Effectiveness of a Video-Based Therapy Program at Home After Acute Stroke: A Randomized Controlled Trial

      Abstract

      Redzuan NS, Engkasan JP, Mazlan M, Freddy Abdullah SJ. Effectiveness of a video-based therapy program at home after acute stroke: a randomized controlled trial.

      Objective

      To evaluate the effectiveness of an intervention using video to deliver therapy at home for patients with stroke.

      Design

      Randomized controlled trial.

      Setting

      The neurology ward and rehabilitation medicine department of a tertiary hospital.

      Participants

      Patients with stroke (N=90). There were 44 patients in the intervention group and 46 patients in the control group.

      Interventions

      The intervention group received a combination of at-home rehabilitation guided by a digital videodisk containing therapy techniques and twice-monthly outpatient follow-up for 3 months. The conventional therapy group (control) attended weekly outpatient therapy sessions.

      Main Outcome Measures

      The primary outcome measure was the modified Barthel Index (MBI) score. The secondary measures were the incidence of poststroke complications and the Caregiver Strain Index.

      Results

      At 3 months, there were no significant differences with regard to the number of patients with improved MBI score, complication rate, or Caregiver Strain Index score between the 2 groups. Both groups had significant increases in the MBI score at 3 months (P<.001 for both groups). Regression analysis revealed that only stroke severity significantly influenced the MBI score (P<.001), complication rate (P<.01), and caregiver stress level (P<.05).

      Conclusions

      Video-based therapy at home for post–acute stroke patients is safe, does not negatively impact independence, and is not stressful for caregivers.

      Key Words

      List of Abbreviations:

      CI (confidence interval), DVD (digital videodisk), MBI (modified Barthel Index)

      Effectiveness of a Video-Based Therapy Program at Home After Acute Stroke: A Randomized Controlled Trial

      Nor Shahizan Redzuan, MBBS, Julia P. Engkasan, MRehabMed, Mazlina Mazlan, MRehabMed, Saini Jeffery Freddy Abdullah, MRehabMed.

      Statement of Need

      Stroke is a leading cause of death and disability both within the United States and abroad. Reduced stroke mortality leads to an increasing need for rehabilitation services to address the residual disabilities of stroke survivors. More than half of stroke survivors need assistance in daily activities at 6 months poststroke. Most studies have shown that organized inpatient care in a stroke unit produces better outcomes in the acute stroke period with regard to mortality, dependency, and the need for institutional care than treatment in general medical wards. However, the most cost-effective rehabilitation site and the appropriate therapy intensity for post–acute stroke patients are still uncertain.
      Because of the large number of patients and the insufficient number of therapists trained in neurologic rehabilitation, most patients receive therapy as little as once a week and are advised to continue therapy at home during the rest of the week. The weekly hospital sessions require staff and incur traveling time and cost for the patient. Thus, a home-based alternative to the current rehabilitation program that does not require therapists is an attractive option that should be assessed.
      Telerehabilitation is one of the interventions that offers distance support and has been shown to be beneficial to both patients and their caregivers. A wide range of telerehabilitation programs, ranging from simple telephone calls to virtual reality environments, have been used in poststroke patient populations. This has prompted the development of innovative methods to ensure that patients receive sufficient therapeutic care, especially in the early stage of stroke when complications are common.
      This journal-based activity has been planned and developed in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the sponsorship of Professional Education Services Group (PESG).

      Accreditation Statement

      PESG is accredited by the ACCME to provide continuing medical education (CME) for physicians.

      Credit Designation Statement

      PESG designates this Journal-based CME activity for a maximum of 2.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
      All other health care professionals completing continuing education credit for this activity will be issued a certificate of participation.

      Educational Objectives

      To support the attainment of knowledge, competence, and performance, the learner should be able to achieve the following objectives:
      • 1.
        Identify the components of telerehabilitation and how it can be applied in practice.
      • 2.
        List the outcomes of home-based therapy.
      • 3.
        Compare cost of home-based therapy to other modalities.
      • 4.
        Evaluate the limitations of teletherapies in stroke patients.

      Planning Committee

      Nor Shahizan Redzuan, MBBS; Julia P. Engkasan, MRehabMed; Mazlina Mazlan, MRehabMed; Saini Jeffery Freddy Abdullah, MRehabMed; Allen W. Heinemann, PhD, ABPP (RP), FACRM; PESG staff; ACRM editorial office staff.

      Faculty Profiles & Disclosure Information

      As a provider accredited by the ACCME, it is the policy of PESG to require the disclosure of anyone who is in a position to control the content of an educational activity. All relevant financial relationships with any commercial interests and/or manufacturers must be disclosed to participants at the beginning of each activity. The faculty and planners of this educational activity disclose the following:

      Nor Shahizan Redzuan, MBBS

      University of Malaya, Department of Rehabilitation Medicine, Kuala Lumpur, Malaysia
      No relevant financial relationships to disclose.

      Julia P. Engkasan, MRehabMed

      University of Malaya, Department of Rehabilitation Medicine, Kuala Lumpur, Malaysia
      No relevant financial relationships to disclose.

      Mazlina Mazlan, MRehabMed

      University of Malaya, Department of Rehabilitation Medicine, Kuala Lumpur, Malaysia
      No relevant financial relationships to disclose.

      Saini Jeffery Freddy Abdullah, MRehabMed

      University of Malaya, Department of Rehabilitation Medicine, Kuala Lumpur, Malaysia
      No relevant financial relationships to disclose.

      Allen W. Heinemann, PhD, ABPP (RP), FACRM

      Deputy Editor, Archives of Physical Medicine and Rehabilitation Chicago, IL
      No relevant financial relationships to disclose.

      PESG Staff

      No relevant financial relationships to disclose.

      ACRM Editorial Office Staff

      No relevant financial relationships to disclose.

      Resolution of Conflict of Interest

      PESG has implemented a process to resolve conflict of interest for each CME activity. In order to help ensure content objectivity, independence, and fair balance, and to ensure that the content is aligned with the interest of the public, PESG has resolved the conflict by external content review.

      Unapproved/Off-Label Use Disclosure

      PESG requires CME faculty to disclose to the participants:
      • 1.
        When products or procedures being discussed are off-label, unlabeled, experimental, and/or investigational (not US Food and Drug Administration [FDA] approved); and
      • 2.
        Any limitations on the information presented, such as data that are preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion. Faculty may discuss information about pharmaceutical agents that is outside of FDA-approved labeling. This information is intended solely for CME and is not intended to promote off-label use of these medications. If you have questions, contact the medical affairs department of the manufacturer for the most recent prescribing information.

      Intended Audience

      This program is intended for physicians and healthcare professionals responsible for the comprehensive care for individuals with chronic illness and disabilities.

      Method of Participation

      In order to claim credit, participants must complete the following:
      • 1.
        Pre-activity self-assessment questions
      • 2.
        Read the activity
      • 3.
        Complete the CME Test and Evaluation. Participants must achieve a score of 70% on the CME Test.
      Participants can complete the pre-activity self-assessment and CME Test and Evaluation online by logging on to http://acrm.cds.pesgce.com Upon successful completion of the online tests and evaluation form, you can instantly download and print your certificate of credit.
      To better define and meet the CME needs of health care professionals and enhance future CME activities, PESG will conduct an outcomes-measurement survey following the conclusion of the program. This follow-up survey is designed to measure changes to participants' practice behaviors as a result of their participation in this CME activity. You will be contacted by email 60 days following the conclusion of this activity with an outcomes measurement survey. We would greatly appreciate your participation.

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      For all CME certificate inquiries, please contact us at [email protected] .
      This continuing education activity is active starting December 1, 2012 and will expire November 30, 2013.
      Estimated Time to Complete This Activity:2.0 hours
      STROKE IS A LEADING cause of death and disability
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      Global mortality, disability and the contribution of risk factors: Global Burden of Disease Study.
      and is the third largest cause of death in Malaysia.
      • Ong T.Z.
      • Raymond A.A.
      Risk factors for stroke and predictors of one-month mortality.
      Reduced stroke mortality leads to an increasing need for rehabilitation services to address the residual disabilities of stroke survivors. More than half of stroke survivors need assistance in daily activities at 6 months poststroke.
      • Wade D.T.
      • Hewer R.L.
      Functional abilities after stroke: measurement, natural history and prognosis.
      Most studies have shown that organized inpatient care in a stroke unit produces better outcomes in the acute stroke period with regard to mortality, dependency, and the need for institutional care than does treatment in general medical wards.
      Stroke Unit Trialists' Collaboration
      Organised inpatient (stroke unit) care for stroke.
      However, the most cost-effective rehabilitation site and the appropriate therapy intensity for post–acute stroke patients are still uncertain.
      • Duncan P.W.
      • Zorowitz R.
      • Bates B.
      • et al.
      Management of adult stroke rehabilitation care: a clinical practice guideline.
      There has been great interest in community- and home-based rehabilitation programs. For example, early supported discharge, which involves the participation of various allied health professionals in delivering a home-based therapy program after early discharge, has proven to be a feasible option that does not result in functional deterioration, is preferred by patients, and appears to be more cost-effective than inpatient rehabilitation.
      • McNamee P.
      • Christensen J.
      • Soutter J.
      • et al.
      Cost analysis of early supported hospital discharge for stroke.
      • Widén Holmqvist L.
      • von Koch L.
      • Kostulas V.
      • et al.
      A randomized controlled trial of rehabilitation at home after stroke in Southwest Stockholm.
      • von Koch L.
      • Holmqvist L.W.
      • Wottrich A.W.
      • Tham K.
      • de Pedro-Cuesta J.
      Rehabilitation at home after stroke: a descriptive study of an individualized intervention.
      • Anderson C.
      • Rubenach S.
      • Mhurchu C.N.
      • Clark M.
      • Spencer C.
      • Winsor A.
      Home or hospital for stroke rehabilitation? Results of a randomized controlled trial, I: health outcomes at 6 months.
      • Mayo N.E.
      • Wood-Dauphinee S.
      • Cote R.
      • et al.
      There's no place like home: an evaluation of early supported discharge for stroke.
      • Hackett M.L.
      • Vandal A.C.
      • Anderson C.S.
      • Rubenach S.E.
      Long-term outcome in stroke patients and caregivers following accelerated hospital discharge and home-based rehabilitation.
      • Fjaertoft H.
      • Rohweder G.
      • Indredavik B.
      Stroke unit care combined with early supported discharge improves 5-year outcome: a randomized controlled trial.
      • Donnelly M.
      • Power M.
      • Russel M.
      • Fullerton K.
      Randomized controlled trial of an early discharge rehabilitation service: the Belfast community stroke trial.
      However, this method requires human resources and community support services to ensure its effectiveness.
      Rehabilitation medicine is a relatively young specialty in Malaysia. First established about 20 years ago, it is only now becoming an important component of the country's health care planning. Because of the limited number of available inpatient rehabilitation settings in Malaysia, most patients are discharged soon after stroke and attend outpatient rehabilitation programs. Because of the large number of patients and the insufficient number of therapists trained in neurologic rehabilitation, most patients receive therapy only once a week and are advised to continue therapy at home during the rest of the week. These weekly hospital sessions require staff and incur traveling time and cost. Thus, a home-based alternative to the current rehabilitation program that does not require therapists is an attractive option that should be assessed.
      Telerehabilitation is 1 of the interventions that offers distance support and has been shown to be beneficial to both patients and their caregivers.
      • Johansson T.
      • Wild C.
      Telerehabilitation in stroke care–a systematic review.
      A wide range of telerehabilitation programs, ranging from simple telephone calls to virtual reality environments, have been used in poststroke patient populations.
      • Lai J.C.
      • Woo J.
      • Hui E.
      • Chan W.M.
      Telerehabilitation – a new model for community-based stroke rehabilitation.
      • Boter H.
      HESTIA Study Group
      Multicenter randomized controlled trial of an outreach nursing support program for recently discharged stroke patients.
      • Piron L.
      • Turolla A.
      • Agostini M.
      • et al.
      Exercises for paretic upper limb after stroke: a combined virtual-reality and telemedicine approach.
      This has prompted the development of innovative methods to ensure that patients receive sufficient therapeutic care, especially in the early stage of stroke when complications are common. The present study utilized multimedia technology in the form of digital videodisk (DVD)-based therapy to reduce patient visits.
      This study evaluated the effectiveness and safety of at-home, video-based therapy for post–acute stroke patients in Malaysia. We hypothesized that patients receiving the alternative therapy would have equivalent functional and neurologic outcomes and stroke-related complication rates as those receiving standard outpatient care.

      Methods

      Participants

      Patients who were admitted to the neurology ward at the University Malaya Medical Centre for stroke were screened for study inclusion. Those diagnosed with an acute stroke according to the World Health Organization definition
      • Hatano S.
      Experience from a multicentre stroke register: a preliminary report.
      who had experienced their first hemiplegic stroke, had a caregiver for the 3-month duration of the study, and who were discharged to their home were included in the study. Patients with any psychiatric illness, patients with epilepsy, or patients premorbidly dependent on a caregiver were excluded.

      Randomization

      Suitable patients were identified within a week of admission, and those who consented to participate were randomized to either usual care or the intervention group. A blocked randomization sequence (block of 10) was generated using a computer program. The randomization list was kept by 1 of the investigators who was involved in patient recruitment and assessment. Given the nature of the intervention, it was not possible to blind participants and caregivers from knowing what group they were in.

      Intervention

      The intervention was a self-instructional audiovisual DVD of standardized rehabilitation procedures and patient handling techniques that was designed by University Malaya Medical Centre's neuromedical rehabilitation team to guide therapy delivery at home. It included a 45-minute self-instructional therapy in 2 languages: English and Malay. It consisted of 6 sections: (1) patient positioning and handling; (2) bed mobility; (3) passive range of motion exercises, stretching, and strengthening of the upper limbs; (4) passive range of motion exercise, stretching, and strengthening of the lower limbs; (5) transfer techniques from bed to wheelchair and vice versa, and wheelchair into the car and vice versa; and (6) activities of daily living (grooming, desk activities, and upper and lower garment dressing). These activities were identified by the therapists to be the range of exercises and handling techniques routinely taught to patients and their caregivers. The content of the video was reviewed by physiotherapists, an occupational therapist, and a rehabilitation physician.

      Procedures

      During their hospital stay, patients in both groups received similar poststroke care, which included daily hour-long sessions of occupational and physical therapy (2h total). Participants in the intervention group were introduced to the video just before hospital discharge. An investigator and the therapist would go through the video content with each patient and determine the appropriate sections and/or exercises and emphasize the important parts of the video according to the patient's stroke severity and resulting impairment. Caregivers and/or patients were encouraged to do the exercises along with the video as often as possible and were asked to record their exercises in a diary.
      Upon discharge, patients in the intervention group were assigned to twice-monthly outpatient therapy appointments and received a video to guide therapy at home. At the 2-week follow-up, all problems related to following the instructions in the video were documented. Patients in the control group had weekly outpatient appointments (1 hour each for physical and occupational therapy). The patients and/or caregivers in this group were taught how to perform therapy at home and were advised to do so. However, other than verbal instruction at the weekly sessions, no other resources were provided.

      Outcomes

      The primary outcome was independence level measured using the modified Barthel Index (MBI) (0–100)
      • Shan S.
      • Vanclay F.
      • Cooper B.
      Improving sensitivity of the Barthel Index for stroke rehabilitation.
      at recruitment and 3 months after discharge. We were interested in analyzing the difference in the MBI score improvement between the 2 groups rather than the mean scores. Secondary outcomes were the incidence of stroke-related complications (contracture, spasticity, and shoulder subluxation) and caregiver stress level as measured by the Caregiver Strain Index (0–13).
      • Robinson B.C.
      Validation of Caregiver Strain Index.
      Caregivers with scores of ≥7 were considered to have a high level of stress. Except for Caregiver Strain Index, which was assessed only at the 3-month follow-up, all outcomes were measured at recruitment and at the 3-month follow-up. The individuals who performed the assessments were not blinded to group allocation.

      Sample Size

      We aimed to recruit 80 patients in each arm to achieve 80% power and 5% significance to detect a 30-point difference in the mean MBI score.

      Statistical Analysis

      All outcome data were coded and verified by 1 of the investigators. Analyses were performed by an independent statistician using SPSS version 17.0 statistical software.a Descriptive statistics were used to characterize demographics and clinical characteristics for each group. The analysis of baseline and 3-month outcomes between groups was done using Pearson's chi-square test for categorical data (sex; type of stroke; stroke severity predefined as mild, moderate, and severe; improved MBI score; caregiver category; complication incidence; and level of caregiver stress) or independent sample t tests to compare mean differences of continuous data means (the MBI score, age, and length of stay). Paired t tests were used to compare mean differences between baseline and 3-month MBI scores within each group.
      Because there was an imbalance in the MBI score at baseline, we performed multiple regression analysis to determine the predictors of the outcome of interest (the MBI score at 3 months) with age, sex, length of stay, National Institutes of Health Stroke Scale score at admission, the MBI score at admission, and intervention as constants. We used multiple logistic regression to determine predictors of categorical outcomes (occurrence of complications and level of caregiver stress). Statistical significance was defined as a P value of <.05.
      The study was approved by the University Malaya Medical Centre Medical Ethics Committee (Ref No. 739.7). All patients received written and verbal information about the study and provided written informed consent prior to participating in the study.

      Results

      Participants were recruited between August 2010 and March 2011, and the follow-up period was from November 2010 to June 2011. A total of 322 patients were admitted to the neuromedical ward during the recruitment period, and 106 patients who met the inclusion criteria agreed to participate. Initially, 53 patients were randomized to each group. One week after the study, 1 patient asked to switch from the control group to the video group.
      The randomization and participant flow chart is shown in figure 1. We stopped the trial before we reached the intended number of patients in order to comply with our research grant agreement.

      Baseline Characteristics

      Table 1 shows the baseline demographics, stroke characteristics, and independence level for each group. There were no significant differences in demographic data or stroke characteristics between the groups. However, participants in the control group were more independent than in the intervention group, with mean MBI scores of 61.3 and 46.7, respectively (95% confidence interval [CI], 1.25–9.25, P=.014).
      Table 1Baseline Participant Demographics and Stroke Characteristics
      VariableIntervention Group (n=44)Control Group (n=46)P
      Age (y)63.7±1259.4±11.12
      Male21 (40.4)31 (59.6).06
      Type of stroke.21
       Ischemic35 (79.5)41 (89.1)
       Hemorrhage9 (20.5)5 (10.9)
      Length of stay (d)12.9±810.9±7.30
      NIHSS score.28
       Mild stroke (<6)10 (22.8)17 (37.0)
       Moderate stroke (6–14)26 (59.0)24 (52.1)
       Severe stroke (>14)8 (18.2)5 (10.9)
      MBI score.04
      Statistically significant at P<.05.
       Mean46.761.3
       Median46.065.5
       Interquartile range42.035.0
      Main caregivers.68
       Spouse21 (47.7)25 (54.4)
       Children18 (40.9)16 (34.8)
       Relatives5 (11.4)4 (8.7)
       Maid/others01 (2.1)
      NOTE. Values are mean ± SD or n (%) or as otherwise indicated.
      Abbreviation: NIHSS, National Institutes of Health Stroke Scale.
      low asterisk Statistically significant at P<.05.

      Outcome at 3-Month Follow-Up

      At the 3-month follow-up, 60% (26 of 44) of the patients in the intervention group had improved MBI scores compared with 45.7% (21 of 46) of the patients in the control group (P=.202). There was no deterioration in the MBI score in either group. Using a 2×2 table, patients in the intervention group were 1.3 times more likely to have an improved MBI score compared with those in the control group (absolute risk reduction of 13.4% and number needed to treat of 3). The intergroup differences in the mean MBI score are shown in table 2. Although the difference remained significant at the third month, the mean difference between both groups had decreased from 14.6 points at baseline to 8.5 at the 3-month follow-up. Both groups had significant increases in the MBI score at 3 months, but the intervention group showed a larger difference (table 3). The intervention group had a mean increase of 31 points in the MBI score compared with 25 points in the control group. Multiple linear regression analysis revealed that only the MBI score (β=.22, P=.005) and the National Institutes of Health Stroke Scale score (β=−1.88, P<.001) at admission were significant predictors of the MBI score at 3 months.
      Table 2Mean Difference in MBI Score Between and Within Groups
      MBI Score (0–100)Intervention Group (n=44)Control Group (n=46)Mean DifferenceP95% CI
      Improved score, n (%)26 (59.1)21 (45.7).2000.75–3.97
      Same score, n (%)18 (40.9)25 (54.3)
      MBI score at admission, mean ± SD46.7±22.361.3±24.314.6.0044.83–24.41
      MBI score at 3mo, mean ± SD78.8±20.286.6±16.38.4.0307.42–16.20
      Table 3Mean Differences in MBI (0–100) Score From Baseline to 3-Month Follow-Up
      GroupDifference in the MBI Score, Mean ± SD95% CIP
      Control25.35±20.0119.40–31.29<.001
      Video31.5±17.0826.30–36.70<.001
      There was no significant difference in the incidence of stroke-related complications between the groups; 22 of 44 (50%) and 21 of 46 (45.7%) patients in the intervention and control groups had complications, respectively (95% CI, .52–2.73, P=.68). There was also no significant difference in caregiver stress level (Caregiver Strain Index score >7); 9 of 44 (20.5%) patients in the intervention group and 16 of 46 (34.8%) patients in the control group reported high stress levels (95% CI, .19–1.25, P=.13). In the multiple logistic regression, stroke severity was the only significant predictor of both outcomes. A substantial number of patients with severe stroke (10 of 13, 76.9%) had complications at the 3-month follow-up compared with 14.8% (4 of 27) of those with mild stroke (95% CI, 3.61–101.91, P<.01). The number of caregivers of patients with severe stroke who reported a high stress level was 46.2% (6 of 13) compared with 24% (12 of 50) of those caring for patients with mild and moderate stroke (95% CI, 1.01–25.83, P=.04). Approximately one third (18 of 52, 34.6%) of those caring for male patients reported high stress levels compared with 18.4% of caregivers of female patients (95% CI, .10–.90, P=.03). The majority of spouses (60.9%, 18 of 46) and children (79.4%, 27 of 34) who were caregivers did not report high stress levels.
      Neither the patients nor their caregivers regularly recorded their exercise sessions at home in the diary as instructed. Thus, we were unable to analyze whether the intervention affected the frequency of home-based exercise sessions.

      Discussion

      In this study, we provided an audiovisual DVD that showed caregivers how to deliver therapy at home and how to handle patients with stroke. On average, patients in the intervention group received only 6 sessions of outpatient follow-up, while those in the control group received 12 sessions during the 3-month study duration. The results clearly demonstrate that at-home rehabilitation guided by a video-based therapy program is an excellent alternative to conventional hospital-based therapy. It is also safe; completing therapy at home did not lead to increased stroke-related complications, and it had added benefits for the caregivers. We determined that stroke severity was the ultimate factor that influenced all the outcomes of interest in this study.
      Even though previous studies showed that home- or community-based rehabilitation is associated with favorable outcomes, the protocols included regular home visits.
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      Home-based therapy has been shown to have long-lasting effects; patients who received this type of intervention had better activities of daily living outcomes, even after 5 years.
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      There are also reports of trends toward better quality of life for those who received this intervention.
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      In this study, instead of conducting regular home visits, we reduced the number of outpatient visits from weekly to every other week. Nevertheless, the patients still had the benefits of home-based therapy. We believe that the intervention group had achieved remarkable improvement in their independence level based on the targeted 30-point difference in the mean MBI score.
      The gains noted in the intervention group are probably due to family support, initiation of early rehabilitation, the ability to perform therapy at their own pace and in their home environment, and favorable effects of less stressed caregivers.
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      • Duncan P.
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      • Wallace D.
      • et al.
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      • Gunnell D.
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      Although we did not formally include patients' and/or caregivers' opinions about this intervention, the feedback that we received suggested that they are in favor of doing therapy at home. This might reflect the strong bonds of the family system in this country; a similar pattern was observed in a study conducted in Thailand, which found that home-based therapy gave the patients an opportunity to be closer to their families.
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      We also believe the audiovisual material provided a way to improve the caregivers' skills and served as motivation and a reminder to perform therapy more often. It is possible that regular video viewing may reinforce the importance of therapy and the correct techniques of exercising and positioning. This could also explain why the use of a video to guide therapy at home is safe and does not lead to increased complications, even though there was no direct therapist supervision and informal caregivers performed the exercises. However, delivering therapy using this protocol has limitations. The patients who attend regular follow-up sessions exercise during those visits, whereas the video patients do not get any exercise if they do not follow the video. This underscores the importance of caregiver commitment. Because the same DVD was used throughout the 3-month period, it may not be suitable if patients had significant improvement and required more individualized therapy. A progressive video suited to patients' functional improvement may have better outcome compared with the current intervention.
      Several studies have suggested that home-based rehabilitation is more cost-effective than traditional, hospital-based care.
      • Duncan P.
      • Richards L.
      • Wallace D.
      • et al.
      A randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke.
      • Roderick P.
      • Low J.
      • Day R.
      • et al.
      Stroke rehabilitation after hospital discharge: a randomized trial comparing domiciliary and day-hospital care.
      Unlike other studies interested in cost saving for the health care provider, the cost benefits of the alternative therapy affect the patients and their families. Inpatient costs are not an issue because stroke rehabilitation is mainly an outpatient service. Fewer hospital visits mean that patients and caregivers do not have to spend money to travel to the therapy site, and there is also less loss incurred by caregivers who have to miss work to accompany patients. Resource analyses in other studies have to consider the cost of building home rehabilitation service teams and designing a multidisciplinary rehabilitation protocol, which can result in significant costs.
      • Gilbertson L.
      • Langhorne P.
      • Walker A.
      • Allen A.
      • Murray G.D.
      Domiciliary occupational therapy for patients with stroke discharged from hospital: randomised controlled trial.
      Caregivers often play an important role in supporting patients with stroke in the hospital and at home, and they should also be assessed. Taking care of patients with stroke is highly stressful, and caregivers are at substantial risk for developing depression.
      • Han B.
      • Haley W.E.
      Family caregiving for patients with stroke: review and analysis.
      There are mixed results regarding the effects of home rehabilitation on caregivers.
      Stroke Unit Trialists' Collaboration
      Organised inpatient (stroke unit) care for stroke.
      • Anderson C.
      • Rubenach S.
      • Mhurchu C.N.
      • Clark M.
      • Spencer C.
      • Winsor A.
      Home or hospital for stroke rehabilitation? Results of a randomized controlled trial, I: health outcomes at 6 months.
      • Hackett M.L.
      • Vandal A.C.
      • Anderson C.S.
      • Rubenach S.E.
      Long-term outcome in stroke patients and caregivers following accelerated hospital discharge and home-based rehabilitation.
      • Björkdahl A.
      • Nilsson A.
      • Sunnerhagen K.S.
      Can rehabilitation in the home setting reduce the burden of care for the next-of-kin of stroke victims?.
      In this study, the caregivers' level of stress was not influenced by the rehabilitation site, but it was affected by patient sex, stroke severity, and type of stroke. We expected that caregivers in the interventional group would have reduced stress levels because they can perform the therapy on their own time rather than the therapist's. They are also spared the hassle of traveling and taking time off from work to attend therapy sessions at the hospital. Although not statistically significant, 1 of the reasons why we found less caregiver stress in the intervention group may be the possible reduction in traveling costs. Most of the patients in this study were above the Malaysian employment age (56 years old); therefore, their medical expenses, including rehabilitation bills, were either subsidized from their pensions or self-funded. For those in the latter group, the caregivers have to bear a portion of the medical and traveling costs.

      Study Limitations

      The major limitation of this study is the small sample size in which it was not possible to detect any significant changes. Given the trend of the findings, which showed more people improved in the intervention group and a bigger margin of mean differences in the MBI score, it is likely that these differences might be significant with an adequate sample size. In randomized, controlled trials, the intervention and the randomization should be blinded. This was not possible in this study because we have a limited number of therapists servicing the neurology patients. It was not possible for a different therapist to teach caregivers how to use the video and have another assess the outcomes. This study was limited to those with hemiplegic stroke; therefore, the results of this study cannot be directly applied to patients with other types of impairments. Future research should attempt to determine the optimum length of hospital stay and which patient groups would benefit most from home-based rehabilitation and conduct a comprehensive cost analysis to identify the most cost-effective health care. We also recommended that exercise frequency be documented to determine the effect of interventions on this variable. We must emphasize that it is important to select patients carefully. Those who live alone, have an uncommitted caregiver, or have no contact with health personnel may not benefit from this alternative rehabilitation service.

      Conclusions

      Video-based therapy at home for post–acute stroke patients is safe, does not negatively impact independence, and is not stressful for caregivers.
      • a
        SPSS, Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.

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