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Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2018;-:-------

ORIGINAL RESEARCH

Effects of Home-Based Versus Clinic-Based


Rehabilitation Combining Mirror Therapy and
Task-Specific Training for Patients With Stroke:
A Randomized Crossover Trial
Yu-wei Hsieh, PhD,a,b,c Ku-chou Chang, MD,d,e Jen-wen Hung, MD,f,g
Ching-yi Wu, ScD, OTR,a,b,c Mu-hui Fu, MD,d Chih-chi Chen, MDc,h
From the aDepartment of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University,
Taoyuan, Taiwan; bHealthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan; cDepartment of Physical Medicine and
Rehabilitation, Chang Gung Memorial Hospital, Linkou, Taiwan; dDivision of Cerebrovascular Diseases, Department of Neurology, Kaohsiung
Chang Gung Memorial Hospital, Kaohsiung, Taiwan; eDepartment of Neurology, College of Medicine, Chang Gung University, Taoyuan, Taiwan;
f
Department of Rehabilitation, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; gSchool of Physical Therapy, College of
Medicine, Chang Gung University, Taoyuan, Taiwan; and hSchool of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.

Abstract
Objective: We investigated the treatment effects of a home-based rehabilitation program compared with clinic-based rehabilitation in patients with stroke.
Design: A single-blinded, 2-sequence, 2-period, crossover-designed study.
Setting: Rehabilitation clinics and participant’s home environment.
Participants: Individuals with disabilities poststroke.
Interventions: During each intervention period, each participant received 12 training sessions, with a 4-week washout phase between the 2
periods. Participants were randomly allocated to home-based rehabilitation first or clinic-based rehabilitation first. Intervention protocols included
mirror therapy and task-specific training.
Main Outcome Measures: Outcome measures were selected based on the International Classification of Functioning, Disability and Health. Outcomes
of impairment level were the Fugl-Meyer Assessment, Box and Block Test, and Revised Nottingham Sensory Assessment. Outcomes of activity and
participation levels included the Motor Activity Log, 10-meter walk test, sit-to-stand test, Canadian Occupational Performance Measure, and EuroQoL-
5D Questionnaire.
Results: Pretest analyses showed no significant evidence of carryover effect. Home-based rehabilitation resulted in significantly greater
improvements on the Motor Activity Log amount of use subscale (PZ.01) and the sit-to-stand test (PZ.03) than clinic-based rehabilitation. The
clinic-based rehabilitation group had better benefits on the health index measured by the EuroQoL-5D Questionnaire (PZ.02) than the home-
based rehabilitation group. Differences between the 2 groups on the other outcomes were not statistically significant.
Conclusions: The home-based and clinic-based rehabilitation groups had comparable benefits in the outcomes of impairment level but showed
differential effects in the outcomes of activity and participation levels.
Archives of Physical Medicine and Rehabilitation 2018;-:-------
ª 2018 by the American Congress of Rehabilitation Medicine

Supported by Chang Gung Memorial Hospital (grant no. CMRPD1E0391) and partly supported by the Healthy Aging Research Center at Chang Gung University (grant no. EMRPD1F0321), Chang
Gung Memorial Hospital (grant nos. CMRPD1C0401-403, BMRP553, and BMRPD25), and the National Health Research Institutes (grant no. NHRI-EX106-10604PI) in Taiwan.
Clinical Trial Registration No.: NCT02364232.
Disclosures: none.

0003-9993/18/$36 - see front matter ª 2018 by the American Congress of Rehabilitation Medicine
https://doi.org/10.1016/j.apmr.2018.03.017
2 Y.-w. Hsieh et al

Stroke is a significant health care problem and a major cause of


long-term disability.1 Receiving rehabilitation in a hospital
poststroke onset allows the patient rapid access to immediate
multidisciplinary care.2 However, acute hospital lengths of stay
have been significantly reduced.3 After early discharge from the
hospital, rehabilitation therapy can still further improve the
patient’s function.4,5 Accordingly, the number of stroke patients
who need continued rehabilitation and the provision of home-
based rehabilitation is increasing.6
Home-based rehabilitation allows practice of functionally
embedded activities in the patient’s real environment, which may Fig 1 Crossover design and study procedure.
be more beneficial than practice within standardized settings.7 The
programs can be tailored to match the patient’s needs and then
practiced in a natural environment, which makes client-centered
therapy more practicable.8 However, studies of home-based Methods
rehabilitation for the recovery of upper-limb function have
shown promising but inconsistent results. No conclusive effects of Study design and procedure
home-based rehabilitation can be drawn, mainly because of
insufficient study designs and the varied types of treatment This study was a single-blinded, 2-sequence, 2-period, crossover
protocols, such as exercise programs, home visits, tele- design in which each participant received 2 interventions (fig 1).
rehabilitation, constraint-induced therapy, and specific upper-limb During each period, participants received 12 intervention sessions
training programs.3,6,9-14 Further research to more comprehen- for 4 weeks. They were randomly assigned to receive home-based
sively investigate the efficacy of home-based rehabilitation using a rehabilitation first versus clinic-based rehabilitation first. After a
controlled trial design is still warranted.15 4-week washout period, the group that received home-based
Approximately 70% to 80% of stroke patients have upper rehabilitation first received the clinic-based rehabilitation, and
extremity (UE) motor deficts.5 Mirror therapy has emerged as a vice versa.
novel UE rehabilitation approach, and current evidence shows that The same trained therapist provided the 2 interventions for
stroke patients benefit from this therapy.16-19 A case study found all patients to promote consistency. The intervention principles
that mirror therapy can be successfully administered at the and programs were delivered as prescribed; however, the ther-
patient’s home environment.10 Another study showed the bilateral apist could adjust the programs somewhat according to the
movement practice and motor imagery in mirror therapy can be actual performance and condition of the patients. Real-time
regarded as a type of priming technique which can facilitate observations were conducted and videotapes of some initial
subsequent motor learning.20 treatment sessions were prepared, and both were monitored by
Task-specific training, another recommended training for the principal investigator and a senior occupational therapist of
stroke rehabilitation,21 emphasizes adding active, repetitive the study.
practice of functional activities to the treatment.22 Its treatment The allocation sequence was generated via a Web-based
principles include providing challenging, functional, and goal- randomization tool (freely available at http://www.randomizer.
directed activities; feedback; variability in practice conditions; org/). A research assistant, who was not involved in assessing
and promoting engagement, which contribute to successful out- and screening subjects, independently managed the randomiza-
comes.22 Research supports that task-specific training is critical tion procedure. The participants were recruited from the
for enhancing motor and functional recovery and for producing outpatient neurology and rehabilitation clinics, and their elec-
neuroplastic changes poststroke.23-25 tronic records were used for a preliminary screening (fig 2).
With an increased focus on the development of feasible and Outcome measures were administered to the participants by the
effective stroke rehabilitation in home settings, this study same blinded raters. The baseline assessment (ie, evaluation 1)
proposed a novel home-based intervention program using mirror occurred before period 1 of therapy, and 3 other assessments
therapy as a priming and movement practice technique, followed were conducted (see fig 1).
by task-specific training. We investigated the treatment effects of
home-based rehabilitation versus clinic-based rehabilitation on Participants
different aspects of health-related outcomes in patients
with stroke. The inclusion criteria were (1) diagnosed as having had a stroke,
within 1 month to 5 years post onset; (2) able to follow study
instructions; (3) modified Rankin scale score of 2 to 4, indicating
moderately severe to slight disability;26 (4) Fugl-Meyer Assess-
ment score of 18 to 62, indicating moderately severe to mild motor
impairments;27,28 and (5) no severe muscle spasticity in the
List of abbreviations: affected arm (modified Ashworth scale 3). The exclusion criteria
AOU amount of use were (1) cerebellum stroke; (2) other neurologic diseases; (3)
COPM Canadian Occupational Performance serious pain, inflammation, or swelling in the affected arm; and (4)
Measure global or receptive aphasia or other major medical problems. All
EQ-5D EuroQoL-5D Questionnaire
participants provided written informed consent forms approved by
MAL Motor Activity Log
the Institutional Review Board of Chang Gung Memorial Hospital
UE upper extremity
in Taiwan.

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Home-based rehabilitation 3

Fig 2 Flow diagram of the study.

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4 Y.-w. Hsieh et al

Table 1 Examples of the differences of functional task practice between home-based and clinic-based rehabilitation
Task Examples Home-Based Rehabilitation Clinic-Based Rehabilitation
Grooming activities Brushing teeth by using the patient’s own Simulated practice of brushing teeth by using a
toothbrush, toothpaste, and tooth mug cylinder peg or by using a general toothbrush and
a cup
Washing face by using the patient’s own facecloth Washing face by using wipes
Using the patient’s own razor to shave Simulated practice of the shaving movement by
using a cylinder peg
In the bathroom at patient’s home In the activities of daily living room or general space
at the clinic
Meal preparation Cutting vegetables into pieces by using a knife Cutting the putty by using a plastic knife
Vegetable stir-fry by using the patient’s own spatula Simulated practice of stir-fry movement by using a
and pan spoon in a large salad bowl
In the kitchen at patient’s home In the activities of daily living room or general space
at the clinic
Bathroom transfer Practice transfer skills in an individualized Practice transfer skills in a nearly barrier free
environment (eg, with or without handrail, environment (eg, with handrail and nonslip bath
bathtub, nonslip bath mat, and doorstep) mat, and no doorstep)

Interventions environments, objects, and modalities used. For the sessions of


mirror therapy, a variety of modalities or objects with different
Before the 2 types of interventions began, the individualized, sizes, weights, and shapes were available for this group. For the
client-centered Canadian Occupational Performance Measure sessions of functional task training, the treatment modalities
(COPM)29 was administered to help identify the individual and selected in the clinic were not as natural or as individualized as those
important tasks and goals of each patient. Goal-directed treatment in the patient’s home environment. Simulated contexts and equip-
principles were applied in both groups. ment or the objects and modalities in the clinic were provided for
practice of some functional tasks in this group (table 1), for
Home-based rehabilitation example, simulated cooking, grooming, and transfer activities in the
This group received 30 to 45 minutes of mirror therapy, followed activities of daily living room; opening drawers or a door in the
by 45 to 60 minutes of functional task training, at each session. clinic; and indoor walking in the hospital environment.
The intervention took place in the participant’s home environ-
ment. During the mirror practice, the patient was instructed to
watch the image of his or her nonaffected UE on the mirror and
Outcome measures
was encouraged to actively move the paretic UE concurrently with Measurements were selected based on the International Classifi-
the mirror reflection of the movement of the nonparetic UE as cation of Functioning, Disability and Health framework.30
much as possible. Mirror therapy treatment activities included
active range of motion exercise, object manipulation, functional Impairment level
tasks with objects, and sensory stimulation.10 The 33-item Fugl-Meyer Assessment upper-limb subscale was
After mirror therapy, the participants received functional task used to evaluate motor impairments.31 The total score ranges from
training. The functional treatment activities were selected 0 to 66, with higher scores indicating fewer motor deficits. Its
according to each patient’s level of motor deficits and individual psychometric properties have been well established.32,33
needs. Repetitive task training for improving UE motor function, The Box and Block Test is a measure of hand dexterity with
daily activities, mobility, or walking ability was applied. During satisfactory reliability and validity in stroke patients.34,35 The
treatment, the therapist gave the patient clear instructions, feed- participants were instructed to use their affected hand to move
back, and encouragement. Examples of tasks were opening one-by-one as many blocks as possible from 1 compartment to the
drawers, pouring water, picking up a phone, opening a door, other within 1 minute.
twisting a towel, folding clothes, cooking activities, laundry The Revised Nottingham Sensory Assessment is a reliable
activities, transfer techniques, and indoor walking in the home measure of sensory function in stroke patients.36,37 This study
environment. The use of familiar everyday objects and items used the subscales of light touch, proprioception, and stereognosis.
within the person’s daily routine was emphasized.
Activity and participation levels
Clinic-based rehabilitation The Motor Activity Log (MAL) is a self-report scale that was used
The clinic-based rehabilitation group also received 30 to 45 minutes to evaluate the amount of use (AOU) and quality of movement of
of mirror therapy, followed by 45 to 60 minutes of functional task the affected UE. It assesses 30 common daily tasks, and the score
training, at each session. The intervention took place in the hospital of each task ranges from 0 to 5.38
clinics. Most of the treatment principles and instructions were the Functional walking and the ability to stand after sitting in a chair
same as those in the home-based group. However, the major dif- are critical factors of independent living in the community. Previous
ferences between the home-based and clinic-based rehabilitations studies showed that upper-limb rehabilitation interventions led to
were different modes of treatment delivery, treatment contexts, positive and additional benefits on mobility, ambulation, or gait

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Home-based rehabilitation 5

performance of stroke patients.39-41 In addition, the functional tasks of the 2 study periods of intervention and assessment were
provided in this study included transfer, mobility activities, and analyzed (see fig 2). Table 2 summarizes the baseline character-
indoor walking to decrease dependence of patients. The 10-meter istics of the 24 participants included in study period 1. No sig-
walk test42,43 and sit-to-stand test44,45 were thus used. nificant differences were found in the baseline characteristics
During the sit-to-stand test, the participant was encouraged to between the 2 treatment groups (PZ.21-.94).
complete as many full stands as possible from the chair within 30 During study period 1, 8.3% of patients dropped out of each
seconds. The sit-to-stand test procedure was the same for the 2 group; and during study period 2, 18.2% of patients dropped out
treatment groups, except that 2 different chairs with similar height (see fig 2). The baseline characteristics of the patients who were
were used during the study period. initially included in the analyses of period 1 and those who were
The COPM is a client-reported questionnaire to assess an in- included in the analyses of period 2 did not differ significantly
dividual’s perceived performance in self-care, productivity, and (PZ.21-.91).
leisure activities.29 The participants were asked to identify the 5
most important problems/activities that they wanted to improve
Treatment effects on the outcome measures
and to rate their own level of performance and satisfaction with
performance (1-10) for each identified problem. Its reliability and There were no statistically significant differences in any outcomes
validity have been validated.46 of impairment level between the home-based and clinic-based
The EuroQoL-5D (EQ-5D) Questionnaire is a measure for rehabilitation groups (PZ.18-.79, table 3). For the outcomes of
valuing health, with good psychometric properties.47,48 The ratings activity and participation levels, the home-based rehabilitation
on the 5 dimensions can be converted to a single index value, the group had statistically significant greater improvements on the
EQ-Index.49 Patients also rated their overall health on the day of the MAL-AOU (PZ.01) and sit-to-stand test (PZ.03) than the clinic-
interview with the EQ-VAS, a vertical 0 to 100 visual analog scale. based group (table 4). However, the clinic-based rehabilitation
group showed significantly better improvements on the EQ-Index
than the home-based group (PZ.02). No statistically significant
Monitoring potential adverse effects
differences were noted between the 2 groups on the other out-
Fatigue and pain of patients were, respectively, measured with a comes (PZ.21-.86; see table 4), indicating the improvements on
Numerical Rating Scale on a 10-cm vertical line50 supplemented these outcomes were similar. The data of most outcome variables
with the Face Rating Scale51 at the first and final treatment days. met the assumption of normality (skewness <1), except for the
data of the Revised Nottingham Sensory Assessment subscales. In
addition, 1 patient in the clinic-based group had many fewer
Statistical analysis stands ( 5) on the sit-to-stand test caused by physical fatigue, and
the data were removed from the analysis.
A pretest was used to check and rule out a carryover effect after
Patients in the 2 groups rated their subjective pain and fatigue
the 4-week washout period.52 The sum of the scores measured in
at the first and final treatment days as very mild (mean scores <2),
the 2 periods was compared across the 2 sequence groups by using
indicating the programs could be acceptable and tolerable by
the t test. If the test was not statistically significant, indicating a
the patients.
negligible carryover effect, then the usual test for examining group
differences could be applied.52
This study used a per-protocol analysis. The results of pretest
analyses on all outcomes suggested that there was no significant Discussion
evidence of carryover effect (PZ.19-.84). Therefore, the analysis of In this 2-period, crossover study, we demonstrated that the home-
covariance was used to examine treatment effects between the 2 based and clinic-based rehabilitation has differential benefits on
interventions. Changes on the outcome measures of the home-based different aspects of health outcomes. Patients in the home-based
group versus the clinic-based group, regardless of the sequences, group demonstrated better improvements on the AOU of their
were compared; that is, the data of the same type of treatment in the affected UE in daily tasks measured by the MAL-AOU and lower
2 sequences were combined to be analyzed. An effect size of partial extremity force measured by the sit-to-stand test than the clinic-
h2 was also calculated to index the magnitude of group differences. based group. The improved scores on the MAL-AOU and sit-to-
A P value of <.05 was statistically significant. stand test also exceeded or approached minimal clinically
Based on the previous research of a home-based rehabilitation important differences.38,53 The clinic-based rehabilitation group
program versus the same program in the hospital, we estimated an showed greater benefits on the health status measured by the EQ-
effect size d of 0.60.9,15 An estimate of the sample size requirement in Index than the home-based group. Both groups showed compa-
a 2-sample crossover design was 11 pairs of participants given a rable improvements in the outcomes of impairment level and the
power of 0.80, a 2-sided type I error of 0.05, and an estimated cor- COPM, but no between-group significant differences were found.
relation between the 2 treatments within each participant of 0.80. We, Home-based rehabilitation has the advantage of promoting
therefore, planned to recruit approximately 11 participants per group. context-dependent learning, and the objects of relevance to the
participants are frequently incorporated into treatment.54,55 Par-
ticipants who practiced in a familiar home environment were
Results perhaps more likely to transfer the skills they had learned to real-
world activities.56 This may have contributed to greater
Participants’ baseline characteristics improvement and generalization of using the affected UE in daily
activities by self-report than in the hospital contexts. Previous
The study initially enrolled 26 patients from December 2014 to studies also showed that home-based constraint-induced therapy
November 2016, and the data of the patients who completed each and virtual reality enhanced the daily use of patient’s affected UE

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6 Y.-w. Hsieh et al

Table 2 Baseline characteristics of study participants


Home-Based Rehabilitation Clinic-Based Rehabilitation
Characteristic First (nZ12) First (nZ12) All (nZ24) P
Age (y) 53.22 19.18 56.36  18.02 54.79  18.27 .68
Stroke onset time (mo) 15.92  13.04 13.67  10.95 14.79  11.83 .65
Gender .62
Male 10 9 19
Female 2 3 5
Brain lesion side .67
Left 5 4 9
Right 7 8 15
Type of stroke .54
Ischemic 10 11 21
Hemorrhage 2 1 3
Lesion site .39
Cortical 1 1 2
Subcortcial 6 9 15
Others 5 2 7
FMA (0-66) 41.58  16.13 41.17  11.34 41.38  13.64 .94
MMSE (0-30) 27.58  2.64 26.00  3.33 26.79  3.05 .21
MAS 0.29  0.32 0.33  0.27 0.31  0.29 .80
NOTE. Values are mean  SD or number of patients.
Abbreviations: FMA, Fugl-Meyer Assessment; MAS, modified Ashworth scale; MMSE, Mini-Mental State Examination.

measured by the MAL.12,13 In addition, functional task practice treated (eg, motor ability or functional performance) but also to
included the training programs of mobility, transfer, or indoor some factors related to the delivery of this type of treatment (eg,
walking, which may have contributed to the improvement of sit- have more chances to participate in community activities and
to-stand performance in the home-based group. However, the social interaction than the home-based group). When the patients
findings of the sit-to-stand test should be interpreted with caution. received clinic-based rehabilitation, they needed to plan and
One patient had fewer stands caused by physical fatigue. The implement the event of leaving to go to the hospital to receive
30-second sit-to-stand test applied in this study might cause more rehabilitation, which might require motor and cognitive planning
fatigue than the 5-repetition sit-to-stand test. Moreover, 2 different and execution abilities. During the whole event, they might have
types of chairs were used for the test. Further studies are suggested more chances to participate in community transportation, social
to use a consistent chair to minimize measurement errors and communication, and problem solving, which may lead to a better
apply the 5-repetition sit-to-stand test to decrease the influence of self-perceived health state.
endurance.57 Regarding the impairment level of outcomes, the possible
The significant improvement of quality of life in the clinic- explanation for the nonsignificant differences between the 2
based group might be attributed not only to the aspects directly groups may be that the clinic-based rehabilitation can provide a

Table 3 Pretreatment and posttreatment scores between the 2 treatment groups on the impairment level outcomes
Outcomes in Impairment Level Home-Based Rehabilitation Clinic-Based Rehabilitation P Partial h2
FMA .79 <0.01
Pretreatment score 43.48  14.77 41.10  12.75
Posttreatment score 47.33  14.59 45.33  13.57
BBT .41 0.02
Pretreatment score 18.86  16.63 16.10  13.82
Posttreatment score 20.86  17.10 19.48  14.13
RNSA-light touch .72 <0.01
Pretreatment score 14.33  4.31 14.67  4.26
Posttreatment score 14.52  4.50 14.95  3.32
RNSA-proprioception .55 0.01
Pretreatment score 17.62  4.91 17.24  5.54
Posttreatment score 18.29  4.19 18.29  4.19
RNSA-stereognosis .18 0.05
Pretreatment score 17.52  7.56 17.52  7.82
Posttreatment score 17.57  8.12 19.10  6.43
NOTE. Values are mean  SD or as otherwise indicated.
Abbreviations: BBT, Box and Block Test; FMA, Fugl-Meyer Assessment; RNSA, Revised Nottingham Sensory Assessment.

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Home-based rehabilitation 7

Table 4 Pretreatment and posttreatment scores between the 2 treatment groups on the activity and participation levels outcomes
Outcomes in Activity and Participation Levels Home-Based Rehabilitation Clinic-Based Rehabilitation P Partial h2
MAL-AOU .01* 0.15
Pretreatment score 2.21  1.21 2.25  1.17
Posttreatment score 2.83  1.33 2.51  1.23
MAL-QOM .23 0.04
Pretreatment score 2.14  1.37 1.98  1.28
Posttreatment score 2.65  1.54 2.31  1.33
10MWT (min/s) .34 0.03
Pretreatment score 0.60  0.25 0.59  0.22
Posttreatment score 0.73  0.28 0.74  0.28
Sit-to-stand test .03* 0.19
Pretreatment score 7.96  3.20 8.92  2.26
Posttreatment score 9.89  3.83 9.04  2.32
COPM-satisfaction .73 <0.01
Pretreatment score 3.64  1.01 3.05  1.48
Posttreatment score 4.90  1.74 4.50  1.57
COPM-performance .86 <0.01
Pretreatment score 3.83  1.25 3.42  1.32
Posttreatment score 5.03  1.55 4.64  1.32
EQ-Index .02* 0.14
Pretreatment score 0.76  0.18 0.76  0.14
Posttreatment score 0.77  0.18 0.83  0.15
EQ-VAS .21 0.04
Pretreatment score 60.95  16.10 62.62  15.30
Posttreatment score 68.81  15.08 65.71  17.27
NOTE. Values are mean  SD or as otherwise indicated.
Abbreviations: 10MWT, 10-meter walk test; AOU, amount of use; COPM, Canadian Occupational Performance Measure; EQ-Index, Index value of EQ-5D;
EQ-VAS, visual analog scale of EQ-5D; MAL, Motor Activity Log; QOM, quality of movement.
* Statistically significant.

variety of modalities according to each participant’s level of same or similar programs delivered in home-based and clinic-
impairment, whereas the home-based rehabilitation uses objects based rehabilitation contexts.
and tasks familiar and relevant to the participant’s daily life for
practice. Each practice setting has its own advantages to improve
Study limitations
the participants’ sensorimotor impairments, leading to nonsignif-
icant between-group differences. The findings are similar to the First, because the optimal treatment duration and frequency of
previous studies in which they also found no significant differ- home-based stroke rehabilitation have not been established, we
ences in improvements of patients’ UE motor function between adopted a relatively intensive schedule. The therapist delivered
home-based rehabilitation and control interventions.3,12 Further- one-on-one treatment 3 times weekly, which may be impractical
more, both groups showed comparable benefits in self-perceived for home-based rehabilitation. The integration of home-based with
satisfaction and performance measured by the COPM, suggest- clinic-based intervention, including the treatment frequency and
ing the 2 interventions were similarly appreciated by the mode of delivery, to optimize stroke rehabilitation outcomes
participants. warrants further consideration. Second, the study did not estimate
Most previous studies examined treatment effects of home- the costs of home-based rehabilitation (eg, intervention expenses
based stroke rehabilitation by using control groups with different or transportation costs). It is important to assess the cost-
programs (eg, usual care, visits, or conventional rehabilita- effectiveness of home-based rehabilitation for further applica-
tion).2,3,12-14 There is insufficient evidence to conclude the relative tions. Third, although the average stroke onset time was not
effects of home-based rehabilitation compared with different significantly different between the 2 groups, the inclusion criteria
control interventions.15 Piron et al (2008) used the same program of 1 month to 5 years post onset might have affected the study
in the 2 environments to investigate the effects of virtual reality at results. Further studies to compare the treatment effects in patients
the patient’s home versus in the hospital. This small-scale study with subacute versus chronic stroke are suggested.
found that the home-based group improved significantly in motor
function, but the hospital group had no significant change.9 In the
present study, similar programs were also conducted in both en- Conclusions
vironments. The 2 types of treatments had comparable benefits in
the outcomes of impairment level but showed differential effects The implementation of a home-based stroke rehabilitation inter-
in the outcomes of activity and participation levels. However, to vention with patient-oriented goals resulted in mixed outcomes.
make recommendations about which treatment is more or less The home-based rehabilitation demonstrated better improvements
effective, more studies are needed to compare the efficacy of the in the amount the affected UE was used in daily tasks and in lower

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8 Y.-w. Hsieh et al

extremity force, whereas the clinic-based rehabilitation enhanced stroke: a randomised controlled feasibility trial. Clin Rehabil 2017;
self-perceived health status. Further studies are suggested to 31:340-50.
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controlled trial. Clin Rehabil 2017;31:891-903.
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