Home Rehabilitation System in Chronic Stroke: An Observational Study in Central Italy
Keywords: Chronic stroke, disability, home rehabilitation, physical and rehabilitation medicine, physical therapy
In Europe stroke is listed as the cause of death in 10% of men and 15% of women. According to World Health Organization (WHO) Statistics (2002), stroke is responsible for the loss of 7% of the total European population disability adjusted life years, and thus presents a significant burden in respect of population morbidity and not just mortality. By 6 months following a stroke, approximately 65% of stroke survivors cannot incorporate into daily activities, resulting completely dependent.,
Timeliness and specificity of the rehabilitative therapeutic intervention—both in the acute and postacute phases—psychosocial aspects, nutritional status, and environmental features of the area of posthospital discharge currently represent an important object of study in the international literature; all studies agree on the evidence that rehabilitative therapeutic approaches in chronic phase are not yet adequately standardized. An appropriate caregiver training and social reintegration in the home territory is very important for the patient's final outcome; these factors seem to affect the global outcome by increasing psychological residual abilities and improving the specific function and the development of adaptive and compensatory strategies. In his systematic review of 2010, Hillier and Inglis-Jassiem highlighted the importance of creating a network for home rehabilitation by integrating services between the territory and the hospital and improving access to services and to the day hospital outpatient rehabilitation facilities. At the same time, they suggested that it could be crucial to develop training programs with specific clinical pathways, which should be appropriate in modalities, timing, and intensity, in order to create a high-quality home rehabilitation service. These studies have, thus, separately analyzed the outcomes in specific psycho-emotional and motor skills task in institutionalized and home-treated patients. There are no studies comparing all these factors.
The aim of this study is to assess the overall outcome in both psychological and physical well-being, increase in residual abilities, reintegration and social inclusion for people with chronic disabilities resulting from stroke, after home rehabilitation.
Between July 2012 and May 2014, we assessed the functional outcome in a group of 600 patients with disability related to several pathological conditions and undergoing home rehabilitation therapy at the frequency of two sessions per week for 40 sessions per year, as granted by the Public Health [Figure 1].
We performed an initial analysis among all data regarding people degree of autonomy based on the administration of two different rating scales:
The analysis of the first assessment, made by the both Barthel scales and FIM, was carried out using the Statistical Package for the Social Sciences (SPSS) software. Steps were taken to prepare the file data containing the assessment made by the two scales (Barthel and FIM), in SPSS files.
In a group of 73 patients with chronic stroke (29 females, 44 males; mean age 70 years old, range 59–77), we also carried out an overall evaluation, by using specific rating scales, after 120 days (114 ± 6) from the end of the home rehabilitation program.
Based on the compliance with the inclusion criteria, the overall outcome related to the psycho-physical well-being, the increase in residual abilities, and the social reintegration before (T0), at the end of the rehabilitation program (T1), and after 4 months from the end of treatment (T2) were assessed.
Inclusion criteria in the study were: Outcomes of ischemic or hemorrhagic stroke; chronic condition (stroke occurred at least 6 months before); age between 40 and 80 years old; score ≥24 at Mini-Mental State Examination (MMSE); ability to walk independently for 15 m.
Exclusion criteria were: Recurrence of the disease in the last 3 months; concomitant neurodegenerative diseases; orthopedic disorders severely limiting the activity; vertebral collapses (2 or more) in the last year; hip fracture in the last 6 months; thyroid disease not clinically compensated; cardiovascular disease not clinically compensated (ischemic heart disease, congenital cardiomyopathy, syncope, heart failure based on New York Heart Association Class III-IV, aortic aneurysm with surgical indication, carotid stenosis with surgical indication); severe cognitive decline; and disease with poor prognosis in 6–12 months.
The assessment and classification included: Clinical examination and drafting of medical records with medical history, drug history, diagnostic tests, neurological and musculoskeletal examination; rating scales as Tinetti for the assessment of balance and gait and FIM for the measurement of functional independence level; Barthel Index to measure the level of autonomy in ADL; Stroke Impact Scale to assess the multifactorial outcomes after stroke; MMSE to assess cognitive function; Hamilton Depression Scale as a measure of depressive symptoms; Motricity Index to measure the muscle strength of upper and lower limbs; Ashworth Scale for spasticity; 6-Min Walking Test (6MWD); Five repetitions Sit-to-Stand Test; 10-m Walking Test.
The home rehabilitation program consisted of passive motion of lower and upper limbs; posture changes; exercise training aiming to the re-learning of specific motor tasks congruent with the residual abilities; assisted gait; educational training for self-repetition of the re-learned motor task. If possible, the education of caregivers was also provided, in order to optimize the effect of the treatment and the care burden and also to reduce the possible burnout.
Statistical analysis was performed in this case with one-way analysis of variance system with multiple comparisons using Bonferroni test on GraphPad-6 Prism software; the minimum level of significance was set for P < 0.05.
In relation to comorbidities, the following were detected: 22 patients with type II diabetes; 2 patients with type I diabetes; 5 patients with at least one amputation in the lower limbs; and 7 patients with venous vascular insufficiency of the lower limbs. In relation to the stroke-related deficits, the following were found: Hemiplegia in all assessed 29 subjects with severe spasticity; 16 subjects at risk of malnutrition with severe difficulty in swallowing autonomous; alteration of symbolic functions in 14 subjects; conductive hearing loss in 23 subjects; impairment of conjugated ocular motility in 9 subjects; trunk control deficit in 8 subjects; mild cognitive impairment in 5 subjects; sleep disorders associated with anxiety-depressive syndrome in 28 subjects; deficits of short-term memory in 14 subjects; 14 subjects had no chance of help from a family member or care. Only two persons had specific environmental adaptations of the house. They all had the need for adaptations, help with personal hygiene management, and transporting; 22 subjects could not feed independently; all subjects were able to walk with adaptations for few meters.
The analysis carried out in 530 patients showed a significant change in the level of autonomy in ADLs evaluated with Barthel Scale [Figure 2] in patients with chronic stroke, bone fractures (P < 0.01), cerebral palsy, osteoarthritis, and cerebrovascular chronic disease; a significant variation in the degree of independence assessed by FIM scale [Figure 3] in patients with chronic stroke, bone fractures (P < 0.01), cerebral palsy, Parkinson disease, and osteoarthritis (P < 0.05).
In 73 patients with stroke, T0 results were: a level of autonomy of 78 ± 11.0 with the FIM scale; a score of 57.5 ± 9.5 at the Barthel scale; score of 151 ± 22.13 at the Stroke Impact scale; average score of 26.1 ± 17.13 at Motricity Index; score of 14.9 ± 4.27 at Tinetti Balance scale; lower limb spasticity in the hemiplegic side equal to 3.75 ± 1.12; walking speed estimated at 25.5 ± 6.15 s with the 10-m Walking Test; a resistance quantifiable in 88 ± 7.91 m assessed by 6-Min Walking Test; coordination score of 24 ± 2.70 at 5 Repetitions Sit-to-Stand Test; mood assessed with Hamilton Depression scale in a score of 22.1 ± 5.25. One patient died during the 16-month study, therefore the final assessment was performed on 72 subjects.
At T1 we found: a level of autonomy 83.4 ± 12.7 with the FIM scale; a score of 65.5 ± 9 at the Barthel scale; score of 157 ± 22.27 at the Stroke Impact scale; average score of 32.4 ± 19.95 at Motricity Index; score of 17.8 ± 4.31 at Tinetti Balance scale; limb spasticity in the hemiplegic side equal to 3.35 ± 0.91; walking speed estimated at 25.31 ± 5.87 s with the 10-m Walking Test; resistance in gait of 94 ± 8.45 m assessed by 6-Min Walking Test; coordination score 22 ± 1.98 at 5 Repetitions Sit-to-Stand Test; and a score of 20.7 ± 4.5 at the Hamilton Depression scale.
At T2 we found: a level of autonomy of 79.5 ± 11.23 with the FIM scale; a score of 61.2 ± 9.2 at the Barthel scale; score of 153 ± 21.9 at the Stroke Impact scale; average score of 29.7 ± 21.72 at Motricity Index; score of 15.7 ± 14.4 at Tinetti Balance scale; level of spasticity in the hemiplegic side equal to 3.5 ± 0.98; walking speed at 25.39 ± 5.92 s in the 10-m Walking Test; resistance quantifiable in 91 ± 14.8 m at 6-Min Walking Test; coordination score of 23 ± 23.2 at 5 Repetitions Sit-to-Stand Test; Hamilton Depression scale score of 20.3 ± 3.68 (P < 0.05).
All results are summarized in [Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10],[Figure 11],[Figure 12],[Figure 13].
The results show a significant improvement of the parameters related to functional independence and movements only in the period of the home rehabilitation treatment and a decrease of 40% in the results assessed during the follow-up carried out after 4 months from the end of the treatment period. In particular, the Bonferroni test for multiple comparisons highlighted a statistically significant improvement between T0 and T1 (P < 0.001) as regards to the scores of the FIM and Barthel scale, Motricity Index, Tinetti scale, 6-min Walking Test and 5-Repetitions Sit-to-Stand Test. The same parameters still change with a statistically significant value at T2 but with opposite trend (40% loss of the results). The parameters for the Stroke Impact scale, and the 10-m Walking Test did not change significantly in any of the evaluations.
The emotional factor, evaluated with Hamilton Depression scale, is the only parameter which significantly improves both at the time T1 and T2 (follow-up after 4 months). Through the Hamilton assessment, we found an improvement in mood over the entire period; this fact, in line with what reported in literature, may be indicative of the importance and the need for adequate family and social relationships in the management of patients with chronic stroke.
With this study, we experienced how the characteristics of the discharge area and living environments strongly affect outcomes in patients with functional disability. This is in line with the statement made by Deutsch and Silvius-Byron et al. about the importance of discharging the patient in an overall functional territory. The execution of task-oriented exercises and re-education treatment may induce improvement in the short term, improving quality of life (QoL) in terms of independence in daily activities as well as improvement in mood; however, the time lapse between the beginning of a rehabilitative cycle and the next (on average 2.7 months) represents a sufficient time to lose a significant amount of the improvement when there is no possibility to use any other kind of rehabilitative outpatient treatment (lack of infrastructure and the transport system, particularly in rural areas). This is due to the lack of social care organization and the absence of legislation in this regard, as the rehabilitation programs are decided on the basis of the chronicity of the disease at the time of discharge rather than on the subjective characteristics of the individual and then on a real customized rehabilitation plan.,,,,,,,,
Despite the efforts exerted in terms of health and social views in recent years, disability literature still describes several problems about social inclusion mainly linked to environmental factors. Philibert et al. (2015) in a literature review evaluated the socioenvironmental problems related to disability. He noted that few studies have been published about that. He assessed the main works published between 2007 and 2014 and found the existence of many environmental and socioeconomic factors associated with disability, particularly in the rural areas. All these studies indicated significant inferences of the socioenvironmental contexts in the disability process. The review identified two other major issues related to the association between disability and socioenvironmental factors. Some authors fit into the evaluation process with the use of public transport.,,,, It can be associated with characteristics of the site (e.g., the transport network and the distances associated with the characteristics of the territory). Thus we can see how every social and environmental factor contributes in a different way in disability characterization.
In rehabilitation it is indicated to define clinically relevant targets which should be reached in a defined timeline, comparing the progress made in every follow-up assessment. The objectives should be identified by the whole team and should also be articulated in their purpose according to professional skills. Clearly, our analysis outlines how home management of patients with disabilities represent a delicate and complex work which cannot be reduced to a mere prescheduled care intervention and structured according to schedules reflecting the institutional needs instead of the patient's needs.
The problem of choosing between outpatient and home rehabilitation is much debated; several studies have been performed with mixed results, as conditioned by the organizational differences between different health care systems, differences in patient selection, and other factors. The three main elements of analysis are represented by effectiveness, cost, and type of intervention. At this time there is not a strong evidence of effectiveness which supports the choice of a particular rehabilitation environment as gold standard. There is evidence of effectiveness of home treatment in reducing disability and improving QoL compared to the inpatient treatment, at the cost, however, of greater anxiety for the caregivers. The comparison between hospital, outpatient, and home rehabilitation does not lead to differences in the prognosis of the chronic phase, but highlights some differences in costs. It is estimated that home care costs 27% more than in the hospital, 2.6 times more than in outpatient treatment, and 25% less than the day hospital.,, Probably the best cost–benefit ratio could be achieved with mixed house/clinic intervention.
The potential benefits of rehabilitation at home are: convenience for the patients since they do not move; absence of transportation costs; importance of the proximity of family members in case of cognitive disorders; better adaptation of disability in the house environment; increase in self-employment, and reduction in the risk of comorbidities. The potential disadvantages are: difficulty in coordinating the rehabilitation plan; lack of adequate and also technologically advanced equipment; loss of time for the displacements of the therapists, with a decrease in the number of patients treated per time interval. Most of the authors agree in considering that a perfect system should provide the alternation and integration of outpatient and home rehabilitation through the social and health interventions.
The ideal policy strategies should promote security, accessibility, social support, and equal access to health and social services. The implementation of informed policies requires, however, empirical evidence and the application of a theory which should be internationally recognized and statistically significant. In a 2014 study, Grimaud et al. evaluated the impact of deprivation of social relations in terms of survival in the acute phase of stroke. The study showed that 284 patients (16.1%) died within 90 days from the stroke; there was no association between deprivation of social relationships and mortality in the period in which patients were in intensive care; whereas after discharge, mortality increased gradually. The gradient of after-stroke mortality was evident only after the acute hospital discharge. Therefore, the quality of care and the social support in the postacute phase are considered as potential determinants of these variations.
Silvius-Byron et al. (2014) evaluated the perception of the patient living in a regime of restriction of the external visits during the period of hospitalization, showing that this condition does not improve the perception of rest nor implies changes in the circadian rhythm of sleep.
A depressive episode occurring within 6–12 months after stroke is a frequent event. It is estimated that a mood disorder occurs in about a third of the survivors, although there is considerable variability between studies, linked to diagnostic and methodological issues. Nuyen et al., showed that the survivors after the acute phase tend to prolong the duration of hospital stay and increase their need to be discharged in an institutionalized structure rather than at home, when there is a preexisting depressive syndrome.
Park (2014) studied the incidence of suicide episodes in the Korean population on the basis of characteristics of the living environment, concluding that there is the need for intervention services and prevention of suicide, that for which they prove to be particularly at-risk older people. It is, therefore, essential for older people the home care and social care in the post-stroke and in all situations involving a limitation in daily activities.
A study carried out in 2011 among the inhabitants of rural areas of the Appalachian Kentucky showed an increased risk of negative health outcomes due to poor QoL secondary to stroke. It assessed the experience of the survivors and their caregivers in order to develop appropriate interventions and to improve health and social support services. The results indicated the need for further studies on how to improve services and the chances of recovery in rural areas through the careful verification of the results, the planning of specific interventions, the possibility of corporative support, the opportunity to use Internet to improve access to information and services, the involvement of faith communities, and the management of mental health needs and services in supporting caregivers.
Smeeton (2004) studied the outcome differences between patients with stroke in two different environments, namely Barbados and the southern suburbs of London. Three months after stroke, the level of social activity was found to be higher in people of Barbados; no difference was found in daily activities; less need for institutionalization was found in Barbados, but with a higher risk of 3-month mortality. However, in Barbados survival appears to be of higher quality, probably due to a better social activities in the short term compared to the inhabitants of the southern London.
Aziz et al. in 2013 showed that 85% of stroke deaths occur in developing countries due to limited access to secondary prevention and simultaneous increase in average age of the population. He showed that there is an increase in cardiovascular risk even in these areas, associated with rehabilitative treatment approaches not adequately standardized.
A systematic review of Hillier and Inglis-Jassiem in 2010 stated the importance of creating a support network for home rehabilitation through the integration of services between the territory and the hospital in order to strengthen the access to day hospital services and outpatient rehabilitation facilities, and at the same time, investing in training in order to create a high-quality home rehabilitation service, by planning specific and appropriate clinical pathways. The caregiver training is also crucial in terms of global influence on the outcome of the patient. Among the deficits contributing to limit autonomy, there are the alteration of kinematics and kinetics of gait and the lack of balance with the associated risk of falling. The resulting walking pattern is constituted by a set of normal and abnormal movements with different clinical significance, increase of energy consumption, and reduction of functional ability.
In our opinion, a project aimed at improving the territorial rehabilitation system should consider some fundamental aspects:
Disability is strictly related to the person–environment interaction and both physical and social environments should be the main targets of intervention in order to improve well-being, social participation, and independence.
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Conflicts of interest
There are no conflicts of interest.
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