Stroke Rehabilitation-Comparing hospital and home-based physiotherapy: the patient's perception.
Stroke patients (Health aspects)
Stroke patients (Care and treatment)
Physical therapy (Usage)
Physical therapy (Health aspects)
Physical therapy (Analysis)
Therapeutics, Physiological (Usage)
Therapeutics, Physiological (Health aspects)
Therapeutics, Physiological (Analysis)
|Publication:||Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2003 New Zealand Society of Physiotherapists ISSN: 0303-7193|
|Issue:||Date: July, 2003 Source Volume: 31 Source Issue: 2|
|Geographic:||Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand|
The purpose of this research was to explore the perceptions of patients with stroke towards outpatient physiotherapy in the hospital- and home-based settings. Qualitative semi-structured interviews were conducted with six participants with stroke recruited from the Wellington region. Participants received outpatient physiotherapy; three in the hospital setting and three in the home setting. Data analysis was conducted using a phenomenological approach to determine patients' perspectives of hospital- and home-based therapy. Eleven themes were identified through data analysis of the interviews: Transition, Preparation, Transport, Resources, Relevance, Patient Involvement, Communication, Emotional Impact, Social Interaction, Family Involvement and Professional Respect.
The findings of these themes were compared to the literature. Both advantages and disadvantages to receiving therapy in the hospital or home setting were identified from the patient's perspective. Findings of this research highlight the need for physiotherapists to be aware of the impact of the therapy setting on the patient. A mixed model is recommended to incorporate the benefits of the hospital and home settings but this needs investigating further. Leigh Hale, *Donna Bennett, *Maria Bentley, *Anita Crawshaw, *Helen Davis. Stroke Rehabilitation--Comparing hospital-and home-based physiotherapy: the patients' perception. New Zealand Journal of Physiotherapy 31(2): 84-92.
Key Words: stroke, home-based rehabilitation, hospital-based rehabilitation, qualitative
Traditionally patients with stroke have received health services including physiotherapy within a hospital setting (Thomas & Parry, 1996), however the increasing costs of hospital-based rehabilitation and the impetus of the Independent Living Movement have increased the attractiveness of home-based rehabilitation programmes (Eldar, 2000; McPherson, Donovan, Taylor & McNaughton, 2000).
In a review of the literature investigating the impact of community physiotherapy Forster and Young (1990) highlighted several advantages and disadvantages of this mode of service delivery for patients with stroke. Advantages of the home-based setting included elimination of patient travel resulting in decreased cost and fatigue, therefore increasing treatment effectiveness. The increased flexibility of home-based therapy resulted in a shorter stand down period between inpatient and outpatient therapy. Patients were more relaxed and co-operative in their own environment, and treatment had more relevance. Family awareness of progress and ability increased resulting in improved continuity of the rehabilitation process. The disadvantages included increased frequency of patient depression and isolation, increased travel time for therapists (with up to eight percent of the day being lost in transit), and increased isolation for therapist from the multidisciplinary team.
Further perceived benefits of domiciliary rehabilitation include appropriate formulation of goals relevant to the home environment (Young & Forster, 1992), improved patient initiative in setting their own goals (Von Koch, Wohlin Wottrich & Widen Holmqvist, 1998) and patients feeling more comfortable in their own surroundings (Seymour & Kerr, 1996). Improved initiative in goal setting was established in a qualitative study (Von Koch et al., 1998) and later validated (p = 0.021) by Widen-Holmqvist, Von Kock and de Pedro-Cuesta (2000). Home visits have the further advantage of improving caregiver confidence and reducing the social isolation of the patient, consequently improving psychosocial well-being (Baskett, Broad, Reekie, Hocking & Green, 1999; Futter, 1996; Rodgers et al., 1997).
Thomas and Parry (1996) reviewed two small British qualitative studies on perspectives of patients with stroke to their rehabilitation. Most patients in these studies did not mind making outpatient visits even though this was often a time consuming exercise. They found it a good way 'to get out of the house' and to meet people in a different social setting, as well as enabling carers to have a period of respite. The stress levels of informal carers of patients receiving home-based rehabilitation were found to be high. The authors recommended that therapists needed to be aware that a mixture of inpatient, home-based services and day care may be needed to meet patient requirements.
In a more recent qualitative study Stephenson and Wiles (2000) investigated the views of patients who received both hospital- and home-based therapy in the United Kingdom. Advantages identified in the home setting were convenience, decreased stress of travel and increased comfort and privacy. The home was found to be a less distracting environment for some subjects. Disadvantages of the home setting were lack of equipment and floor space, decreased social interaction and increased stress on caregivers.
In New Zealand there is currently a paucity of research into the preferences of patients with stroke to hospital- and home-based physiotherapy services. Baskett et al. (1999) in a randomised controlled trial of 100 New Zealand patients investigated the efficacy of continuing self-directed exercises (supervised at home once a week), with hospital-based outpatient or day programmes for people discharged home after a stroke. They found no significant difference in efficacy between groups on outcome measures (p>0.01) but the perspective of the patient to these services was not assessed.
The purpose of this research was to explore participants' perceptions to outpatient hospital-and home-based physiotherapy in a New Zealand setting. This study was conducted in the Wellington region of New Zealand, which is served by the Capital Coast District Health Board (CCDHB). This covers a population of 350,000 (McNaughton, Weatherall, McPherson, Taylor & Harwood, 2002).
The assessment, treatment and rehabilitation service at CCDHB offers a mix of outpatient physiotherapy services for people with stroke including hospital-based outpatient and day programmes and home-based therapy. The type of outpatient service received is determined by the therapist in consultation with the patient, and is decided on the basis of which environment would most benefit the patient.
A phenomenological approach using in-depth interviews was used (Jensen, 1989; Shepherd, Jensen, Schmoll, Hack & Gwyer, 1993).
Participants were recruited from the rehabilitation department of CCDHB. To be eligible participants met the following inclusion criteria:
1. A primary diagnosis of stroke.
2. Received outpatient physiotherapy.
3. Residing at home.
National Ethics Approval for the study was gained from the Wellington Regional Ethics Committee and Legal Approval from the Capital Coast District Health Board.
The research and participant criteria were explained to physiotherapists from the rehabilitation department who in turn identified and approached appropriate patients for consent. All participants gave oral and written informed consent prior to commencement.
In-depth interviews were used to explore the perceptions of individual participants. Prior to the interview process the authors discussed the areas they perceived were necessary to explore in order to understand the patients' perspective of outpatient services following stroke. From this discussion an initial conceptual framework was constructed. A conceptual framework explains, graphically or in narrative form, the main issues to be studied and the presumed relationship between them. It helps to bind the scope of the study and guide data collection and analysis (Miles & Huberman, 1994). Using these conceptual frameworks the authors planned their interviews and formulated five open-ended questions with which to guide their interviews.
1. What do you like/dislike about receiving your physiotherapy at the hospital/home?
2. How do you think your physiotherapy could be improved?
3. How is your physiotherapy relevant to your needs?
4. How adequate are the physiotherapy resources, equipment, and facilities?
5. How would you feel about having physiotherapy at the hospital/home?
The authors contacted consenting participants and made times for interviews at venues convenient for the participants. Two authors conducted each interview. With the participants' permission the interviews were audio-taped. Interviews were terminated when no new information was forthcoming from the participant. The interviews were transcribed in extenso and the participants sighted the transcripts to ensure that their views were correctly represented.
Data were analysed using phenomenographic methodology (Merriman, 1988; Strauss and Corbin, 1990). The transcripts were read several times and common themes were identified using line by line analysis. These concepts were then grouped into categories, and coded in such a way as to reduce the data. Verbatim quotes relevant to these themes were extracted. All the authors compared and discussed quote allocation until complete agreement was reached. A second conceptual framework was constructed from these coded categories, which reflected the patients' perceptions of the impact of setting of therapy.
Six participants consented to be interviewed. Three participants (A, B and C) were receiving hospital-based physiotherapy. Participants A and C were attending group therapy sessions in the hospital and participant B received individual hospital-based therapy. Three participants (D, E and F) were receiving home-based physiotherapy on an individual basis.
Data analysis of the interview transcripts identified eleven themes: Transition, Preparation, Transport, Resources, Relevance, Patient Involvement, Communication, Emotional Impact, Social Interaction, Family Involvement and Professional Respect. The perceptions of the participants as they relate to each of the themes are presented below.
Participants in both settings identified difficulties during transition from inpatient to outpatient services: "The only thing I found quite odd was the transition from inpatient to outpatient ... I found that quite a shock ... I had a stand down period of two weeks, and it was a really long two weeks" (Participant B; hospital-based). "The period from getting out of hospital, that definitely needs sorting out. That's a real area for criticism ... that was a big problem, because in that two or three weeks I went backwards a heck of a lot."
(Participant D; home-based). Participant D suggested earlier discharge planning including referral to outpatient services prior to discharge. Participants in both settings found that the responsibility for treatment and self-care shifted during the transition stage: "It was a bit of a shock, because the onus falls on you a lot" (Participant B; hospital-based). "The hospital's good, they make all your meals ... and you don't have to do any dishes. When you get home it is hard initially ... like the six weeks there, you get institutionalised really fast" (Participant F; home-based).
Concurrently with the shift of responsibility came the decreased frequency of treatment with outpatient services: "I kind of found that quite weird, moving from a ten session physio a week to a two session" (Participant B; hospital-based). "I suppose if I had a dislike as such, it was just that I missed the kind of intense physio" (Participant F; home-based).
One participant suggested that contact with community support groups, such as the stroke foundation prior to inpatient discharge would ease the transition period.
In preparation for a physiotherapy home-visit participants stated that they felt comfortable with the therapist entering their home: "It didn't worry me ... they just take me as they find me" (Participant D; home-based).
In preparing for a hospital-based therapy session participants reported that they had difficulty remembering appointment times as they felt out of routine on discharge home: "I've been out of routine for a month and I think I missed my first appointment because of that ... it's hard to remember ... " (Participant B; hospital-based). One participant suggested that a reminder system might help patients: "It might be good idea to remind new patients who have just moved into outpatients, because it's a real new routine for them" (Participant B; hospital-based).
One of the main problems in attending outpatient therapy was transport, in particular relying on others (family, public and ambulance services) for transport: "She has to waste a lot of time to bring me to the hospital because I still can't drive" (Participant E; home-based). "In the early stages it would have been impossible because it was quite a long time before I could drive and there was no public transport around" (Participant D; home-based).
One participant considered transport as a component of his treatment: "But the physios encouraged me to go out and walk a lot as part of the rehab, so the travel was part of that as well" (Participant B; hospital-based).
All participants identified a difference in resources between the two settings. The hospital setting has a wide range of facilities and equipment while the home setting only has the participant's own resources: "They're much better equipped from the physio's point of view. They must be better off at the hospital ... there was a limit to what they could use here" (Participant D; home-based).
For some participants the extra equipment in the hospital setting became a focus and motivation: "Because they had more equipment over there and I just feel that it's a better yard stick to measure myself by because there is just so many more things to work on" (Participant B; hospital-based). "Actually when I was discharged I was enjoying going to the hospital because of the facilities and I feel more focused because I am using the facilities. But at home I am not feeling as focused cos this is my home" (Participant E; home-based).
Not all participants felt that the difference in resources impacted negatively on their treatment: "I think I would only have really wanted to go to the hospital if it was clear that there was something that I would need to do there. ... I've got stairs, I've got flat access available for walking and I had some rails put in ... I had the dynaband. I had cold water. I had a mirror to check my shoulder was down ... and all those things were in the house" (Participant F; home-based). "It's not so much what you have as what you do, you know I think a gym would have been great, but actually it was fine doing it here" (Participant F; home-based).
One participant found that the hospital setting could be distracting: "The rehab ward, it's kind of cluttered, and sometimes there is not much space in there when there is inpatient's and outpatient's physio going on at the same time" (Participant B; hospital-based).
All participants in the home setting but only one participant in the hospital setting set and targeted functional goals to ensure their treatment was relevant: "The co-ordination exercises would help me move, and start my typing a lot faster, and improve my speed at typing, and my finger stretches so I would be able to move and reach all the words on the keyboard" (Participant B; hospital-based). "One of the big ones [goals] was to be able to pick up my baby granddaughter, and I can ... I guess I sort of understood that if I wanted to pick up my granddaughter I had to be able to get my arm and shoulder going" (Participant F; home-based). "The physio knew I wanted to get back to my boat sailing ... we rigged up a thing out in the workshop there, a pulley to pull the arm up and that sort of thing ... made up a few bits and pieces of things to squeeze" (Participant D; home-based). "Like one of my goals was to be able to walk down the aisle in church to see my daughter get married ... so what happened was that we went directly to the church ... because it's a different surface area ... I also had to practice wearing the shoes I'd be wearing on the wedding day" (Participant E; home-based).
In addition, one participant considered homebased physiotherapy to be particularly relevant as her therapist could assess the safety of her home environment: "The other benefit is that the physio can see me in my own environment ... and she's there to say 'that's fine, that's fine, no look I don't actually think it's a good idea to do that until you are a bit more sure' ... so it's good" (Participant F; home-based).
One of the participants in the hospital setting considered her treatment sessions not to be relevant: "But I didn't receive what I'd call physio ... they say it's physiotherapy, but it wasn't really suitable for me ... I'm not complaining about what I had, but I don't think it was the right thing for me ... it wasn't tailor made for each of us" (Participant C; hospital-based).
Participants in both settings discussed motivation and goal setting when asked about their involvement in treatment. Participants reported that their ability to stay motivated impacted on their involvement in treatments. Sometimes participants relied on the therapist, family or other patients to motivate them: "The hardest thing of all is too keep your motivation up, and not to get really, really, really sick of it, and that is the hardest thing ... I mean basically now my hand and shoulder are heaps, heaps better, and that is purely down to her [the therapist] telling me about the exercises and helping me ... keeping going" (Participant F; home-based). "My sister says 'Don't worry, keep on trying" (Participant C; hospital-based). "So I could actually see the improvements and it was quite good to see people improving, and it gives you the motivation to say hey, since they can do it, you can do it as well" (Participant B; hospital-based).
Participants in both settings reported that they set goals through discussion with the therapist: "First I had to choose my goals to see which was practical and then each physio would add 'say would you want to do this on top of it because that is kind of linked towards that?' ... the physios would ask me 'since you have achieved this, were do you want to go from here?" (Participant B; hospital-based). "She often asked me what my goals are and things like that ... and then we work out a plan ... She always asks me what my next goals are. So she would try to show me how to achieve my next goal" (Participant E; home-based). "By then we had worked out what our approach would be, along with her advice ... I would have goals ... sometimes I didn't achieve them, but a lot of the time I did, because the physio worked with me to do it" (Participant F; home-based).
One participant in the hospital setting did not appear to have a lot of involvement: "Do you feel you can put suggestions in as what you'd like to do?" (Interviewer) "No I don't think so ... they'll suggest we do this and that today" (Participant A; hospital-based).
All participants discussed the necessity of patient-therapist communication. Clear communication facilitated goal setting and education: "Basically the physio would tell me what each exercise would do and that ... What I liked was the quick feedback that they could basically tell me what I needed to work on and what was happening with my physio week to week ... they could tell you how far you have improved, and guide you towards extra improvements in the future" (Participant B; hospital-based).
One participant was originally in the hospital setting but through conversation, his therapist realised the implications of travel and they transferred to the home setting: "Later on she realised that we were consuming a lot of time with my missus, because she's working and she has to bring me to the hospital ... so she realised and said 'why don't we see you at home because you'll be more relaxed there?" (Participant E; home-based).
One participant in the hospital setting did not seem to have efficient communication lines with her therapists: "I kept going to the day programme in the hopes that they'd sort of wake up and realise that it wasn't what I needed" (Participant C; hospital-based).
One participant spoke of the emotional lability following stroke and how the home setting allowed her to show her true emotions: "I've had really good physios who have been sensitive to emotional needs but that's possibly really important to be aware of ... you'll go into people's houses and you don't know what kind of emotional state they're going to be in and most of the time they'll be fine but there will be sometimes ... there will be a lot that are depressed, that are angry ... just wanting to have a big cry" (Participant F; home-based). "Does having treatment at home make it easier to be more open ... ?" (Interviewer). "Absolutely ... normally you have a civilising influence with your emotions. But ... with the stroke ... when I lose it, I just lose it. So if I went to the hospital I think I would not have gone that day because I felt so terrible or I would have got myself together" "(Participant F; home-based).
Participants in both settings discussed the isolation they encountered following discharge from inpatient services: "Staying at home was quite boring, and at that time I didn't go out much" (Participant B; hospital-based)." And I'm not getting out and about much yet" (Participant D; home-based). "Eventually they would stop coming to see me so I would feel like I was neglected ... so I feel a bit sensitive because they're not coming to see me as often" (Participant E; home-based).
Participants in the hospital setting were able to gather support from others in the same situation: "Well listening to other peoples' opinions ... they may say A and then you say and think it's B and that sort of thing" (Participant A; hospital-based), whilst participants in the home setting gained support from their therapist: "The physiotherapists are great because you've got somebody coming once a week or whatever and they're saying 'how's it going?' It was tremendous to have somebody coming and visiting me ... " (Participant F; home-based).
Although all participants said they had been given the opportunity to involve family in their rehabilitation, only one participant had actively done so. There appeared to be a distinction between family support of the rehabilitation process and active family participation: "He [my husband] has been fantastic ... it would have been really hard to recover on my own ... but I haven't included him in the goals ... or actively in the physio exercise" (Participant F; home-based)." Well my family wasn't around much because most of the time everyone's at work, so I've got to work on my own" (Participant B; hospital-based).
Participants in both settings discussed the professional ability and nature of the therapist: "With the physio's eye and their speciality they could tell how far you have improved and guide you towards extra improvements in the future" (Participant B; hospital-based). "It was interesting ... in the end I came to the conclusion that what she had been suggesting was exactly the right thing ... one thing you do is you do what your physio tells you ... " (Participant F; home-based). "She's here to do her job. She just wanted to focus on what we were doing" (Participant E; home-based).
One participant in the home setting also identified a friendly relationship with their therapist: "I have been really lucky with the physio's that have worked with me, or else all physio's are really nice. I enjoyed it actually, we always had a few laughs and it's been good" (Participant F; home-based).
One participant in the home setting discussed the importance of physiotherapy to her overall rehabilitation: "Physio's are so crucial ... they have been the ones that have been there all the time. They've kind of filled the gaps ... I absolutely think I would have been in real trouble in my recovery if I hadn't had a physio to do what she did" (Participant F; home-based).
The purpose of this research was to explore participants' perceptions of outpatient physiotherapy in the hospital- and home-based settings. The trustworthiness or reliability of data was ensured by the following steps: 1) interviews continued until no new information was forthcoming from participants; 2) a member check in which participants checked that the transcripts of their interviews correctly represented their views; and 3) the use of multiple researchers who discussed and cross-checked the transcripts until complete agreement was reached on themes and verbatim quotes. A purposeful opportunistic sampling strategy was used limiting the applicability of the results to the wider population, however a number of themes were identified that may be relevant to all patients with stroke.
Analysis of Themes
In order to formulate the five open-ended questions used in the participant interviews, the authors discussed what impact the setting for therapy might have on people with stroke. A conceptual framework representing this discussion, the authors' prior perceptions, can be seen in Appendix 1.
Following analyses and identification of themes from the interview data, the authors revised the conceptual framework so that it represented participants' perception of the impact of the setting on their rehabilitation following stroke. This revised conceptual framework is shown in Appendix 2.
This study explored the impact the physical setting has on rehabilitation after stroke. The initial conceptual framework identified distinct advantages of both home- and hospital-based settings on stroke rehabilitation. However, the participants' perspectives were not so tangible, and in many cases the same aspect was viewed both as an advantage and as a disadvantage depending on the participant. In addition, participants highlighted areas that they considered important to successful rehabilitation, and on which the setting had less impact than did the therapist, such as the importance of communication and participant involvement in relevant goal setting, and the transition stage from inpatient to outpatient rehabilitation.
Participants in both settings identified difficulties during transition from inpatient to outpatient services. Participants found that the responsibility for treatment and self-care shifted to themselves during the transition stage and that the frequency of treatment decreased with a period of time when they received no treatment at all, regardless of therapy setting. This transition from inpatient to outpatient services has been identified in other studies and has been found to increase the incidence of depression (Baskett et al., 1999; Forster & Young, 1990; Sabari, Meisler & Silver, 2000). Forster and Young (1990) found that the length of transition was less in the home-based setting because therapists in this setting were able to be more flexible with appointment times. Sabari et al. (2000) used a focused ethnographic approach to collect qualitative information about personal experiences with stroke rehabilitation and participants in their study spent a significant amount of time discussing their difficulties in making the transition from the hospital to their own homes.
Participants in the present study felt that this transitional stage could be made easier if the rehabilitation team conducted home visits to provide an opportunity for the practice of day-today tasks and if a list of available resources that might assist them in their adjustment to living after their stroke could be provided.
Participants receiving therapy in the home setting were not concerned about preparing the home environment for therapy sessions, and felt comfortable about the therapist coming into their home. This is in contrast to the views of Tamm (1999) who explored the meaning of a "home" in relation to home-based rehabilitation. Tamm expressed concern that home-based rehabilitation could turn a home into "workplace" which is "no longer sheltered from the intrusion of public life" (p.49).
Participants in the hospital setting identified that punctuality and remembering appointment times was a difficulty and suggested a reminder service may be appropriate for the first appointment after post discharge.
All participants experienced difficulties with transport, especially in the early outpatient stage. Participants were not confident enough to use public transport, which resulted in dependency on others for their transport needs. This feeling of dependency has not previously been highlighted; rather other studies have focussed on the physical costs of travel for the patient. Forster and Young (1990) and Stephenson and Wiles (2000) found that transport to the hospital setting resulted in an increase cost and time for the patient receiving therapy. Travel was found to be uncomfortable and tiring, resulting in increased muscle tone and decreased therapy effectiveness.
Cost and time spent in travel were not eliminated in the home setting, but were transferred onto the therapist, resulting in decrease time for the therapist to spend with patients in therapy (Forster & Young, 1990; Stephenson & Wiles, 2000).
An unexpected finding was that one participant considered the walking and the use of public transport when travelling to the hospital to be necessary components of rehabilitation.
Participants reported that the hospital setting has a wider range of equipment available to them for use in therapy. One participant found this equipment useful as an outcome measure to evaluate progress by assessing how well he was able to perform with it. However, one participant said that it was not the equipment that helped so much but what you did in therapy, and did not identify a lack of equipment as a need to attend hospital-based therapy.
The hospital setting was reported to be a focusing and motivating environment to work in compared to the home setting for some participants. In contrast some participants found the hospital setting busy and distracting.
The variation on the impact of the setting on therapy is confirmed in the literature.
Stephenson & Wiles (2000) reported that for some participants there were fewer distractions in the home setting than in the hospital setting. The majority of participants in the Stephenson & Wiles study identified that they were more comfortable and relaxed in the home setting, which was beneficial for therapy. However, other participants considered the familiar home environment to be distracting and a less motivating and a less beneficial setting for therapy.
The variation of impact of setting on participant therapy may be a personal matter. In the hospital setting, the focus and motivation for therapy may come from the setting itself. In the home setting, the focus for therapy is more internal that is, it comes from the patient. The difference may come in the way in which people can best focus and learn, and on the importance of meaningful goal setting.
Relevance, Patient Involvement and Communication
The three themes of relevance, patient involvement and communication were found to be inter-linked, as seen in Figure 2. Participants reported that involvement in relevant goal setting was consistently a focus in both settings if they were receiving individualised therapy, whereas for the two hospitalbased participants involved in group therapy, goal setting was not an active part of their therapy. Von Koch et al. (1998) found the hospital setting to be disempowering, and that the home setting was a more meaningful context. Participants in the home setting had a different role set that enabled them to take the initiative and they had confidence to express goals more freely during therapy. The home targets participation in life activities and not just functional ability, and is therefore considered more relevant (Foster & Young, 1990; Von Koch et al., 1998). Stephenson & Wiles (2000) reported no difference between goal setting in the two settings (home and hospital) but attributed this to the client-centred approach therapists used in their study.
Two of the hospital-based participants in this study were attending the group day programme. In the day programme set activities are organised for the whole group, as compared with individual therapy sessions, and this may have decreased participant's active involvement in goal setting.
Communication was important to all participants in this study regardless of setting.
In order for the participant's therapy to be relevant and for them to be actively involved, the lines of communication needed to be open and effective between the participant and the therapist. Communication in regards to the themes of patient involvement and goal setting relevance have been previously identified and discussed in the literature. (Stephenson & Wiles, 2000; Thomas & Parry, 1996; Von Koch et al., 1998).
In this research participants felt comfortable to show their true emotions in the home. This enabled therapists to get a realistic view of the patient's day-to-day life and problems. This finding is similar to that of Stephenson & Wiles (2000) who suggested that patients were able to talk freely due to increased privacy in the home. Stephenson and Wiles (2000) and Forster and Young (1990) both consider that increased comfort in the home results in increased therapeutic effectiveness.
All participants felt isolated following discharge from inpatient services, no matter the setting. However participants in the hospital setting gained some social interaction from therapists and people in the same situation as them whereas in the home setting participants appeared to rely on therapists for socialisation.
Forster and Young (1990) in their review of the literature found that there was a high frequency of depression and isolation among stroke patients. Hospital-based therapy was considered beneficial in decreasing social isolation (Forster & Young, 1990; Thomas & Parry,1996) but could probably be mitigated by the increase in availability of stroke clubs and day centres.
Stevenson and Wiles (2000) established that for the majority of their participants there was no disadvantage in social contact in the home setting. However, in this study a minority of the participants commented on missing the opportunity to go out during the week and decreased ability to compare progress with others.
The majority of participants in our research reported that although family was an important part of support for rehabilitation they did not take an active part in therapy, regardless of setting. This finding may be explained by the fact that participants in this study were at a high functional level and therefore did not require family involvement for activities of daily living and could continue with therapy independently. Forster and Young (1990) considered that patients with stroke might be more dependent than necessary, increasing the burden on family and caregivers. Therapy at home may enable family and caregivers to have an increased understanding of level of function. Therapists can also train family and caregivers about handling and lifting techniques and exercise regimes thus making rehabilitation a continuous process.
This research found that all participants, in both settings, felt their therapists were very professional and yet were able to maintain a friendly relationship. Participants considered physiotherapy to be an important part of rehabilitation. Although the majority of their participants in the Stephenson and Wiles study (2000) expressed feelings of gratitude and good fortune for the therapy received, two participants reported that the home setting proved to be a less serious and un-helpfully informal setting.
The main clinical implication of this study is that neither a hospital- nor a home-based setting alone appeared optimal for the rehabilitation of patients with stroke, as both settings had advantages and disadvantages, often depending on the needs of the individual patient. Ideally the rehabilitation team needs to discuss both options with patients and be flexible to change if a chosen option does not then work. Secondly, patients need to be supported in the transition from inpatient rehabilitation to the start of outpatient rehabilitation, possibly with prior mental preparation for discharge and telephonic support from the rehabilitation team or community support groups during the transition stage.
Physiotherapists, according to participants, have a crucial role to play in rehabilitation, and maintaining an open communication line with patients so that patients can be actively involved in setting relevant goals for therapy is extremely important.
In-depth interviews were used to explore the perceptions of six patients with stroke regarding their rehabilitation setting and analysis of these dialogues identified both advantages and disadvantages to receiving therapy in the hospital or home setting. This highlights the need for physiotherapists to be aware of the impact of the therapy setting on individual patients and the need to ensure appropriate selection of the therapy setting. A mixed model incorporating both the hospital and home settings is recommended as most appropriate to maximise the benefits of each setting.
Further research is necessary to investigate the effect of the therapy setting on patients with stroke in other population groups, such as different cultural groups and in rurally-based groups.
The authors wish to thank:
* The participants for their time and their willingness to be interviewed
* The physiotherapists from Capital Coast District Health Board who assisted in participant selection
* William Levack, Physiotherapy Team Leader, Wellington Hospital for advice
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ADDRESS FOR CORRESPONDENCE:
Dr L.A. Hale, School of Physiotherapy, University of Otago, PO Box 56, Dunedin, New Zealand. firstname.lastname@example.org
Leigh Hale, PhD, School of Physiotherapy
* Donna Bennett, BPhty, School of Physiotherapy
* Maria Bentley, BPhty, School of Physiotherapy
* Anita Crawshaw, BPhty, School of Physiotherapy
* Helen Davis, BPhty, School of Physiotherapy
* This author was, at the time this study was undertaken, a 4th year Physiotherapy Student at the University of Otago.
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