Scale-out of a home-based arm and hand exercise program for stroke: A multisite implementation-efficacy trial

Stroke is a major cause of disability worldwide, with approximately 80 % of individuals experiencing upper extremity (UE) dysfunction. After being discharged home, individuals with stroke typically need further treatment such as in-home rehabilitation to restore and maintain their UE function. Home-based rehabilitation programs targeting at UE recovery have been shown to be effective on UE function and performance of activities of daily living. This service can be a cost-saving alternative to conventional in hospital stroke rehabilitation therapy. Especially in times of pandemic and in rural and remote areas, home-based rehabilitation programs will be able to decrease the need for in-person contact and save time and expenses on travel. However, little has been done to understand how to translate these interventions to real-world programs. Implementation research is an emerging field of study to address the disconnection between clinical studies and real-world healthcare practices. By studying how efficacious clinical innovations and interventions should be adapted to achieve comparable results in different settings and organizations, implementation research promotes the uptake of research findings into routine practice. To address the current challenges in the uptake of evidence-based rehabilitation following stroke, our proposed research project will evaluate the implementation of an evidence-based supervised home-based arm and hand exercise program (home-based GRASP program) in 4 hospitals. The primary aim of this 4-year project is to evaluate the implementation of the home-based GRASP program at rehabilitation clinics across 4 hospitals. This process evaluation will follow the REAIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. The second aim is to determine the efficacy of the home based GRASP program relative to the usual home program on improving health outcomes, including UE motor function, daily function, quality of life, and motor control strategies. This project will be carried out in two stages: 1) implementation planning of the home-based GRASP program stage (0-6 months) and 2) implementation and clinical trial stage (7-48 months). In the 1) implementation planning stage, a stakeholder advisory group will be formed that consists of the University researchers and occupational therapists working at the rehabilitation clinic at each site (4 sites) to develop the implementation plan. In the 2) implementation and clinical trial stage, a mixed-methods study will be conducted with a multi-center (4 hospitals), assessor-blinded, randomized controlled trial (RCT) with an embedded qualitative study. The RCT will be used to determine the effectiveness of the 8- week home-based GRASP program on UE motor function, daily function, quality of life, and motor control strategies (as measured by kinematics) compared to the control group which receives usual occupational therapy home program. The nested qualitative study will be used to explore stroke patients’ and occupational therapists’ views and perspectives of the program. Both the RCT and the nested qualitative study will be used to inform the implementation outcomes of the study, which will be mapped to a robust implementation evaluation model, the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. 118 chronic stroke patients will be recruited and randomly assigned to one of the two interventions: the Home-based GRASP group or the control group. Stroke participants will receive either intervention for 8 weeks (3 sessions/week). Stroke participants will be evaluated before, immediately after, and 3 months after the trial on their clinical outcomes (clinical and kinematic measures). Twenty-five occupational therapists working at the rehabilitation clinics of four brances of Chang Gung Memorial Hospital will be recruited. Therapist participants will be trained for the delivery of the home-based GRASP program. Interviews and surveys will be administered to understand patients’ and therapists’ perspectives on the implementation of the home-based GRASP program. Other data sources such as documentation and field notes will also be collected. Completion of this study will build the evidence base for the home-based program to improve UE recovery, expedite the clinical uptake of the evidence-based practice, develop the best practice for stroke rehabilitation in real-world settings, and ultimately influence the current delivery of rehabilitation services. The model, findings, and experiences of this project can also be used to implement other clinical innovations/interventions for different populations.

Project ID:PG11301-0108
External Project ID:NHRI-EX113-11210PC