Maggie Killington

Telerehabilitation for older people using off-the-shelf applications: acceptability and feasibility

We investigated the feasibility of providing telerehabilitation in the home as an alternative to conventional ambulatory rehabilitation. Two groups of patients were accepted for telerehabilitation. The first group were community patients who needed rehabilitation, e.g. following a stroke, a fracture or prolonged hospital admission. The second group was from two rural nursing homes where residents were identified with a recent injury, fall or hospitalisation. Telerehabilitation employed a coaching model, with fewer therapist home visits, more feedback and “homework” for the patient. Patients had a tablet computer loaded with a videoconferencing app to connect with therapists and relevant therapeutic apps. Multidisciplinary care was provided for up to 8 weeks. The majority (86%) of eligible patients consented to receive telerehabilitation in their own home (n = 61) or in the country nursing home where they lived (n = 17). Most services were delivered using the 3G and 4G wireless networks with few technical problems. On average participants felt that they had achieved 75% of the goals set at the beginning of the programme. High levels of satisfaction were recorded. There was a 50% reduction in home visits by staff, or 10 visits per patient. Speech therapists were able to double occasions of service and direct patient contact time, whilst halving their travel time. Previous experience with technology and age were not barriers to this method of delivery but did affect recruitment. Telerehabilitation using off-the-shelf technology is feasible for post-acute treatment.

Effect of affordable technology on physical activity levels and mobility outcomes in rehabilitation: a protocol for the Activity and MObility UsiNg Technology (AMOUNT) rehabilitation trial

Introduction People with mobility limitations can benefit from rehabilitation programmes that provide a high dose of exercise. However, since providing a high dose of exercise is logistically challenging and resource-intensive, people in rehabilitation spend most of the day inactive. This trial aims to evaluate the effect of the addition of affordable technology to usual care on physical activity and mobility in people with mobility limitations admitted to inpatient aged and neurological rehabilitation units compared to usual care alone. Methods and analysis A pragmatic, assessor blinded, parallel-group randomised trial recruiting 300 consenting rehabilitation patients with reduced mobility will be conducted. Participants will be individually randomised to intervention or control groups. The intervention group will receive technology-based exercise to target mobility and physical activity problems for 6 months. The technology will include the use of video and computer games/exercises and tablet applications as well as activity monitors. The control group will not receive any additional intervention and both groups will receive usual inpatient and outpatient rehabilitation care over the 6-month study period. The coprimary outcomes will be objectively assessed physical activity (proportion of the day spent upright) and mobility (Short Physical Performance Battery) at 6 months after randomisation. Secondary outcomes will include: self-reported and objectively assessed physical activity, mobility, cognition, activity performance and participation, utility-based quality of life, balance confidence, technology self-efficacy, falls and service utilisation. Linear models will assess the effect of group allocation for each continuously scored outcome measure with baseline scores entered as a covariate. Fall rates between groups will be compared using negative binomial regression. Primary analyses will be preplanned, conducted while masked to group allocation and use an intention-to-treat approach. Ethics and dissemination The protocol has been approved by the relevant Human Research Ethics Committees and the results will be disseminated widely through peer-reviewed publication and conference presentations. Trial registration number ACTRN12614000936628. Pre-results.

Early supported discharge by caregiver-mediated exercises and e-health support after stroke: A proof-of-concept trial

Background and Purpose— This proof-of-concept trial investigated the effects of an 8-week program of caregiver-mediated exercises commenced in hospital combined with tele-rehabilitation services on patient self-reported mobility and caregiver burden. Methods— Sixty-three hospitalized stroke patients (mean age 68.7, 64% female) were randomly allocated to an 8-week caregiver-mediated exercises program with e-health support or usual care. Primary outcome was the Stroke Impact Scale mobility domain. Secondary outcomes included length of stay, other Stroke Impact Scale domains, readmissions, motor impairment, strength, walking ability, balance, mobility, (extended) activities of daily living, psychosocial functioning, self-efficacy, quality of life, and fatigue. Additionally, caregiver’s self-reported fatigue, symptoms of anxiety, self-efficacy, and strain were assessed. Assessments were completed at baseline and at 8 and 12 weeks. Results— Intention-to-treat analysis showed no between-group difference in Stroke Impact Scale mobility (P=0.6); however, carers reported less fatigue (4.6, confidence interval [CI] 95% 0.3–8.8; P=0.04) and higher self-efficacy (−3.3, CI 95% −5.7 to −0.9; P=0.01) at week 12. Per-protocol analysis, examining those who were discharged home with tele-rehabilitation demonstrated a trend toward improved mobility (−9.8, CI 95% −20.1 to 0.4; P=0.06), significantly improved extended activities of daily living scores at week 8 (−3.6, CI 95% −6.3 to −0.8; P=0.01) and week 12 (3.0, CI 95% −5.8 to −0.3; P=0.03), a 9-day shorter length of stay (P=0.046), and fewer readmissions over 12 months (P<0.05). Conclusions— Caregiver-mediated exercises supported by tele-rehabilitation show promise to augment intensity of practice, resulting in improved patient-extended activities of daily living, reduced length of stay with fewer readmissions post stroke, and reduced levels of caregiver fatigue with increased feelings of self-efficacy. The current findings justify a larger definite phase III randomized controlled trial. Clinical Trial Registration— URL: http://www.anzctr.org.au. Unique identifier: ACTRN12613000779774.

Investigating the preferences of older people for telehealth as a new model of health care service delivery: A discrete choice experiment.

Introduction Telehealth approaches to health care delivery can potentially improve quality of care and clinical outcomes, reduce mortality and hospital utilisation, and complement conventional treatments. However, substantial research into the potential for integrating telehealth within health care in Australia, particularly in the provision of services relevant to older people, including palliative care, aged care and rehabilitation, is lacking. Furthermore, to date, no discrete choice experiment (DCE) studies internationally have sought the views and preferences of older people about the basic features that should make up a telehealth approach to these services. Methods Using a DCE, we investigated the relative importance of six salient features of telehealth (what aspects of care are to be pursued during telehealth sessions, distance to the nearest hospital or clinic, clinicians’ attitude to telehealth, patients’ experience of using technology, what types of assessments should be conducted face-to-face versus via telehealth sessions and the costs associated with receiving telehealth). Data were obtained from an online panel of older people aged 65 years and above, drawn from the Australian general population. Results The mean age for 330 study participants was 69 years. In general, individuals expressed strong preferences for telehealth services that offered all aspects of care, were relatively inexpensive and targeted specifically at individuals living in remote regions without easy access to a hospital or clinic. Participants also preferred telehealth services to be offered to individuals with some prior experience of using technology, provided by clinicians who were positive about telehealth but wanted all or some pre-telehealth health assessments to take place in a hospital or clinic. Preferences only differed by gender. Additionally, respondents did not feel that telehealth led to loss of privacy and confidentiality. Discussion Our findings indicate a preference amongst respondents for face-to-face pre-telehealth health assessments and, thereafter, a comprehensive telehealth model (in terms of services offered) targeted at those with some technological know-how as a substitute for attendance at hospitals and clinics, especially where these health facilities were far away from older people’s homes. The findings may be usefully incorporated into the design of future telehealth models of service delivery for older people.

'Well, if the kids can do it, I can do it': older rehabilitation patients' experiences of telerehabilitation.

Although trials continue to emerge supporting the role of telerehabilitation, implementation has been slow. Key users include older people living with disabilities who are frequent users of hospital rehabilitation services but whose voices are rarely heard. It is unclear whether the use of technologies and reduced face‐to‐face contact is acceptable to these people. We report on a qualitative study of community dwelling participants who had received a home telerehabilitation programme as an alternative to conventional rehabilitation.

Video and computer-based interactive exercises are safe and improve task-specific balance in geriatric and neurological rehabilitation: a randomised trial

QUESTION Does adding video/computer-based interactive exercises to inpatient geriatric and neurological rehabilitation improve mobility outcomes? Is it feasible and safe? DESIGN Randomised trial. PARTICIPANTS Fifty-eight rehabilitation inpatients. INTERVENTION Physiotherapist-prescribed, tailored, video/computer-based interactive exercises for 1 hour on weekdays, mainly involving stepping and weight-shifting exercises. OUTCOME MEASURES The primary outcome was the Short Physical Performance Battery (0 to 3) at 2 weeks. Secondary outcomes were: Maximal Balance Range (mm); Step Test (step count); Rivermead Mobility Index (0 to 15); activity levels; Activity Measure for Post Acute Care Basic Mobility (18 to 72) and Daily Activity (15 to 60); Falls Efficacy Scale (10 to 40), ED5D utility score (0 to 1); Reintegration to Normal Living Index (0 to 100); System Usability Scale (0 to 100) and Physical Activity Enjoyment Scale (0 to 126). Safety was determined from adverse events during intervention. RESULTS At 2 weeks the between-group difference in the primary outcome (0.1, 95% CI -0.2 to 0.3) was not statistically significant. The intervention group performed significantly better than usual care for Maximal Balance Range (38mm difference after baseline adjustment, 95% CI 6 to 69). Other secondary outcomes were not statistically significant. Fifty-eight (55%) of the eligible patients agreed to participate, 25/29 (86%) completed the intervention and 10 (39%) attended > 70% of sessions, with a mean of 5.6 sessions (SD 3.3) attended and overall average duration of 4.5hours (SD 3.1). Average scores were 62 (SD 21) for the System Usability Scale and 62 (SD 8) for the Physical Activity Enjoyment Scale. There were no adverse events. CONCLUSION The addition of video/computer-based interactive exercises to usual rehabilitation is a safe and feasible way to increase exercise dose, but is not suitable for all. Adding the exercises to usual rehabilitation resulted in task-specific improvements in balance but not overall mobility. REGISTRATION ACTRN12613000610730.

Isokinetic strength training of lower limb muscles following acquired brain injury

Primary objective: To investigate the effectiveness of isokinetic strength training of ankle and knee muscles in adults with chronic acquired brain injury (ABI). Research design: Series of single case studies. Methods: Twelve people with ABI participated in a 2.5-week baseline, 12-week intervention and a 4-week follow-up phase. Intervention: Concentric isokinetic exercise, twice a week, for plantarflexors (PFs), dorsiflexors (DFs), knee flexors (KFs) and knee extensors (KEs). Outcomes: Peak torque and power at 60 and 90° s−1, PFs and KFs tone at 60° s−1, gait speed and timed chair rises. Results: For single case analyses strength improvements were noted in 11/12 participants’ PFs, 5/12 participants’ DFs and 7/12 participants’ KEs and KFs. Gait speed improved in 8/12 participants and chair rise time improved in 7/12 participants. PFs tone increased in three participants, KFs tone increased in six participants and three participants reported knee pain. For group analyses, peak torque of PFs and KEs, fast gait speed and timed chair rises demonstrated improvement (p < 0.05). Conclusions: Isokinetic strength training may be effective to improve lower limb muscle strength; however, care needs to be taken in selecting suitable candidates as some individuals reported knee pain with this intensive programme.

An isokinetic muscle strengthening program for adults with an acquired brain injury leads to meaningful improvements in physical function

Primary objective: To investigate if an isokinetic strength training programme for leg muscles lead to personally meaningful changes in adults with an acquired brain injury (ABI). Research design: A qualitative exploratory design. Methods: Twelve people with ABI participated in pre- and post-intervention face-to-face interviews with open ended questions. Data were initially analysed using a case study research approach exploring individuals experiences and then cross case analysis to determine common themes for the group. Intervention: Twelve-week isokinetic strength training programme for ankle and knee muscles. Outcomes: Participants perceived changes. Results: Thematic analysis determined four main themes arising from the interviews; occupation, vitality, sense of self and personal interactions. Participants reported reductions in impairments as a response to the exercise programme and these changes led to increased function and participation in activities they valued. Also marked improvements in vitality were reported as well as increases in self-esteem and general well-being for many participants. Conclusions: An isokinetic strength training programme resulted in improvements in motor skills and functional abilities that were meaningful for the participants.

‘Massive potential’ or ‘safety risk’? Health worker views on telehealth in the care of older people and implications for successful normalization

BackgroundTelehealth technologies, which enable delivery of healthcare services at distance, offer promise for responding to the challenges created by an ageing population. However, successful implementation of telehealth into mainstream healthcare systems has been slow and fraught with failure. Understanding of frontline providers’ experiences and attitudes regarding telehealth is a crucial aspect of successful implementation. This study aims to examine healthcare worker views on telehealth, and their implications for implementation to mainstream healthcare services for older people. The study includes a focus on two further dimensions of urban versus rural services and level of clinician experience with telehealth.MethodsSeven semi-structured focus groups were conducted with a total of 44 healthcare workers providing services to older people in the areas of rehabilitation and allied health, residential aged care and palliative care. Focus groups included both telehealth experienced and inexperienced groups. Of the experienced groups, two provided services to both urban and rural patients, and two to rural patients. Inexperienced groups included one rural and two urban. Thematic analysis was undertaken to identify predominant themes. Between-group differences and agreement in viewpoints for each of these themes are discussed and mapped to the theoretical constructs of Normalization Process Theory.ResultsThe views of participants varied with the extent of telehealth experience and perception of accessibility of healthcare services. Four themes describing clinician attitudes and perceptions that could impact on successful implementation of telehealth services are outlined: 1) Workability of telehealth: exponential growth in access or decay in the quality of healthcare? 2) What is an acceptable level of risk to patient safety with telehealth? 3) Shifting responsibilities and recalibrating the team; and 4) Change of architecture required to enable integration of telehealth service delivery.ConclusionsThe use of telehealth technologies to provide healthcare services to older people may be more readily normalized in areas where existing services are limited. Though exposure to telehealth may be a factor, changes to the perceived feasibility of telehealth in relation to conventional services, as well as supportive infrastructure and training and skill recalibration may be more critical to successful normalization of telehealth services for older people.

Struggling to maintain individuality – Describing the experience of food in nursing homes for people with dementia

PURPOSE OF THE STUDY To describe the food and dining experience of people with cognitive impairment and their family members in nursing homes. DESIGN AND METHODS Interviews and focus groups with people with cognitive impairment and their family members (n=19). Thematic analysis was undertaken using NVivo10 data analysis software package to determine key themes. RESULTS The main themes identified tracked a journey for people with cognitive impairment in nursing homes, where they initially sought to have their individual needs and preferences recognised and heard, expressed frustration as they perceived growing barriers to receiving dietary care which met their preferences, and ultimately described a deterioration of the amount of control and choice available to the individual with loss of self-feeding ability and dysphagia. IMPLICATIONS Further consideration of how to incorporate individualised dietary care is needed to fully implement person-centred care and support the quality of life of those receiving nursing home care.