physical exercise instead of
psychosocial
support for adapting to a new life situation:
I suppose I have a folder full of programmes!
. . . I have
been taking walks, but . . . somebody should
also ask about
psychological aspects. . .. (Jacob, 54)
Exploring community services
As a part of the home-based rehabilitation,
the physiotherapists
assisted the participants in using local
community services. Getting familiar with
local possibilities,
such as swimming and group gymnastics,
was important to some participants. Ann told
that
new leisure activities had facilitated her
recovery:
Nowadays I go to the gym . . . There are still
two visits left
and then there will be a summer break . . . I The discussions addressed experiences of
went to the progress and recovery as well as the
gym twice a week when I had no other challenges of a
engagements. It has new situation. They offered a possibility to
been very good, especially for my left leg. I express
have become fears and uncertainty, to share the joy of
stronger. (Ann, 80) progress
Guided activities were highly appreciated, and to make plans for moving on:
especially by those who had difficulties in . . .I found it very helpful to do something
keeping together and to
up their activities or who needed help with engage in discussions. We reviewed my
transportation: situation and my
There should be control and organisation. progress. Sometimes we discussed during the
The physiotherapist whole meeting.
made home visits, we went for a walk, had a But I found it very important to have a
timetable: possibility to
today to the gym, tomorrow Nordic walking, talk with a professional, it was helpful. (Paul,
then swimming. 56)
It was really meaningful, and every now and A: . . .she (physiotherapist) was also
then I controlling my
go for a walk. (Jacob, 54) progress.
At the time of the interviews, most of the Q: Is it important to have somebody to follow
participants you up?
still found it challenging to actually use local A: Yes, yes, it is. I was depressed, and as my
services regularly by themselves. It was wife was at
especially work, I needed to have somebody to push me
challenging for people who lived alone and forward.
had a (Jake, 65)
limited supportive network. Personal Paul referred to the home-based rehabilitation
problems, such as a
as poor balance, fatigue, feeling clumsy and meaningful partnership, whereas the physical
having exercise
difficulty using the affected hand, were did not meet his expectations. Some others
mentioned as talked
obstacles. External restrictions were also about their cognitive or other problems and
mentioned, the significance
such as lack of suitable services, having of psychosocial support:
nobody to go My adaptation process is totally unfinished, I
out with and bad weather. Several know it. Last
participants were winter I had a hard time and I discussed it
simply afraid of going outside: with the physiotherapist.
I go out for a walk with poles, but not often She advised me to contact my doctor, which I
because of bad also did. (Paul, 56)
weather . . . Sometimes I consider going out, The physiotherapist was appreciated as a
but I am afraid person
to go there all alone. (Barbara, 79) who was easy to talk with and as a
When somebody gives you guidance, it is representative
great, but to go and contact person of the public healthcare
there alone, when the weather is bad, I’m just system.
not up to it, Returning to work
you know. (Jacob, 54) All four clients who had worked before the
Having dialogue with professionals stroke
The home environment seemed to offer a considered returning to work as a goal of
natural context their
for dialogue between the professionals and rehabilitation. When discussing their
clients. experiences of
the home-based rehabilitation, they mostly wrong with my head. I forget tasks and were based on their own wishes or
focused things. It is suggestions.
on physical functioning, communication and hard to explain . . . Work has been the
coping essence of my life. learning practical coping
with cognitive problems. Joint endeavours to When you are used to it, you don’t know strategies in a familiar physical and social
find what else to do context
solutions to work-related challenges were after it’s gone. enhances the feelings of safety, autonomy
seldom Q: Quite. Did they handle these things during and control.
mentioned. your stay at This finding is consistent with earlier studies
James had his own business and had the rehabilitation centre? (Dixon et al. 2007, Jones et al. 2008, Wood et
gradually A: I do not recall. At that time I did not talk al. 2010).
started to work. When evaluating his about it. As I Linking tasks with a client’s former activities
recovery, he said, I thought I was in a good condition, and
was very conscious about the challenges he straight away roles is meaningful and encourages the client
was facing ready to go home and return to work. to go
at work. He had tried to find strategies to (Peter, 68) outdoors. Going through the difficult stages
manage Rehabilitation had not met his expectations of shopping
with his speech and the use of his right hand. concerning with the support of a professional is an
He work. Eventually, he had to retire, which was example
also mentioned practising hand functions not an easy decision to make. of learning strategies for coping in the social
with the Discussion context.
therapist and doing writing tasks by himself. This study addresses clients’ experiences of a Morris and Williams (2009) emphasise the
The homebased importance
availability of technical aids or devices was rehabilitation intervention consisting of a of physical exercise as a means of health
not physiotherapist’s promotion
discussed: visits once or twice a week for a period in stroke rehabilitation. In this study, having
. . .of course my goal is to return to my earlier of 3 months after discharge from a a physical exercise coach was appreciated,
life, I have rehabilitation centre. especially
been trying to recover as far as possible . . . The client’s active role in planning and by those who considered physical recovery as
I’m on sick monitoring their
leave till the end of this year . . . but I have the process was emphasised in the primary goal. They had been physically
been trying to intervention. active before
start working. I need to make some changes Fourteen clients were interviewed the stroke and aimed to keep up their earlier
to my tasks to approximately leisure
match them with my abilities. Working in the 7 months after the stroke. activities. In particular, coaching was found
shop is a bit Homecoming is an important event from the useful at
difficult: to keep a card reader in the right viewpoint of the recovery process (see home where it could easily be linked to
hand and to Olofsson individual
insert a bank card in it – my right hand is still et al. 2005, Ellis-Hill et al. 2009). When the interests.
groping client Removing access barriers and helping
around, I need to support the wrist with my returns to ‘real life’ and to the home persons to
left hand. But environment, cope with them is an important aspect of
I have been trying to cope with all the tasks to the challenges of recovery and reintegration home-based
get more present rehabilitation. Having explored local
practice. (James, 51) themselves more clearly than before. The possibilities with
Peter had worked as a private practitioner participants the rehabilitation staff, some participants
before of this study appreciated the offered home engaged in
the stroke. At the time of discharge from the visits. In the home environment, they were new hobbies or physical activities, such as
rehabilitation able to swimming
centre, he had regarded himself as ready to evaluate their own performance and the or fitness training. The home-based
return to work. The problems had manifested barriers rehabilitation succeeded
when they needed to overcome. They had practised, in removing some access barriers. However,
he had returned home: with many found it challenging to leave home by
Physical coping has been getting better but the help of the professional, several activities themselves;
there is something that it was difficult especially for persons who
lived alone and had a small social network.
The participants
reported several psychological, physical and
environmental barriers restricting the use of
services
(see also Scheer et al. 2003, Rimmer et al.
2008). Common
personal barriers included feelings of
weakness,
fatigue or frustration, as also reported by
O’Sullivan
and Chard (2010). Going outdoors alone was
typically
hindered by a fear of falling, to which extra
attention should be paid in physiotherapy.
Several
participants mentioned bad weather as a
barrier to
going out. In Finland, snow and ice create
significant
Evaluations of the effectiveness of
strengthening and
physical conditioning programs for people
who have
sustained a stroke have shown evidence of
increases in
strength,1 ambulation,2 mobility,3 and
function.4 Nevertheless,
authors stress that it is an underresearched
area that
requires investigation into the efficacy and
feasibly of training
programs2 and the retention of effects.1 The
American
Heart Association recently published the
recommendation5
that stroke survivors participate in regular
physical activity,
giving some urgency to the need for sound
recommendations
regarding effective and feasible programs.
It is generally well established that supervised
programs
administered over several weeks improve
physical ability in
the short term,6–8 although little is known
about long-term
effectiveness. Short supervised educational
programs that
teach people to continue their exercises
unsupervised at home
or in a fitness center are clearly more feasible
and costeffective
environmental barriers during the winter
months,
especially for those who have difficulties
with
balance.
Making sure that stroke clients reintegrate
into the
community and adopt an active lifestyle
requires the
availability of local services after a
rehabilitation
intervention. It is a challenge for
communities to provide
health promotion and guided recreation
services
that are available throughout the year and are
also
suitable for those with limited functioning.
Good interaction between the client and the
professional
than supervised several-week programs, but
their
effectiveness has not been established in this
population, and
retention of effects is unknown. If these
programs could be
shown to be effective, it would be possible to
provide the
required education in the last week of formal
rehabilitation,
making them an attractive and cost-effective
alternative to
supervised, several-week programs.
Subjects
Each potential participant was screened for
eligibility, including the
following: (1) age _20 years; (2)
thromboembolic or hemorrhagic
cerebrovascular disorder with many, but not
all, confirmed by CT
scan; (3) able to walk a total of 15 minutes
with rests, with or without
assistive devices (except a 4-point walker);
(4) able to tolerate
activity for 45 minutes with rests; (5) no
coronary artery disease of
sufficient severity that would limit
involvement in an exercise
program as judged by cardiologist and
determined by the Dobutamine
Stress Echocardiography criteria11; and (6)
no contraindications
is associated with greater satisfaction with
rehabilitation (Mangset et al. 2008). In our
study, having
a dialogue with professionals was specifically
connected to psychosocial coping. With some
of the
participants, emotional support – sharing of
experiences
and being heard – formed a central part of the
home visits. With others, the main interest
was in
informative support: in monitoring the
process
together with a professional and in getting
information
or advice on future activities
Individualised home-based rehabilitation
after stroke in eastern Finland – the
client’s perspective2016
to exercise testing as specified by American
College of Sports
Medicine (1995) and as reported by the
cardiologist
Interventions
Intervention consisted of supervised exercise
sessions conducted in
1.5-hour sessions 3 days per week for 10
weeks (supervised) and 3
days per week for the first week followed by
a home program for 9 weeks (unsupervised).
Subjects joined the class of 3 or 4 participants
as they were
admitted. Each supervised session included
the following:
(1) a 5- to 10-minute warm-up consisting of
leisurely walking,
mild stretching, and range of motion
exercises of lower limbs; (2)
aerobic exercise consisting of a graded
walking program and/or
cycling, depending on subject preference and
capability; (3) strength
training; and (4) a cool-down period
consisting of 5 to 10 minutes of
leisurely walking and muscular relaxation
exercises. Subjects were
taught how to take their pulse and to maintain
exercise within target
range (between 50% and 70% of age-adjusted
maximum and
adjusted for _-blockers) and how to conduct
their exercises and
progress in them. With rests as indicated by
the subjects, the program
took subjects _1.5 hours to complete.
Aerobic conditioning used procedures
modified from those recommended
for healthy elderly adults.13 During the first 5
weeks of
the program, walking intensity was increased
from 50% to 70%
aerobic working capacity, and walking
duration per session was
increased from 10 to 20 minutes. Exercise
intensity and duration
were kept constant between 50% and 70% of
maximum and 20
minutes, respectively, during the second 5
weeks of the program. A
Polar Heart Rate Monitor was worn, and
perception of effort was
monitored with the use of Borg’s 15-point
(scale of 6 to 20)
Apart from impairments resulting from stroke,
in
many subjects persistent disability arises from
adaptations
that follow disuse and use of maladaptive
behaviors.
Since inactivity exacerbates disability, a lack
of activity
programs after discharge from rehabilitation
may be a
major oversight in stroke management.9
However, given
the cost constraints on health care in most
countries,10,11
continued one-to-one exercise with a physical
therapist
can be unaffordable. Moreover, community
gyms do not
have appropriate personnel or equipment to
improve hand
dexterity.11 Then, alternative rehabilitative
programs are
needed to reduce long-term disability resulting
from UE
hemiparesis.12
The literature shows that several training
components
contribute to restoring UE function after
stroke. Muscle
psychometric scale.14 Strength training
concentrated on hip flexors,
extensors, and abductors; knee extensors and
flexors; and ankle
dorsiflexors and plantar flexors with
particular attention to muscle
groups with obvious deficits. Theraband
(Hygenic Corporation),
simple weights, and functional exercises were
used. Programs were
tailored to each subject’s needs and were
adjusted weekly as
indicated for supervised subjects. Subjects in
the unsupervised group
were given written and verbal instructions on
advancing in their
exercises.
Outcome Measures
The primary outcome of this study was (1)
the 6-minute walking
strengthening is essential.13 Sufficient UE
strength is
related to the ability to perform motor
activities adequately
and can improve function without increasing
tone
or pain.14 Likewise, re-acquiring bimanual
coordination
is indispensable to progress toward autonomy
since most
ADL require the use of both hands.1,15
Besides, chronic
deficit recovery is increased when exercises
focus on
function and provide high intensity and
repetitive practice
of movements.16
Accordingly, strength programs focused on
the
paretic UE of stroke survivors are of great
interest.13,17–20
The Borg scale has been widely used to
efficiently rate
the perceived exertion during exercise.23–25
A recent study
indicated that this scale can be used as a
measure of perceived
exertion during isometric contraction in
subjects
after stroke.26 Thus, it could be used to set the
intensity
progression of intervention as in previous
research in the
speed. Secondary outcome measures were (2)
Human Activity
Profile (HAP) adjusted activity score; (3)
Medical Outcome Study
36-Item Short-Form survey (SF-36) Physical
Component summary
score; (4) SF-36 Mental Component
summary; (5) sum of the
strength of lower limb muscles; and (6)
Physiological Cost Index
(PCI). Measures 1 to 4 reflect disability, and
measures 5 and 6 reflect
impairments.
Six-Minute Walk Test
A protocol for the 6-minute test used in
standard practice was
Implemented
A Randomized Controlled Trial of
Supervised Versus Unsupervised Exercise
Programs for Ambulatory Stroke
Survivors 2005
hemophilic arthropathy.27 Therefore, we
designed a community-
based group PT program given its proven
advantages.
17,28 This program combines resistance
exercises13,14
with elastic bands and bimanual functional
training,15 and
the intensity is set by the Borg scale.27 Hence,
to assess
the clinical feasibility and effects of this
program to counteract
inactivity in chronic stroke a logical approach
is to
test it in a pilot randomized controlled trial.
The UE group underwent a PT program aimed
at
improving the affected UE muscle strength
and function. A
nine 5-min station circuit session was
designed (Figure 1).
Muscle strengthening exercises using elastic
bands were
alternated with bimanual activities. Patients
worked
2 + 2 min on each exercise, with a 30-s rest
between the
2-min periods and between each station.
Strengthening
exercises included shoulder flexors, abductors
and lateral
rotators, serratus anterior push-ups and wrist
extensors.
Stations of bimanual exercises consisted of:
(1) passing
lentils/flour from one glass to another +
pushing a plunger
of a syringe/coffee machine; (2) following a
drawing of
a star on the wall by rolling a ball + arm
cycloergometer;
(3) gripping and releasing objects of different
sizes (small
rubber balls, chickpeas, grains of coffee, rice
…). Each
training session had a 10-min warm-up and
cool-down
period in which participants performed range
of motion
exercises and stretching of the UE muscles.
Exercise
strength and intensity were set weekly.
Progression
was based on a gradual increase of the rate of
perceived
exertion27 (RPE) measured by the Borg scale
0–10.30 According to the training session, a
certain level of RPE had to be achieved for
each exercise. An example of the progression
of one participant is shown in Figure 2. The
duration of the training session was 75 min.
The LE group performed an interval training
protocol
to improve functional capacity and strength of
the lower
limb. The circuit consisted of a set of eight
cardiovascular
exercises performed at moderate intensity
(60–80% maximum
heart rate) interrupted by 1-min active breaks
of
task-oriented exercises. Cardiovascular
exercises included
toe touch on the floor in different directions,
knee raises,
fast walking on the floor, step up and down,
cycling on
a static bike and sloping walk (treadmill).
Task-oriented
exercises consisted of graded reaching, walk
and turn,
toe touch with the non-affected side on boxes
of different
height, heel raises and walking over different
surfaces,
with obstacles, sideward and backwards. Each
training
session also had a 10-min warm-up and cool-
down period
and lasted 75 min.
After completing the intervention, a handout
of the
exercises was provided, and participants were
prescribed
to continue with their programs at home.
Discussion
The present study aimed to assess the
feasibility and effect
of a PT program composed of strengthening
exercises
with elastic bands and bimanual functional
activities on
the paretic UE, setting the intensity with
clearly defined
doses based on the RPE (Borg scale), to
counteract inactivity
of subjects with chronic stroke.
The suitability
of subjects after stroke with UE problems to
engage in
repetitive practice or strengthening exercises
is limited.
For this reason, at present, the most frequently
prescribed
exercises are low intensity exercises.42
However, our program showed good
feasibility. When compared to the LE group,
more participants in the UE group (3 vs. 1)
continued the PT program at the same
intensity at home. After
three months, the percentage of adherence in
the UE group
(43%) was higher than the 20.3% reported
previously.43
Nevertheless, as in the study of Jurkiewicz et
al.44 the
adherence to the PT protocol was superior
when participants
attend scheduled sessions than in the follow-
upperiod. In addition,
in agreement with Pang et al.17 participants
were satisfied and stated that they were likely
to
participate in a similar long-term program in
the future
Other important question to consider is the
time since
stroke. In this regard, it was observed a huge
variability
between subjects in the LE group (from 10 to
72 months)
and particularly in the UE group (from 6 to
108 months
after stroke). Thus, there could be differences
in the underlying
mechanism for recovery. Little has been
studied
about neural mechanism in the long-term
recovery after
stroke.48,49 It has been noted that at any time
after the
stroke, motor skills may improve by means of
the cerebral
processes involved in ordinary learning.12
One of the most
potent modulators of cortical structure and
function is
behavioral experience.50 Consequently, the
proposed PT
program could have enhanced motor skills. In
fact, several
studies revealed that UE motor recovery is
characterized
by an improved ability to selectively control
the different
joints in the paretic UE, as reflected by
increasing scores
on the FMA.51 Nonetheless, the impaired
ability is caused
not only by neural factors that affect motor
control, but
also by changes in muscle fibers and atrophy
induced by
inactivity and sedentary behaviors.9 It is
possible that prolonged
sitting and sedentary behaviors start early after
the stroke survivors return to home.52
However, muscle
weakness, altered muscle tone affecting range
of motion,
and compromised cardiorespiratory fitness
could be more structured in chronic subjects
with more than a year after stroke. Therefore,
the studied PT program involved the
subjects in a more active behavior, which
could be the
reason for the great improvement in FMA,
rather than
the strengthening exercises and the bimanual
techniques
employed. In this regard, it would have been
helpful that
the control group had performed a PT program
based on
UE management without structured intensity
progression,
to better know the isolated effect of carrying Pilot randomized controlled trial to assess a
out strength physical therapy program on upper
training and bimanual techniques with well- extremity
defined doses
Stroke is one of the major causes of chronic disability.
Stroke mortality rates have been declining, translating into a larger
number of chronic stroke survivors (Feigin et al, 2003). Many of
these survivors continue to live with residual physical impairment.
This population, suffering from stroke-related deficits, warrants con-
tinued attention in an effort to reduce deterioration in, and improve,
quality of life. The development and implementation of strategies
aimed at minimising stroke-related disability are at the forefront of
neurological rehabilitation research.
Gait impairment is a major determinant of disability after stroke.
At least 50% of stroke survivors suffer from persistent hemiparetic
gait deficits, resulting in reduced mobility (Gresham, et al, 1975;
Jorgensen et al, 1995) and reduced mobility leads to a decrease in
cardiorespiratory fitness furthering disability (a vicious
cycle).(Mackay-Lyons and Makrides, 2004; Michael and Macko,
2007). Several studies and meta-analyses investigating physical
fitness interventions, such as circuit class training, cycling exercise
and water-based exercises, have demonstrated beneficial effects on
cardiovascular fitness and walking performance in all post-stroke
phases (English and Hillier, 2010; Pang et al, 2006; Saunders et al,
2004; van de Port et al, 2007; Wevers et al, 2009).
Whereas post-stroke individuals undergo intensive training as part of
their routine during hospitalisation in a rehabilitation hospital, the
level of training drastically decreases upon returning home
(Jurkiewicz et al, 2011). Only 31% of stroke patients exercise
regularly compared with 45% of age-matched healthy individuals
(Shaughnessy et al, 2006). Factors such as fatigue and poor health
may prevent post-stroke individuals from beginning a structured
exercise programme (Payne et al, 2001).
Previous studies showed that stroke patients can benefit from
exercises, but the duration, type and time of beginning of
intervention significantly varies
Inclusion criteria
function to counteract inactivity in chronic
stroke 2016
Ability to walk independently (with or without walking aids), total
functional independence measure (FIM) score ≥60 at mid-
hospitalisation evaluation.
Exclusion criteria
Rheumatologic and orthopaedic disorders hindering the ability to
walk; neglect; apraxia; and cognitive disorders impeding
collaboration
Individuals admitted to the rehabilitation hospital about a week after
the stroke. The hospitalisation period in the acute neurologic
rehabilitation department ranges from 1.5 to 3 months (average
hospitalisation period is 60 days). Standard rehabilitation included
45-minute daily sessions of physical therapy, 60 minutes of
occupational therapy (30 minutes of individual treatment sessions
and 30 minutes of group exercises) and, if needed, 30 minutes of
speech therapy.
During the last week of hospitalisation, subjects in the
intervention group received a list with detailed exercise instructions,
including drawings and explanations of each exercise. The list of
exercises was prepared by team of psychiatrist and physical
therapists using PhysioTools software. The list included 6 exercises
in a supine position aimed at improving pelvic, trunk and upper limb
control (e.g. pelvic lift, posterior anterior pelvic tilt, knee roll, and
self-assisted arm lift), and 8 exercises in a standing position aimed at
improving balance and lower limb strength (e.g. side-to-side and
anterior-posterior weight shifting, mini-squats, mini-lunges, and calf
muscle stretches).
All exercises were performed at least twice before discharge under
the guidance of a physical therapist. Physical therapists ensured that
subjects understood the exercises and were able to perform them
independently, according the list. Subjects in the control group
performed the same exercises as part of their routine rehabilitation
programme, but not specifically before discharge and did not receive
the list of instructions.
The intervention group was instructed to continue the exercises at
home in addition to a directive to walk for at least 30 minutes in the
course of the day (in one or two sessions, indoors or outdoors).
Subjects were instructed to perform the specific exercises and walk
every day for three months after hospitalisation, until the follow-up
hospital visit. To monitor the execution of the exercises, each subject
in the intervention group received a diary in which the number of
exercises performed and amount of time spent walking were daily
recorded. In addition, the subjects in this group received a telephone
call every two weeks encouraging the continuation of home-based
training. Subjects in the control group received only one telephone
call with a reminder of the follow-up visit. Adherence was calculated
in the intervention group as ratio of days of exercise (at least 15
minutes of exercises) and walking (at least 30 minutes in total)
divided by number of days between E2 and E1.
The 10-metre walk test (10MWT) is a standard test assessing
walking speed in metres per second over a short duration period in
post-stroke individuals. The patient walks 14 metres without
assistance. Time is measured for the intermediate 10 metres to allow
for acceleration and deceleration. The MWT displayed excellent
test-retest reliability (ICC=0.95–0.99) (Collen et al, 1990).
The 6-minute walk test (6MWT) is widely used to test post-
stroke individuals (Fulk et al, 2008; Mudge and Stott, 2009) The test
measures the distance an individual is able to walk on a hard, flat
surface for a total of 6 minutes. The goal is for the individual to walk
as far as possible in 6 minutes. He is allowed to self-pace and rest
when needed as he traverses back and forth along a marked walkway.
The 6MWT displayed good test-retest reliability (ICC=0.88–0.94)
(Rikli and Jones, 1998).
Timed Up & Go (TUG) is a simple test used to assess a
person’s mobility, requiring both static and dynamic balance
(Podsiadlo and Richardson, 1991). It measures the time that it takes
for a person to rise from a chair, walk 3 metres, turn around, walk
Stroke confers heightened risk for further cardiovascular events,
with one 26 third of people experiencing a recurrent stroke.1 Risk
factor management includes physical activity,2 with each 60 minute
per day increase in activity potentially reducing risk of all-cause
mortality by 28%.3 In addition, physical activity is pivotal for
recovery of function after stroke.4 Independent of physical activity,
time spent sitting is also a risk factor for cardiovascular
disease.5,6 Breaking up periods of prolonged sitting promotes
upright activity and may also be beneficial for cardiometabolic
health by reducing glucose and insulin levels,7 positively
influencing adiposity5,8 and reducing resting blood pressure.9
However, physical activity is low after stroke, with people
performing only half the daily step
counts of healthy matched peers once home.10 During waking
hours, stroke survivors spend up to 74% of their day sedentary
(sitting), both in hospital11,12 and in community settings.13,14
Therefore, to improve recovery and reduce cardiovascular risk, it is
essential to identify factors underlying reduced activity after stroke.
The environment may be an important factor for promoting physical
activity and reducing sitting after stroke. Interventions targeting the
environment can influence sitting time in the general population,15
and differences in the hospital ward environment appear to influence
back to the chair and sit down. During the test, the person is expected
to wear their regular footwear and use any mobility aids that they
would normally require. The test displayed good test-retest
reliability (ICC=>0.95)(Ng and Hui-Chan, 2005).
Discussion
Results of the study demonstrated that home-based exercises
significantly improve walking capacity in post-rehabilitation stroke
individuals. This is in accord with other studies that evaluated home-
based rehabilitation programmes for post-stroke individuals
(Duncan et al, 1998; Hui-Chan et al, 2009). The most prominent and
statistically significant difference between the groups was found in
the 6MWT. In addition, adherence was found to be significantly
correlated with change in the 6MWT. This test is a performance-
based measure of functional exercise capacity and endurance.
Therefore, it is possible that the influence of home-based exercises,
including daily walking, is foremost and based on functional exercise
capacity and endurance of the patients.
The 10MWT and the TUG also showed significant within-group
improvements by assessing the individuals’ capacity to walk and
move. It can cautiously be concluded that home-based exercises,
clearly and thoroughly explained by physical therapists to the
individuals and performed on a daily basis concurrent with diary and
telephone monitoring, improve functional exercise capacity and
endurance of post-stroke individuals better than unsupervised,
voluntarily performed exercises.
Results of the study showed that home-based exercises
improved walking capacity and self-esteem in post-rehabilitation
stroke individuals. We believe that home-based exercises should be
a routine part of post-hospitalisation stroke rehabilitation.
TREGER2014 INFLUENCE OF HOME BASED EXC
ON WALKING AND FUNCTION
upright time and activity in stroke survivors.16 A key change in
environment after stroke is from hospital rehabilitation to the home.
It is unclear how this transition impacts activity levels, and how
physical and psychological factors may modify any change.
Understanding such factors is important for the design of
interventions to facilitate change in activity after stroke.
Stroke survivors spent less time sitting and more time
standing and walking in their first week at home than in the final
week of hospital-based rehabilitation. Our results suggest that the
environment can positively influence stroke survivors’ activity and
sitting behaviour. The presence of depression in particular modified
the association, such that those with depression spent more time
sitting at home than in hospital. Other factors, such as physical
performance,presence of a caregiver, cognition and stroke severity,
were not associated with change in activity during the transition
home. Rehabilitation environments should promote physical
activity. However, in our study, it was the home environment that
was associated with lower total daily sitting time in the order of 45
minutes per day, with behaviour transferring to upright postures,
including 12 minutes and724 steps more walking. The home may
provide greater opportunity for activities of daily living such as
cooking, cleaning, social and community activities, and there may
be fewer external restrictions such as hospital routines and safety
concerns around mobilisation.29 Few studies have examined the
effect of environment on activity levels. Early supported discharge
from an acute stroke unit facilitated greater daily step count and time
spent upright in the home.30 However, whether this reflects the
environment or the effect of the supported therapy remains unclear.
Changes to the rehabilitation environment may promote activity.
Physically, cognitively and socially enriched stroke
rehabilitation environments appear to increase activity by 20%.31
The most common symptom poststroke is hemiparesis.1 Physical
therapy (PT) and occupational therapy (OT) focus on reducing the
motor impairments early after stroke while enhancing the
individual’s functional ability, but few studies have objectively
quantified the upper and lower extremity activities performed by
individuals who are undergoing rehabilitation. Hundreds of
repetitions of movement are required for learning and cerebral
plasticity to occur.2,3 Observational analysis of typical stroke
inpatient activities has provided useful information on the content of
activities within therapy as well as during nonstructured time
through the rest of the day. Lang et al4 observed 312 inpatient and
outpatient therapy sessions of PT or OT and reported on average 32
repetitions of upper-extremity movement and 367 lower-extremity
steps per therapeutic session. Bernhardt et al5 observed 58 acute
stroke patients between 8 am to 5 pm for approximately 1 minute at
10-minute intervals over 2 days and reported that these patients spent
only 13% of
the day involved in mobility activities. For 17 inpatients, Esmonde
et al6 reported no involvement in structured therapy for two thirds of
the 9 am to 5 pm day and that for only half of these observations
were they engaged in motor activities. De Wit et al7 observed 160
inpatients from 7 am to 5 pm and recorded observations at 10-minute
intervals for 4 European stroke rehabilitation units (1800
observations at each of the 4 sites). The total time spent in therapeutic
activities ranged from 1 to 2 hours and 46 minutes per day, of which
40% of the time was for PT. The percentage of nontherapy time
ranged from 72% to 90% of the day.
Participants were consecutive adults admitted to 2 inpatient
rehabilitation centers within 60 days of sustaining a stroke as
confirmed by CT or MRI. Patients were excluded if they were
younger than 19 years old, had a significant musculoskeletal
condition within the past 6 months, had a neurological condition
other than stroke, or if they had communication or cognitive
difficulties that prevented them from providing informed consent.
Clinical assessments were used to determine the level of
motor and functional ability of the upper and lower extremities and
were undertaken at both assessment 1 (on admission) and assessment
2 (3 weeks later). The FuglMeyer Motor assessment23 (upper-
extremity scale) was used to assess the motor impairment of the
Stroke is a major cause of death and disability throughout the
world,consumingsignificant resources(Isard1992).Itistherefore
imperative that stroke services are effective and efficient.
Problemsaffecting the upper limb following stroke are often
persistent and disabling, with only 20% (Parker 1986) to 56%
(Nakayama 1994) of patients regaining useful upper limb function
Wards which include communal areas promote more time spent
upright,32 and the need to transport patients further for personal care
may create opportunities for activity.16 The low activity levels in
hospital and at home found in our study, and prior reports of people
in hospital spending over half their day inactive,11,33 indicate that
there is clearly more work to done in promoting activity after stroke.
The impact of home versus hospital rehabilitation
environment onactivity levels of stroke survivors 2018
paretic upper extremity, and its validity and reliability have been
well established in stroke.23,24 Scores range from 0 points (no
active movement) to 60 points (full active movement). The Action
Research Arm Test25 is a reliable and valid measure for function of
the paretic upper extremity of individuals with stroke26 and
measures the quality of movements such as grip, grasp, pinch tasks,
and gross movements. Scores range from 0 points (a nonfunctional
hand) to 57 points (a fully functional hand). The Berg Balance
Scale27 was administered to assess the ability to maintain balance
while performing 14 functional tasks and is a reliable and valid
measure of balance in stroke.28 Scores range from 0 points (poor
balance) to 56 points (excellent balance ability). Mobility was
determined by using 2 walking tests:
10-Meter Walk Test29 (gait speed in m/s over 10 m) and
the Six-Minute Walk Test (6MWT, distance walked in meters over
6 minutes).30 These measures are valid and reliable for use with
individuals with stroke.31 In addition, the functional ability of the
patients performing basic activities of daily living was assessed
using the Functional Independence Measure (FIM),32 which has
been found to be reliable and valid when used with individuals with
stroke.
Our findings partially supported the hypothesis that daily
use of the lower extremity increases over inpatient stroke
rehabilitation. However, our results do not support the hypothesis
that daily use of the upper extremity increases over inpatient stroke
rehabilitation.
Our findings supported the second hypothesis that the
amount of daily use of upper and lower extremities of the older
community-dwelling adults was substantially higher compared with
daily use of the stroke patients at discharge to the community. The
median steps/d (5202) of our healthy controls fell within the
expected range from population-based studies of older adults.33
Most investigators consider the original recommendation of 10 000
steps/d to be unrealistically high, especially for older adults
DISPARITY BETWEEN FUNCTIONAL
RECOVERY AND DAILY USE OF THE UPPER LOWER
EXT DURING SUBACUTE STROKE REHABILITATION
DEBBIE RAND 2012
after three months. In addition, motor impairment hasbeen shown to
be the most influential factor in determining well-being, one year
after stroke (Wyller 1998). Improving upper limb function is
therefore oftenacore elementofrehabilitation
afterstroke,inordertomaximise patient outcomes and reduce
disability (Langhorne 2003).
 Description of the intervention
Increasingly the trend within health service delivery (including
stroke care) is toward decreasing lengths of stay for inpatient care
and moving care into the community, which has led to the
development of home-based stroke services(ESDT 2005).
ACochrane review of therapy-based rehabilitation services for stroke
patients at home (OPT 2006) found such services reduce the odds of
a poor outcome in terms of ability to perform activities of daily living
(ADL), and have a beneficial effect on a patient’s ability to perform
personal ADL and extended ADL, compared with conventional or
no care. This review specifically investigated therapy service
interventions primarily aiming to improve task-orientated behaviour
(not upper limb interventions or outcomes) and was based on a
review of heterogeneous interventions. Our review, in contrast,
exclusively investigated the effects of home-based therapy
programmes targeted at upper limb recovery.
Therewas insufficient evidencetodetermineif
hometherapyprogrammes were more or less effective than usual care
(visits to hospital or local healthcentre or hospital inpatient care),
nointerventionoraplacebointervention.
Onlyfourstudiesmettheinclusion criteria for this review. These four
studies included essentially two different programmes of therapy and
so are not representative of all the therapies available.
HOME-BASED THERAPY PROGRAMMES FOR
UPPER LIMB FUNCTIONAL RECOVERY FOLLOWING
STROKE (REVIEW)

Potential reasons for incomplete upper limb recovery, beyond the extent of neurological damage, may be the limited amount of outpatient post-
stroke care that is typically received and the small number of movement repetitions completed during typical outpatient sessions. (9–11) Strategies
used in clinical practice to bridge this gap are home exercise and activity programs. While commonly suggested, there is limited information on
how to create home programs that address upper extremity function after stroke in physical and occupational therapy training texts.
(12–15) Such home programs range from a one size fits all approach to individualized programs(16,17) and consist of designated exercises or
activities with a recommended dosage. Those withstroke usually receive training in carrying out a program and may receive handouts
orinstructions to keep an exercise or activity log. (17,18)While home programs are commonly used and persons after stroke typicallyacknowledge
the value of upper extremity exercise in recovery, adherence to such programswithout concurrent therapy is often low. (19,20) Such individuals
indicate difficulties incompleting home programs for a variety of reasons. These include lack of knowledge on how tobegin or proceed with
exercises, difficulty maintaining motivation, musculoskeletal issues,fatigue, lack of time, family obligations, depression, and lack of enjoyment.
(19,21)
DISCUSSION
The barriers for engagement inhome programs are both numerous and somewhat distinct from those previously cited in theliterature. (19,21) Our
participants reported frustration, fatigue, and cognitive barriers (memoryand initiation) in addition to more commonly mentioned barriers such as
lack of enjoyment,motivation, and musculoskeletal issues. These findings suggest that persons after stroke value theopportunity to continue
recovery, but likely need additional encouragement to carry out a homeprogram
Most participants reported having received instruction with prior home programs, but thetraining that they recalled was vague. The non-
specific nature of the home exercise programs may have made it difficult to incorporate these activities into a daily routine. Furthermore,
afterparticipants stopped receiving direct therapy services, it appeared that they had developed or modified their own home program routines. This
suggests that programs carried out at homeshould continue to be monitored in order to ensure that the approaches being used are appropriate and
that the person is following through and not encountering difficulties. To remedy this, home activity/exercise programs may need to have a more
intensive focus during rehabilitation with continued follow-up and monitoring via telephone or the Internet to ensure carryover and enable more
effective self-management. Current research on tele-rehabilitation
suggests that these techniques may be a viable option to extend therapy services. (34–36)
Understanding Upper Extremity Home Programs and the use of Gaming Technology for Persons After Stroke 2015

IntroductionThe physical rehabilitation of
stroke survivors is basedaround movement
[1]. This physical activity is central to
therecovery of motor skills impaired by
stroke, with evidence ofthe positive
relationship between activity and recovery
con-tinuing to emerge [2]. Physical activity
is also a recognisedfactor in preventing
future health problems, with recommen-
dations of 20 to 60 minutes of moderate-
intensity physical activity on 3 to 5 days
per week during the rehabilitationperiod
[3]. Furthermore, physical activity is
important for theprevention of early
medical complications associated
withimmobility [4]. Recent work,
however, has quantified verysedentary
behaviours among stroke survivors [5,6].
A recentbehavioural mapping exercise
categorised 74% of daytimeactivity as
‘sedentary’ in stroke patients (n = 104)
during theirstay at a rehabilitation facility
[7], and these observations areechoed
across the general stroke population
[8].Early supported discharge is now the
preferred optionfor stroke survivors who
are medically stable and can besupported at
home. A recent meta-analysis produced
robustevidence that survivors with mild-to-
moderate disabilityreceiving early
supported discharge with a co-ordinated
multidisciplinary team had better
functional outcomes atfollow-up (median 6
months, range 3 to 12 months)
thansurvivors receiving conventional,
inpatient care [9]. What isnot known is the
mechanism through which this
improvedresponse occurs, with possible
factors including less depend-ency on
carers and a more tailored care and
rehabilitationpackage [9]. It is possible
that, through re-engagement withfamiliar
domestic and social roles, a stroke survivor
naturallyincreases the intensity and
frequency of their physical activ-ity, with
the consequent positive effect on motor
recoveryand physical health. On the other
hand, early supported dis-charge may have
a deleterious effect on a stroke
survivor’sphysical activity through
reduced contact with
rehabilitationtherapists. Any change in
physical activity is likely to beaffected by
a range of medical and demographic
factors, suchas severity of stroke, co-
morbidities and age
A major goal for the rehabilitation
of stroke survivors isto return to the type
and level of physical activity
associatedwith living in the community
[14]. These results suggest thatearly
supported discharge helps stroke survivors
attain thisgoal. Askim et al. demonstrated
Hand impairment after stroke
contributes substantially to disability in the
United States and around the world [1].
Intensive movement practice can reduce
hand impairment [2–6], but issues such as
cost and access may limit the dose of
rehabilitation exercise delivered one-on-
one with a therapist. Because of these and
other factors, most individuals do not
perform the large number of exercise
repetitions required during therapy to
maximize recovery [7–8]. Home-based
rehabilitation programs may be prescribed
after stroke with the intent to increase the
amount of rehabilitation exercise
individuals perform. However, the most
common approach to home-based hand
therapy is following a printed handout of
exercises. This approach is often not
Home-based prescribed physical activity
programs with telephone support are
thought to work by embedding exercise into
daily routine, and avoiding the need for
travel to an exercise centre. However, they
may fail by not facilitating inter-personal
connections between the individual and
his/her peers, and by the prescriber having
limited capacity to monitor the person’s
physical progress. Structured gym-based
programs may have an advantage over
home-based programs, by controlling the
amount and quality of direct training and
supervision, allowing personal attention and
immediate verbal feedback from the
exercise facilitator. Motivation for exercise
may also be enhanced via social support and
that stroke survivors can bephysically
active for up to 20% of waking time; a
value thatapproximates the amount
attained by the stroke participantsin this
study during their early supported
discharge experi-ence [15]. At the very
least, the levels of activity attainedby acute
stroke survivors during early supported
discharge(approximately 2 hours of
standing activity per day) could bea useful
target for rehabilitation teams.
Conclusion
This observational cohort study found that
stroke sur-vivors double their levels of
physical activity when movingfrom
motivating and thus is associated with low
compliance and high dropout rates [9–13].
To address this problem, other
types of home-based rehabilitation
programs for the hand have been proposed.
For example, one pilot study explored a
modified form of constraint-induced
movement therapy performed under the
supervision of a nonprofessional coach in
the home and found similar benefits to the
same program performed with a trained
therapist in a clinic [14]; a larger study
using this protocol found that home-based
constraint-induced movement therapy led
to significantly greater self-reported use of
the impaired limb than conventional
therapy [15]. Another common approach is
telerehabilitation, which allows a therapist
to guide therapy remotely [16]. While this
approach is gaining popularity, a recent
interaction between exercise group
members with similar health issues
Home-based program with telephone
support Participants allocated to the home-
based intervention were also given a 12-
month, individualised, exercise program.
Each participant was encouraged to
complete a 1-hour exercise session, three
sessions per week, at home. The home-
based exercise program was supervised via
five telephone calls over the first 10 weeks,
approximately 25 to 30 minutes in duration.
The total time in minutes to complete the
five phone calls for each participant was
comparable to that spent supervising each
participant in the gym over a 12-month
intervention period
hospital-based rehabilitation to community
living withearly supported discharge. This
improvement was unrelatedto changes in
mobility or time delay between data
collectionperiods. These findings support
the use of early supported dis-charge in
stroke care, and provide practical physical
activitytargets for stroke units prior to
discharge.
KERR A, ET AL. CHANGES IN THE
PHYSICAL ACTIVITY OF ACUTE
STROKE SURVIVORS BETWEEN
INPATIENT AND COMMUNITY
LIVING WITH ESD(2015),
Cochrane systematic review of 10 trials
with 933 total participants found limited
evidence to support its use and no studies
that examined its cost-effectiveness [17].
Other approaches to home-based hand
rehabilitation include functional electrical
stimulation [18], computer gaming with
custom devices [19–21], and music-based
therapy [22]. However, despite the variety
ofoptions, few home-based programs have
been tested in controlled studies [23].
Further, it is still unclear which methods
are the most effective and efficient means
of providing an increased dose of
rehabilitation, though the use of computer
games and music has been found to be
highly motivating [20,24–26]
HB hand rehab_RCT compare
conventional_zondervan2016
The strength-training component involved
six to eight exercises for the upper and
lower body (eg, sit to stand, calf raise, bicep
curl, triceps push-down, lateral pull-down,
chest press or scapula retraction) using body
weight or an elastic exercise banda to
provide resistance. The aerobic component
included community walking or, if
participants had access to their own exercise
equipment such as a stationary bike, this
was incorporated
The 6-minute walk test,31 which measures
the distance a participant is able to walk in 6
minutes, was performed once per participant
at each time point, using the American
Thoracic Society guidelines. In community-
dwelling adults aged _ 65 years, the 6-
minute walk test showed correlations with
the Short Physical Performance Battery gait (0.80), maximal gait (0.80) and stair PAUL JANSONS 2017 GYM AND
(0.61), chair stand time (–0.62), habitual climb time (–0.83).32 HOME BASED IN ADULT W/
CHRONIC CONDITION