Systematic Review and Meta-Analysis of Home-Based Rehabilitation on Improving Physical Function Among Home-Dwelling Patients With a Stroke

Journal Pre-proof Systematic Review and Meta-analysis of Home-Based Rehabilitation on Improving Physical Function Among Home-dwelling Patients with a Stroke Nai-Fang Chi, Yi-Chieh Huang, Hsiao-Yean Chiu, Hsiu-Ju Chang, Hui-Chuan Huang PII:

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https://doi.org/10.1016/j.apmr.2019.10.181

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ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION

Received Date: 3 May 2019 Revised Date:

30 September 2019

Accepted Date: 2 October 2019

Please cite this article as: Chi N-F, Huang Y-C, Chiu H-Y, Chang H-J, Huang H-C, Systematic Review and Meta-analysis of Home-Based Rehabilitation on Improving Physical Function Among Home-dwelling Patients with a Stroke, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2019), doi: https://doi.org/10.1016/j.apmr.2019.10.181. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc. on behalf of the American Congress of Rehabilitation Medicine

Title: Systematic Review and Meta-analysis of Home-Based Rehabilitation on Improving Physical Function Among Home-dwelling Patients with a Stroke Running title: Stroke and Home-based rehabilitation Nai-Fang Chi,1,2,3,4 Yi-Chieh Huang,5 Hsiao-Yean Chiu,5 Hsiu-Ju Chang5 Hui-Chuan Huang5 Authors: Nai-Fang, Chi, MD 1

Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. Address: 250 Wu-Hsing Street, Taipei 11031, Taiwan

2

Department of Neurology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan. Address: No.291, Zhongzheng Rd., Zhonghe District, New Taipei City, 23561, Taiwan

3

Cerebrovascular Research Center, Taipei Medical University, Taipei, Taiwan Address: 250 Wu-Hsing Street, Taipei 11031, Taiwan

4

Faculty of Medicine, School of Medicine, National Yang-Ming University Address: No.155, Sec. 2, Linong St., Beitou District, Taipei City 112, Taiwan E-mail: [email protected]

Yi-Chieh Huang, RN, MSN E-mail: [email protected] Hsiao-Yean Chiu, RN, PhD E-mail: [email protected] Hsiu-Ju Chang, RN, PhD E-mail: [email protected]

Hui-Chuan Huang, RN, PhD E-mail: [email protected] 5

School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan Address: 250 Wu-Hsing Street, Taipei 11031, Taiwan.

Corresponding Author: Hui-Chuan Huang, RN, PhD Address: 250 Wu-Hsing Street, Taipei 11031, Taiwan. E-mail: [email protected] Tel.: +886-2-27361661 ext. 6349 Fax: +886-2-2377284

Conflicts of Interest: The authors have no conflicts of interest or sources of funding to declare

Funding: This work was funded by a grant (106TMU-SHH-16) from Taipei Medical University-Shuang Ho Hospital.

1

Title: Systematic Review and Meta-analysis of Home-Based Rehabilitation on Improving

2

Physical Function Among Home-dwelling Patients with a Stroke

3

Running head: Stroke and Home-Based Rehabilitation

4

Abstract

5

Objective: To evaluate the effects of home-based rehabilitation on improving physical

6

function in home-dwelling patients after a stroke.

7

Data sources: Various electronic databases, including PubMed, CINAL, Embase, the Cochrane

8

Central Register of Controlled Trials, and two Chinese datasets (i.e., Chinese Electronic

9

Periodical Services and China Knowledge Resource Integrated) were searched for studies

10

published before March 20, 2019.

11

Study selection: Randomized controlled trials conducted to examine the effect of home-based

12

rehabilitation on improving physical function in home-dwelling patients with a stroke and

13

published in English or Chinese were included. In total, 49 articles in English (n=23) and

14

Chinese (n=26) met the inclusion criteria.

15

Data extraction: Data related to patient characteristics, study characteristics, intervention

16

details, and outcomes were extracted by two independent reviewers.

17

Data synthesis: A random-effects model with a sensitivity analysis showed that home-based

18

rehabilitation exerted moderate improvements on physical function in home-dwelling patients

19

with a stroke (g = 0.58, 95% confidence interval [CI] 0.45~0.70). Moderator analyses 1

20

revealed that those stroke patients of a younger age, of a male gender, with a first-ever stroke

21

episode, in the acute stage, and receiving rehabilitation training from their caregiver showed

22

greater improvements in physical function.

23

Conclusions: Home rehabilitation can improve functional outcome in stroke survivors and

24

should be considered appropriate during discharge planning if continuation care is required.

25 26

Keywords: home care, meta-analysis, physical function, rehabilitation, stroke

27

2

28

INTRODUCTION

29

Stroke is the second leading cause of death worldwide and a major cause of chronic

30

neurological disability in adult populations.1 Estimated prevalence rates of disability in stroke

31

survivors range 36%~45%.2, 3 Stroke survivors with permanent functional disability might

32

become dependent in activities of daily living (ADLs) which may further increase

33

psychological distress and worsen their quality of life.4 According to the theory of

34

neuroplasticity, those patients after a stroke receiving massed practice of rehabilitation

35

exercise can benefit their brain to rewire functions from damaged areas over to healthy parts,

36

thereby promoting functional recovery.5 Previous studies found that stroke survivors receiving

37

suitable rehabilitation can improve their physical function in the post-acute and chronic

38

phases.6, 7 Thus, providing early and continuous rehabilitation training for stroke patients with

39

disabilities should be considered.

40

Under current care plan, early hospital-based rehabilitation is provided to improve

41

function in stroke patients with disabilities. To reduce health care cost, many patients with

42

stroke undergo early hospital discharge and may continue with rehabilitation in home care or

43

outpatient environment.8 Outpatient rehabilitation with structured training, including

44

physiotherapy (PT), occupational therapy (OT), or speech therapy (ST), is performed by

45

professionals in a clinical setting. A previous study found that providing regularly outpatient

46

rehabilitation supervised by professionals could increase physical function of individuals after 3

47

a stroke.9 In addition, patients who participate in outpatient rehabilitation may benefit from

48

social interaction, increased self-esteem, and decreased depression. 10 However, transportation

49

difficulties, cost, and impairment can hinder patient and caregiver participation. 11,12 Home-based rehabilitation, otherwise known as home care rehabilitation is another form

50 51

of service delivery where rehabilitation services are provided at the patient’s home. The

52

service providers may include but not limited to PTs, OTs, and STs. Patients learn and apply

53

the functional skills in their home environment.13 Previous studies showed that most disabled

54

patients with a stroke and their families tend to accept home-based rehabilitation because of

55

environmental familiarity, convenience, and continuity of care.14, 15 Thus, home-based

56

rehabilitation can be considered an effective way to continue patient care and improve

57

function outcome. Some recent studies examined the effects of home-based rehabilitation on functional

58 59

outcome of patients with stroke. While some studies reported benefits in physical function; 7,

60

16, 17,

61

first-ever stroke patients19, 21 or first-ever and recurrent stroke patients18, 22), type of stroke

62

(e.g., ischemic stroke6,13 or ischemic and hemorrhagic stroke18, 19), and stage of the stroke

63

(e.g., acute22 or chronic stage23) and interventional characteristics such as the number of home

64

visits, interventions performed by an individual practionier6, 7, 13 or a multidisciplinary team,19,

65

22, 24

others did not.18-20 The difference in sample such as the stroke episode (e.g., only

and types of rehabilitaion, including exercise,6, 17 ADL training,18, 19, 22 and PT and OT,25, 4

66

26

67

controlled trials (RCTs), conducting meta-analyis that examines the effects of home-based

68

rehabilitation on functional outcome of home-dwelling stroke survivors is clinically relevant.

69

may account for the difference in findings. With more recent publications of randomized

On the basis of these gaps in the literature, we conducted a meta-analysis with recent

70

studies to examine the overall effect of home-based rehabilitation on improving physical

71

function in home-dwelling populations with a stroke and identify whether patient

72

characteristics and intervention components modulated the effects of home-based

73

rehabilitation on physical function.

74

METHODS

75

The meta-analysis was completed according to guidelines recommended by the Preferred

76

Reporting Items for Systematic Reviews and Meta-analyses statement.27

77

Inclusion and exclusion criteria

78

Inclusion criteria of studies in the meta-analysis were: (1) the target population was

79

home-dwelling stroke survivors; (2) the intervention was performed in a home setting; (3) the

80

types of rehabilitation aiming to improve physical function were PT, OT, exercise, or daily

81

activity training; (4) the adopted comparison groups comprised usual care, no treatment, or

82

other activity controls; and (5) the outcome measure was physical function, which was

83

defined as the ability of an individual to achieve personal independence in ADLs. The

84

outcome was assessed by instruments with suitable reliability and validity such as the Barthel 5

85

index, modified Barthel index, functional independence measure, or other scales that measure

86

the ability to perform daily activities28. In addition, (6) the study design had to be an RCT.

87

Those studies of home-based rehabilitation performed by non-professionals were excluded to

88

avoid misestimating the effect of home-based rehabilitation on the physical functioning of

89

stroke patients.

90

Data sources and search strategy

91

Systematic searches using the identified keyword combinations of “stroke” or

92

“cardiovascular disease” AND “physical therapy” or “physiotherapy” or “occupational

93

therapy” or “rehabilitation” or “exercise” or “physical activity” AND “physical function” or

94

“function recovery” or “recovery of function” were applied to search eligible articles. All

95

eligible articles were searched from inception to March 20, 2019 from various electronic

96

databases including PubMed, CINAL, Embase, and the Cochrane Central Register of

97

Controlled Trials. In addition, two Chinese databases, i.e., Chinese Electronic Periodical

98

Services and China Knowledge Resource Integrated, were also fully searched. To ensure

99

literature saturation, we reviewed the reference lists of included studies or relevant reviews

100

identified through the search. Additionally, no language restrictions or year of publication

101

were applied to the searched articles. Two researchers (HC Huang and IC Huang)

102

independently hand-searched eligible articles using the aforementioned search strategy and

103

then screened the title and abstract of all identified papers for their relevance. Full texts of 6

104

eligible articles were subsequently reviewed and evaluated. Any discrepancies between the

105

included studies were resolved through discussion, until a consensus was reached.

106

Data extraction

107

Data extraction was performed by two independent researchers according to a

108

predesigned data sheet. Contents of the extracted data included patient characteristics (e.g.,

109

age, gender, stroke episode (e.g., first-ever or recurrent stroke), type of stroke, and days after

110

stroke onset), study characteristics (e.g., the numbers of participants recruited in the

111

experimental and control groups, publication language, and location), intervention details

112

(e.g., type of service, type of rehabilitation, duration, the number of practitioners, type of

113

control group, and the inclusion of caregiver and environment alterations), and outcome

114

measures (instruments used and measurements). Regarding missing or unclear data, the

115

original authors were contacted by e-mail at least once to obtain complete data. Discrepancies

116

with data extraction were resolved by consensus.

117

Methodological appraisal of the included studies

118

Methodological appraisal of each eligible study followed the Cochrane Handbook for

119

Systematic Reviews of Interventions Version 5.1.0.29 Assessments of risks of bias comprised

120

random sequence generation (selection bias), allocation sequence concealment (selection bias),

121

blinding of participants and personnel (performance bias), outcome assessments (detection

122

bias), incomplete outcome data (attrition bias), selective outcome reporting (reporting bias), 7

123

and other potential sources of bias. Possible risks of bias in each of the six domains were

124

categorized as high risk, low risk, or unclear according to the information reported in the

125

study. Two researchers independently evaluated each eligible study according to these criteria,

126

and a consensus was reached by discussion of discrepancies in the risk of bias assessment of

127

these studies.

128

Data analysis

129

Data management and analysis were performed using Comprehensive Meta-Analysis

130

vers. 2.0 software. The standardized mean difference (SMD) was used to indicate the

131

difference between the intervention and control groups in each study and was calculated

132

according the reported data format including the mean and standard deviation (SD) of pre-

133

and post-intervention scores or post-intervention scores only, sample size, and p values. If

134

data were reported by the median and range or interquartile range, an appropriate formula was

135

used to convert them to the mean and SD.30 Each effect size (ES) in the trial was calculated

136

using Hedges’ g formula (Hedges ′  =

137

using random- and fixed-effects models and the strength of the pooled ESs was interpreted as

138

a small, medium, or large effect, referring to 0.20, 0.50, and 0.80, respectively, based on

139

Cohen’s criteria.31 Moreover, a sensitivity analysis was performed by removing a study with

140

an ES of > 2, which was identified as an outlier to examine whether the large effect might

141

have misestimated the overall ES in the meta-analysis.32

       

8

). The pooled ES was represented

142

Assessment of heterogeneity

143

The heterogeneity of the included studies was examined using the Q statistic and I2

144

statistic. Significant Q statistics (p < 0.10) and an I2 value of > 25% were identified as

145

heterogeneity across studies, and a moderator analysis was used to explain the source of

146

heterogeneity.33 In addition, a random-effects model was adopted to demonstrate the pooled

147

ES for significant heterogeneity, while the fixed-effects model was used when no

148

heterogeneity was observed.

149

Moderator analysis

150

Moderator analyses including a subgroup analysis and meta-regression model were used

151

to explore potential reasons explaining the observed heterogeneity and examine comparative

152

effects of participant characteristics (e.g., age, gender, episode of stroke, type of stroke, and

153

days after stroke onset), study characteristics (e.g., number of study participants, language

154

published, and location), and intervention details (e.g., type of service, type of rehabilitation,

155

duration, practitioners, type of control group, the inclusion of a caregiver, and environmental

156

alterations) on the physical function of patients with a stroke. A subgroup analysis was

157

conducted to compare ESs among studies of groups of interest for the categorical moderator,

158

and a meta-regression model was used to examine the relationship of ESs and variables of

159

interest for a continuous moderator. To ensure sufficient data for analyses, each moderator

160

analysis was limited to instances in which groups were represented by at least two studies. 9

161

Publication bias

162

Publication bias was tested using the fail-safe N and the trim-and-fill method.34 The

163

fail-safe N was used to estimate the number of unpublished studies with an insignificant effect

164

that would reduce the overall estimation of the ES to a non-significant level (p > 0.05). The

165

trim-and-fill method reexamined the pooled ES after considering the number of missing

166

studies in the meta-analysis to adjust for publication bias.35 The adjusted pooled ES becoming

167

insignificant indicated a potential publication bias that threatened results of the meta-analysis.

168

RESULTS

169

Study identification

170

Figure 1 illustrates the process of study identification. In total, the full text of 68 articles

171

was reviewed after removing duplicates (n=8440) and irrelevant studies (n=12,083). Of these,

172

19 articles were excluded because two articles were a protocol,36, 37 three studies provided

173

insufficient information to identify their relevance because only an abstract was

174

published,38-40 six articles used home-based rehabilitation training for the control group,41-46

175

one study had an unclear control group,47 three articles described an unclear intervention

176

program for the rehabilitation training performed at home,48-50 and four articles had

177

unavailable data after contacting the original authors.51-54 Finally, 49 articles in Chinese (n=26)

178

and English (n=23) were included in the meta-analysis (citations of all 49 articles are listed in

179

the supplementary file). 10

180

Characteristics of the included studies

181

Demographic and disease characteristics

182

Table 1 shows demographic and disease characteristics of study participants. In total,

183

4597 study participants were recruited in the 49 articles. The mean age was 66.2 years, and

184

the percentage of females was 42.1%. Ten studies recruited only first-ever stroke victims, and

185

11 studies recruited participants with first and recurrent strokes. Regarding the type of stroke,

186

most studies recruited ischemic and hemorrhagic stroke patients (n=26), and only three

187

articles focused on ischemic stroke survivors. Moreover, 11 studies recruited stroke patients in

188

the acute stage (≤ 6 months after stroke onset), and six studies included stroke patients in the

189

chronic stage. According to the category of socioeconomic status defined by the International

190

Monetary Fund in 2017,55 the majority of studies were conducted in developing countries

191

such as China, Turkey, and India (n=31), and 18 studies were conducted in developed

192

countries comprising Australia, Denmark, New Zealand, Norway, Portugal, Sweden, Taiwan,

193

the UK, and the US.

194

Interventional details

195

Table 2 summarizes characteristics of the interventions in these 49 RCTs. These articles

196

were published between 1992 and 2017. Regarding the type of rehabilitation, 32 studies

197

provided only ADL training, five studies combined ADL training, PT, and OT, seven studies

198

described the intervention program as only rehabilitation, and two studies adopted exercise as 11

199

the intervention program. Regarding the type of service, 45 studies adopted only home visits,

200

while four studies combined home visits and phone interviews. For the intensity of the

201

interventions, the average length of interventions was 18.9 weeks, and ranged 3~144 weeks.

202

Regarding practitioners, a multidisciplinary team (physician, physiotherapist, occupational

203

therapist, nurse, or social worker) was commonly used (n=29) rather than an individual

204

therapist (n=19). Additionally, most studies included caregivers in the training program

205

(n=37), and only 22 studies made environmental modifications and added necessary

206

equipment to the home setting. Regarding the types of control groups, 18 studies designed an

207

activity control (e.g., outpatient rehabilitation), and 31 studies used an inactive control (e.g.,

208

usual care, health education, or no treatment). Among these studies, outcomes were assessed

209

using the Barthel index (BI), functional independence measure (FIM), modified BI (MBI),

210

physical function subscale of the short-form 36, or ADL subscale of the Stroke Impact Scale

211

(SIS), which are well-validated instruments that measure the ability to perform daily activities,

212

representing the level of physical function in stroke patients.

213

Methodological quality of the included studies

214

Table 3 presents the risk of bias assessments of the included articles. Results showed that

215

22 studies fulfilled the criteria of random sequence generation, but only 15 studies clearly

216

reported how they had achieved allocation concealment. Only one study achieved a low risk

217

of blinding participants or personnel. Additionally, 13 studies included a blinded assessor who 12

218

performed the outcome assessment, and the majority of studies clearly addressed how they

219

managed incomplete outcome data (n=28). Only one study had no reporting bias because the

220

protocols had previously been published. Overall, no studies achieved the criteria of low risk

221

bias according to the six domains of bias assessment, indicating no studies had overall good

222

methodological quality.

223

The effect of home-based rehabilitation on improving physical function

224

Overall effect

225

Figure 2a indicates that home-based rehabilitation had a significant effect on improving

226

physical function, and the weighted average ES was 0.80 (95% confidence interval [CI]

227

=0.62~0.98, p < 0.001). However, six studies with large ESs were identified as outliers in the

228

random-effects model. After removing those six studies, a sensitivity analysis showed a

229

significant pooled mean ES (K=43, Hedges' g=0.58, 95% CI=0.45~0.70, p < 0.001).

230

Regarding heterogeneity, the Cochran Q (Q=405.04, p < 0.001) and I2 statistics (I2=88.2%)

231

indicated significant heterogeneity across the 49 selected studies. Therefore, further

232

moderator analyses comprising a subgroup analysis and meta-regression were conducted to

233

examine potential factors explaining the heterogeneity among these studies.

234

Moderator analysis

235

In terms of study participant characteristics, ESs were significantly correlated with age,

236

the percentage of female participants, stroke episode, the stage after stroke onset, location, 13

237

and publication language (p < 0.05). Those studies with an older population and more females

238

showed less improvement in physical function. The studies recruiting first-ever stroke

239

participants had greater improvements in physical function compared to those with recurrent

240

stroke participants (g=1.18 vs. 0.57, p=0.028). Moreover, subjects at an acute stage (≤ 6

241

months after stroke onset) exhibited greater improvements in physical function compared to

242

those at the chronic stage (g=1.32 vs. 0.47, p=0.002). Studies conducted in developing

243

countries indicated greater improvement in physical function compared to those in developed

244

countries (g=1.12 vs. 0.23, p < 0.001). In addition, studies published in the Chinese language

245

demonstrated greater improvement in physical function compared to those studies published

246

in the English language (g=1.01 vs. 0.55, p=0.007) (Table 4).

247

Regarding between-group differences in intervention details, results showed that only the

248

type of control group and the inclusion of caregivers were significant moderators in

249

explaining the effect of treatment. Those studies in which the control group was given an

250

inactive control had greater effects on physical function compared to studies that adopted an

251

active control group (g=0.98 vs. 0.51, p=0.005). Moreover, those studies in which caregivers

252

participated in home-based rehabilitation training showed greater improvements in physical

253

function compared to those with an unclear description (g=0.92 vs. 0.48, p=0.016) (Table 4).

254 255

To assess the influence of the study quality on physical function, results showed that those studies which were identified as having a high or unclear risk of random sequence 14

256

generation, allocation concealment, and blinding of outcome assessments showed greater

257

improvements in physical function compared to these studies with a low risk (p < 0.05).

258

However, those studies which were identified as having a low risk of incomplete outcome

259

data had greater improvements in physical function compared to those with a high and unclear

260

risk (p < 0.05) (Table 4).

261

Publication bias

262

Regarding publication bias in 49 studies that measured physical function, the fail-safe N

263

was estimated to be 3041. Moreover, the trim-and-fill procedure showed that the adjusted ES

264

imputing 16 missing studies was 0.31 (95% CI 0.17~0.45), indicating a significant effect of

265

home-based rehabilitation on improving physical function. Thus, no significant publication

266

bias was observed according to these results.

267

DISCUSSION

268

In-home care is an appropriate strategy to decrease all-cause mortality and

269

hospitalizations and improve ADLs in community-living adults with a chronic disease.56

270

Moreover, Our meta-analysis confirmed that performing home-based rehabilitation can exert

271

moderate improvements in physical function in home-dwelling patients with a stroke.

272

Previous individual studies on home-based rehabilitation outcome showed inconsistent results

273

and few meta-analyses were performed to clarify the issues. In this meta-analysis, we

274

recruited 49 RCTs and adopted rigorous procedures to include and review eligible studies 15

275

comprising strict inclusion criteria and a rigorous assessment of moderators and

276

methodological quality to examine the effects of home-based rehabilitation on physical

277

function. Thus, the results that supported home-based rehabilitation benefiting physical

278

function of stroke survivors should be considered reliable. Because home-based rehabilitation

279

was found to be a cost-effective method to improve physical function compared to

280

day-hospital rehabilitation for patients with a stroke;19, 57 provision of home-based

281

rehabilitation can be considered a regular healthcare service to improve physical function of

282

stroke patients with disability.

283

Two possible reasons can explain the effects of home-based rehabilitation on physical

284

function. First, direct in-home visits may provide convenient and patient-centered care that

285

greatly improves physical function. A systematic review found that personal factors (e.g., a

286

lack of knowledge about what to do and how to access services) and environmental factors

287

(e.g., access to transportation services, economic costs, and embarrassment) were the most

288

commonly reported barriers to physical activity after a stroke.12 Because home-based

289

rehabilitation has advantages of individual satisfaction with personal needs by guided training,

290

the availability of appropriate training equipment, and cost-savings,58 providing rehabilitation

291

in the home setting can increase environmental adaptation and promote continual self-practice.

292

Thus, improvements in physical function can be better maintained. Second, home-based

293

rehabilitation provided in the included studies mostly focused on training to be independent in 16

294

performing daily activities. Previous studies found that providing self-care training and

295

physical activities was correlated with physical functioning of community-dwelling stroke

296

patients.59, 60 Thus, home-based rehabilitation featuring training for daily activities could help

297

stroke survivors achieve a better ability to perform ADLs. Because real-life practices in the

298

home environment might be a critical element in improving physical function, incorporating

299

daily activity practice in home-based rehabilitation should be considered.

300

Our meta-analysis found that home-based rehabilitation training of caregivers to

301

participant in the rehabilitation program produced greater improvements in physical function.

302

Among these studies, the purpose of recruiting caregivers in the program was to assist

303

patients with a stroke in performing training at any time in addition to in-home care.18, 61

304

Those caregivers who are familiar with the steps of rehabilitation trainings can supervise and

305

encourage patients with a stroke to perform correct practice of rehabilitation training.

306

Additional training may increase the frequency of the training which can result in functional

307

improvement. Thus, encouraging caregivers of stroke patients to participate in training

308

programs should be considered as a critical element when designing home-based

309

rehabilitation programs for community-dwelling patients with a stroke.

310

Our meta-analysis showed that stroke patients of an older age or a female gender

311

receiving home-based rehabilitation exhibited lower improvements in physical function

312

compared to younger or male counterparts. An older age and a female gender were identified 17

313

as unmodifiable risk factors that influenced the physical function of stroke survivors.62, 63

314

Older patients with a stroke might have more comorbidities, such as arthritis and heart disease,

315

that decrease the improvements in physical function.64, 65 Moreover, stroke patients of an older

316

age and a female gender were also risk groups for the development of post-stroke

317

depression.66 Depression in stroke patients might influence physical performance.67 Because

318

the included studies did not clearly describe the presence of depressive symptoms at

319

recruitment, no definitive conclusion can be drawn regarding this issue. Therefore, future

320

well-designed studies should be further conducted to clarify this issue.

321

Results revealed that those studies recruiting only first-ever stroke survivors showed

322

greater improvements in physical function compared to those with both first and recurrent

323

stroke survivors. A possible explanation is that most recurrent stroke patients suffer severe

324

neurological impairment and have more problems in carrying out their daily activities;68 thus

325

these residual impairments from previous strokes can become cumulative and impact on

326

functional performance of patients with recurrent stroke. Because the needs of in-home

327

rehabilitation between first-ever and recurrent stroke patients may differ and few studies have

328

focused on recurrent strokes, further investigation to clarify this issue and development of a

329

well-designed RCT to improve physical function of recurrent stroke survivors should be

330

considered.

331

In this meta-analysis, stroke survivors in both the acute (≤ 6 months after stroke onset) 18

332

and chronic stages (> 6 months after stroke onset) benefited from home-based rehabilitation

333

to improve their physical function; moreover, stroke survivors in the acute stage exhibited

334

greater improvements. A previous study proposed that performing skilled and repeated motor

335

tasks provided by rehabilitation training at an early stage after a stroke can greatly increase

336

reconnection of partially spared neural pathways to relearn lost functions and improve the

337

disparity between the impaired skills of a patient and the demands of their environment.69

338

Thus, providing early home-based rehabilitation could be an appropriate treatment strategy

339

during the acute stage of stroke recovery following hospital discharge.

340

Our analysis found that those studies in which the control group was given an inactive

341

control (e.g., usual care, health education, or no treatment) had greater effects on physical

342

function compared to studies that adopted an active control group (e.g., outpatient

343

rehabilitation) and inactive control (e.g., usual care, health education, or no treatment).

344

Previous studies proposed that an inactive control group (e.g., usual care and placebo control)

345

was adopted because no adequate treatments existed, while an active control group was used

346

to examine whether or not the intervention of interest was inferior compared to existing

347

treatments.70, 71 Outpatient rehabilitation is the current effective treatment for patients after a

348

stroke. Because within-group comparisons of the subgroup analysis indicated that the pooled

349

ES of comparing home-based rehabilitation and outpatient rehabilitation was significant, the

350

result of performing home-based rehabilitation benefiting physical function in stroke 19

351

survivors should be reliable. Because the cost of home-based rehabilitation was found to be

352

lower than in-hospital rehabilitation,19, 24, 57 providing early, regular home-based rehabilitation

353

for stroke survivors returning to their home should be considered when evaluating potential

354

stroke rehabilitation delivery methods.

355

In this meta-analysis, methodological risks, including random sequence generation,

356

allocation concealment, and blinding of outcome assessments, might have compromised the

357

effect of home-based rehabilitation on physical function. Those studies without clear

358

descriptions of the randomization procedure and allocation concealment, and the use of

359

independent assessors for outcome assessments reported prominent improvements in physical

360

function compared to those studies with clear descriptions of randomization, allocation

361

concealment, and independent assessors. Lack of appropriate randomization, allocation

362

concealment, and independent outcome assessors might have caused a selection bias and

363

detection bias which might have misestimated the effect of treatment.72 However, review

364

studies found that bias associated with study design characteristics may lead to exaggeration

365

of estimates of intervention effects in trials reporting subjectively assessed outcomes.73, 74 In

366

our study, outcomes were assessed by instruments with clear checklists (e.g., the BI, MBI, and

367

FIM), and each item was rated according to study participant’s performance. Thus, the effect

368

of home-based rehabilitation on physical function was not biased when using objective

369

assessments. Because moderator analyses revealed small ESs of home-based rehabilitation on 20

370

physical function in the studies with low risk of selection bias and detection bias, caution is

371

needed in interpreting these results.

372

Results revealed that home-based rehabilitation performed in developing countries (e.g.,

373

China) showed greater improvements in physical function compared to those performed in

374

developed countries. A previous study found that establishment of stroke care services in low-

375

and middle-income countries was impeded by many barriers such as limited rehabilitation

376

facilities, and insufficient numbers of physiotherapists and occupational therapists.75

377

Identifying the effectiveness of home-based rehabilitation might provide an alternative

378

approach to improve physical function of stroke survivors in developing countries. More

379

investigations conducted to clarify the effectiveness of home-based rehabilitation in

380

developing countries are needed.

381

Study limitations

382

The meta-analysis had some strengths by including a large number of RCTs, using strict

383

criteria for including eligible studies, and making rigorous assessments of the methodological

384

quality of the included studies, which increased the internal validity. Moreover, the inclusion

385

of articles written in both English and Chinese increased the external validity of the review.

386

However, some limitations must be considered when interpreting the findings. First,

387

approximately 50% of the included studies clearly described the episode and stage of stroke;

388

thus, the effect of home-based rehabilitation on physical function modulated by the episode 21

389

and stage of stroke must be interpreted with caution. Second, since only one study satisfied

390

the criterion of blinding of both participants and personnel, performance bias by which

391

patients in the interventions group might become aware and receive additional interventions

392

may have compromised the effect of home-based rehabilitation on improving physical

393

function. Because most of the included studies measured outcomes using objective

394

assessments (e.g., the BI, FIM, and MBI), the effects of home-based rehabilitation on physical

395

function might not have been influenced by performance bias.

396

Conclusions

397

The meta-analysis of data from 49 studies showed that home-based rehabilitation had

398

moderate effect on physical function in home-dwelling patients with stroke. Moreover,

399

some characteristics of study participants, such as a younger age, a male gender, patients with

400

a first-ever stroke, and those in the acute stage (within 6 months after stroke onset), and a

401

combination of caregivers in the rehabilitation program showed greater improvements in

402

physical function. The findings provide further suggestions that the characteristics of

403

home-dwelling patients with stroke can significantly affect their functional improvement

404

with home-based rehabilitation. Because home-based rehabilitation is convenient for

405

patients and their caregivers, it should be considered appropriate when choosing

406

rehabilitation method for stroke patients after hospital discharge

407 408 22

409

Figure Legends

410

Figure 1. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2009

411 412 413 414 415

flow diagram Figure 2a. Forest plot comparing the intervention and control groups in physical function (n=49) Figure 2b. Sensitivity analysis examining the effect of home-based rehabilitation on physical function without a large effect size (≤ 2) (n=43)

416 417

23

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625 626

Figure 1 Preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2009 flow diagram

627

Figure 2a. Forest plot comparing the intervention and control groups in physical function

628

(n=49)

629 630 631

Figure 2b. Sensitivity analysis examining the effect of home-based rehabilitation on physical function without a large effect size (≧2). (n=43)

632 633

29

Table 1 Study participant characteristics of the included randomized controlled trials Sample Size (E/C)

Women (%)

Mean age (SD)

Episode of stroke 1

Type of Stroke 2

Days after the onset of stroke

Assessment3

Location

1.Anderson et al (2000)

42/44

44.2

71.5(11.0)

Mix

Mix

Unclear

Post

Australia

2.Baskett et al (1999)

44/46

43.0

69.8(10.6)

Mix

Unclear

Acute stroke

Post

New Zealand

3.Bjorkdahl et al (2006)

30/29

25.4

49.3( 9.3)

First

Mix

Unclear

Post, 3m,12m

Sweden

4.Cao et al (2016)

48/52

37.0

63.9(14.2)

Unclear

Mix

> 2 weeks

Post

China

5.Chaiyawat et al (2009)

30/30

55.0

66.5(10.5)

Unclear

Ischemic

> 3 days

Post, 24m

Thailand

6.Chen (2006)

25/20

37.8

66.7( 6.6)

Unclear

Mix

< or >12m

Post

China

7.Chen et al (2015)

40/40

35.0

64.3

First

Mix

30-180 days

Post

China

8.Donnelly et al (2004)

59/54

57.0

75.0( 8.2)

Unclear

Unclear

Unclear

ND, 12m

UK

9.Duncan et al (1998)

10/10

ND

67.6( 8.5)

Unclear

Mix

30-90 days

Post

USA

10.Fan et al (2009)

40/40

33.8

61.1(11.3)

Unclear

Mix

Unclear

Post

China

11.Fang and Wang (2017)

40/40

31.3

51.4( 1.3)

Unclear

Mix

15.7±5.7

Post

China

12.Gao et al (2015)

19/21

27.5

62.9(13.0)

First

Mix

Unclear

Post

China

13.Gilbertson et al (2000)

67/71

56.5

71.0(44.9)

Unclear

Mix

Unclear

Post, 6m

UK

14.Gladman et al (1993)

162/165

47.0

70

Unclear

Unclear

≥ 7 days

6m

UK

15.Gjelsvik et al (2014)

60/55

ND

ND

Mix

Mix

≥ 7 days

ND, 3m

Norway

16.Hu et al. (2015)

32/29

39.3

61.7( 7.7)

Unclear

Unclear

6-24m

Post

China

17.Huang (2014)

72/72

47.2

70.8( 8.7)

First

Mix

Unclear

Post

China

18.Huang et al (2011)

51/50

ND

ND

First

Unclear

< 3m

Post

China

19.Koc (2015)

35/37

ND

67.0

Unclear

Ischemic

30-90 days

Post

Turkey

Author (Year)

20.Li (2013)

60/60

26.7

63.8

Unclear

Unclear

Unclear

Post

China

21.Li et al (2011)

40/40

40.0

65.0( 8.6)

First

Mix

≦3m

Post

China

22.Liao (2014)

38/37

46.7

55.3( 3.7)

Unclear

Mix

Unclear

Post,12m

China

23.Lin et al (2004)

9/10

31.6

62.1(10.3)

Mix

Mix

> 12m

Post

Taiwan

24.Lincoln et al (2004)

90/103

47.3

72.0(11.5)

Unclear

Unclear

Unclear

6m

UK

25.Liu et al (2017)

40/40

48.8

70.8(1.5)

Unclear

Unclear

Unclear

Post

China

26.Luo et al (2011)

28/30

50.0

59.9(7.3)

Mix

Mix

< 2m

Post

China

27.Mao and Tang (2016)

40/40

35.0

69.8(5.7)

Unclear

Mix

Unclear

Post

China

28.Mayo et al (2000)

58/56

32.5

69.9(12.7)

Unclear

Unclear

>28days

Post, 3m

Canada

29.Morgan et al (2002)

18/18

ND

ND

First

Ischemic

5-14 days

Post

Mumbai

30.Ozdemir et al (2001)

30/30

33.3

60.5( 7.7)

Mix

Mix

10-82 days

Post

Turkey

31.Pan et al (2017)

25/25

42.0

70.3(13.1)

Unclear

Mix

Unclear

Post

China

32.Rasmussen et al (2016)

31/30

57.7

78.2(10.0)

Unclear

Unclear

Unclear

Post

Denmark

33.Roderick et al (2001)

54/58

53.6

79.0

Mix

Unclear

Unclear

Post

UK

34.Santana et al (2017)

92/93

46.8

67.0( 7.8)

Unclear

Unclear

Unclear

Post, 6m

Portugal

35.Shan et al (2015)

30/30

ND

ND

Unclear

Unclear

Chronic stroke

Post

China

36.Walker et al (1999)

84/79

49.2

74.3( 8.4)

Mix

Unclear

< 1m

Post

UK

37.Wang (2005)

146/52

47.0

62.6(8.2)

First

Unclear

Unclear

Post

China

38.Wang et al (2010)

100/100

41.0

65.8( 8.4)

Mix

Mix

33.1±5.9

Post

China

39.Wang et al (2015)

25/26

41.2

63.7(10.2)

Unclear

Mix

>6m

Post

Taiwan

40.Wang et al (2016) 41.Widen Holmqvist et al (1998)

30/30

43.3

ND

First

Mix

Unclear

Post

China

41/40

45.7

71.7( 8.3)

Mix

Mix

> 12m

Post, 3m

Sweden

1

42.Wolf et al (2000)

10/9

58.1

74

Mix

Unclear

Unclear

ND, 12m

London

43.Xia and Zhu (2004)

26/24

34.0

54.6( 7.7)

Unclear

Mix

15.0±7.1

Post

China

44.Xiao (2013)

68/68

45.6

62.5(10.3)

Unclear

Unclear

1-3m

Post

China

45.Yang (2011)

30/26

ND

ND

Unclear

Unclear

Chronic stroke

Post

China

46.Yang et al (2016)

56/56

37.5

66.9( 6.9)

Unclear

Mix

Unclear

Post

China

47.Young and Foster (1992)

57/50

44.4

72.6 ( 7.1)

Mix

Unclear

< or ≥12wks

Post, 6m

UK

48. Zhang et al (2012)A

30/30

28.3

57.8

Unclear

Mix

Unclear

Post

China

49. Zhang et al (2012)B

57/53

ND

ND

First

Unclear

2-12m

Post, 12m

China

2

3

Episode of stroke: first, recurrent stroke, or mix; type of stroke: ischemic or hemorrhagic stroke, or mix; assessment: post, post treatment and follow-up after the completion of intervention Abbreviation: m, month; ND, no data; UK, United Kingdom; USA, United States of America

Table 2 Study characteristics of the included randomized controlled trials

1.Anderson et al (2000)

Type of service Home visit

Type of rehabilitation ADL training

Total times 1-19

2.Baskett et al (1999)

Home visit

ADL training

3.Bjorkdahl et al (2006)

Home visit

4.Cao et al (2016)

Author (Year)

Weeks

Practitioner

Caregiver

Environment

Group

Yes

Yes

13

Mean:5wk 1~19wks 13wks

Group

Yes

Yes

ADL training

9hrs

3wks

Group

Yes

Unclear

Home visit

ADL training

12

3m

Group

Yes

Yes

5.Chaiyawat et al (2009)

Home visit

3

3m

PT

Yes

Unclear

6.Chen (2006)

Home visit

PT/OT/ ADL training ADL training

24

3m

Group

Yes

7.Chen et al (2015)

Home visit

ADL training

54

6m

Nurse

8.Donnelly et al (2004)

Home visit

PT/OT

30

3m

9.Duncan et al (1998)

Home visit

Exercise

24

10.Fan et al (2009)

Home visit

ADL training

11.Fang and Wang (2017)

Home visit

12.Gao et al (2015)

Control

Instrument

Hospital Rehabilitation Hospital Rehabilitation Hospital Rehabilitation Usual care

MBI

BI

Yes

OPD Rehabilitation Usual care

Yes

Unclear

No treatment

ADL

Group

Yes

Yes

BI

8wks

Group

Unclear

Unclear

Hospital Rehabilitation Usual care

14

17m

Therapist

Yes

Yes

Usual care

BI

ADL training

1/weekly

ND

Nurse

Yes

Unclear

Usual care

MBI

Home visit

ADL training

4

4wks

Group

Yes

Yes

Usual care

ADL

13.Gilbertson et al (2000)

Home visit

ADL training

10

6wks

Therapist

Unclear

Yes

BI

14.Gladman et al (1993)

Home visit

Rehabilitation

ND

6m

Group

Unclear

Unclear

15.Gjelsvik et al (2014)

Home visit

ND

5wks

Group

Unclear

Unclear

16.Hu et al (2015)

Home visit

PT/OT/ ADL training ADL training

8

2m

Group

Yes

Yes

OPD Rehabilitation Hospital Rehabilitation OPD Rehabilitation No treatment

17.Huang (2014)

Home visit ADL training plus phone interview Home visit ADL training

14

3m

Group

Yes

Unclear

Usual care

BI

7

3m

Group

Yes

Yes

Usual care

ADL of SIS

18.Huang et al (2011)

BI FIM MBI

BI

PF of SF-36

BI ADL of NRS MBI

19.Koc (2015)

Home visit

Exercise

24

3m

Nurse

Unclear

Unclear

BI

Yes

Health education No treatment

20.Li (2013)

Home visit

ADL training

6-12

6m

Nurse

Yes

21.Li et al (2011)

Home visit

Rehabilitation

8

3m

Group

Unclear

Unclear

No treatment

MBI

22.Liao (2014)

Home visit

Rehabilitation

ND

12m

Therapist

Yes

Yes

Usual care

MBI

23.Lin et al (2004)

Home visit

10

24.Lincoln et al (2004)

Home visit

PT/ ADL training Rehabilitation

10wks

PT

Yes

Unclear

No treatment

BI

ND

6m

Group

Unclear

Unclear

BI

ADL training

ND

ND

Nurse

Yes

Yes

OPD Rehabilitation Usual care

25.Liu et al (2017)

Home visit

26.Luo et al (2011)

Home visit

ADL training

14

6m

Therapist

Yes

Unclear

MBI

27.Mao and Tang (2016)

Home visit

ADL training

12-20

3m

Unclear

Yes

Unclear

OPD Rehabilitation Usual care

28.Mayo et al (2000)

ND

4wks

Group

Unclear

Unclear

OPD Rehabilitation

BI

29.Morgan et al (2002)

Home visit PT/OT plus phone interview Home visit ADL training

5

10wks

OT

Yes

Yes

Rehabilitation

MBI

30.Ozdemir et al (2001)

Home visit

Exercise

ND

Group

Yes

Unclear

Rehabilitation

FIM

31.Pan et al (2017)

Home visit

ADL training

1time/ weekly ND

5m

Group

Unclear

Unclear

Usual care

BI

32.Rasmussen et al (2016)

Home visit

ADL training

4-20

1m

Group

Yes

Yes

Rehabilitation

MBI

33.Roderick et al (2001)

Home visit

PT/OT

ND

6m

Group

Unclear

Unclear

34.Santana et al (2017)

Home visit

8

1m

Group

Yes

Yes

35.Shan et al (2015)

Home visit

PT/OT ADL training ADL training

72

6m

Group

Yes

Yes

Day hospital BI Rehabilitation OPD FIM Rehabilitation Usual care BI

36.Walker et al (1999)

Home visit

ADL training

ND

5m

OT

Yes

Unclear

Usual care

BI

37.Wang (2005)

Home visit

Rehabilitation

19

36m

Group

Yes

Unclear

No treatment

ADL

38.Wang et al (2010)

Home visit ADL training plus phone interview

14

3m

Researcher

Yes

No

Usual care

FIM

BI

ADL

BI

39.Wang et al (2015)

Home visit

40.Wang et al (2016)

12

12wks

PT

Yes

Unclear

Usual care

BI

Home visit ADL training plus phone interview Home visit ADL training

8

6m

Group

Yes

Yes

Usual care

BI

ND

3m

Group

Yes

Unclear

ADL

Home visit

Rehabilitation

ND

3m

Group

Unclear

Unclear

OPD Rehabilitation Usual care

43.Xia and Zhu (2004)

Home visit

ADL training

8

2m

Therapist

Yes

Yes

No treatment

MBI

44.Xiao (2013)

Home visit

ADL training

72

6m

Group

Yes

Yes

No treatment

BI

45.Yang (2011)

Home visit

ADL training

72

6m

Group

Yes

Yes

Usual care

BI

46.Yang et al (2016)

Home visit

ADL training

ND

6m

Nurse

Yes

Unclear

Usual care

BI

47.Young and Foster (1992)

Home visit

PT

ND

8wks

PT

Unclear

Unclear

BI

48.Zhang et al (2012)A

Home visit

ADL training

6-12

6m

Nurse

Yes

Unclear

Day hospital Rehabilitation No treatment

49.Zhang et al (2012)B

Home visit

ADL training

28

6m

Group

Yes

Yes

No treatment

BI

41.Widen Holmqvist et al (1998) 42.Wolfe et al (2000)

ADL training

Abbreviations: ADL= Activities of daily living, BI=Barthel Index, FIM= Functional Independence Measure, MBI= Modified Barthel Index, m=month, ND = no data, NRS= Numerical Rating Scales; SF-36=Short-Form 36, SIS= Stroke Impact Scale

BI

BI

Table 3 Risk of bias assessment for the methodological quality of the included studies Author (Year) 1.Anderson et al (2000) 2.Baskett et al (1999) 3.Bjorkdahl et al (2006) 4.Cao et al (2016) 5.Chaiyawat et al (2009) 6.Chen (2006) 7.Chen et al (2015) 8.Donnelly et al (2004) 9.Duncan et al (1998) 10.Fan et al (2009) 11.Fang and Wang (2017) 12.Gao et al (2015) 13.Gilbertson et al (2000) 14.Gladman et al (1993) 15.Gjelsvik et al (2014) 16.Hu et al (2015) 17.Huang (2014) 18.Huang et al (2011) 19.Koc (2015) 20.Li (2013) 21.Li et al (2011) 22.Liao (2014) 23.Lin (2004) 24.Liu et al. (2017) 25.Lincoln et al (2004) 26.Luo et al (2011) 27.Mao and Tang (2016) 28.Mayo et al (2000)

Random sequence generation

Allocation concealment

Blinding of participants and personnel

Blinding of outcome assessment

Incomplete outcome data addressed

Selective reporting

L L ? ? L ? ? L L L L L L L L ? L ? L ? ? ? ? ? L ? ? L

L L L ? L ? ? L L ? ? ? L L L ? ? ? ? ? ? ? ? ? L ? ? L

? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? L ? ? ? ? ?

L L L ? H ? ? L ? ? ? ? L L L ? ? ? ? ? ? ? L ? ? ? ? L

L H H L H L L H ? L L L L H H H L L L ? L L L L H ? L H

? ? ? ? ? ? ? ? ? ? ? ? ? ? L ? ? ? ? ? ? ? ? ? ? ? ? ?

29.Morgan et al (2002) L 30.Ozdemir et al (2001) H 31.Pan et al (2017) ? 32.Rasmussen et al (2016) L 33.Roderick et al (2001) L 34.Santana et al (2017) L 35.Shan et al (2015) ? 36.Walker et al (1999) L 37.Wang (2005) ? 38.Wang et al. (2010) ? 39.Wang et al (2015) L 40.Wang et al (2016) L 41.Widen Holmqvist et al (1998) L 42.Wolfe et al (2000) L 43.Xia and Zhu (2004) ? 44.Xiao (2013) ? 45.Yang (2011) ? 46.Yang et al. (2016) ? 47.Young and Foster (1992) L 48.Zhang et al (2012)A ? 49.Zhang et al (2012)B H L=low risk, H=high risk, ?=Unclear risk of bias

L H ? L ? L ? L ? ? L ? L L ? ? ? ? ? ? H

? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?

? ? ? H L ? ? L ? ? L ? L L ? ? ? ? L ? ?

? ? L H H H L H L L L L L H L L L L H ? L

? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?

Table 4 Moderator analysis Variables

K

β

Hedges’ g

95% CI

p+

Study participant characteristics Age Gender (percentage of female ) Sample size

42

-0.04

-0.06, -0.03

< 0.001

41

-0.02

-0.03, -0.02

< 0.001 0.112

*

≦30

4

0.51

0.14, 0.87

> 30

45

0.84

0.65, 1.03* *

Episode of stroke

0.028

First

10

1.18

0.75, 1.60

Mix

12

0.57

0.24, 0.90*

3

1.99

0.58, 3.41

*

26

0.92

0.67, 1.18*

Type of stroke Ischemic Mix

0.144

Stage of stroke Acute Chronic

0.002 11

1.32

0.87, 1.77*

6

0.47

0.20, 0.75*

Location

< 0.001

Developed countries

17

0.23

0.12, 0.34*

Developing countries

32

1.12

0.88, 1.35*

Type of language

0.007

Chinese language

27

1.01

0.79, 1.22*

English language

22

0.55

0.31, 0.80*

Intervention details Type of service only home visit home visit plus phone Interview Type of rehabilitation Only ADL training ADL training plus PT/OT Only rehabilitation Exercise

0.171 45

0.84

0.64, 1.04*

4

0.53

0.14, 0.93*

32

0.88

0.69, 1.06

*

5

0.96

0.03, 1.88*

10

0.45

0.04, 0.86*

2

1.28

0.272

-0.29, 2.84

Weeks ≦18

0.378 28

0.68

0.45, 0.91

*

> 18

18

0.84

0.57, 1.11* *

Number of practitioner

0.089

Individual

19

0.94

0.68, 1.20

Group

29

0.65

0.43, 0.87* *

Control group

0.005

Active control

18

0.51

0.25, 0.77

Inactive control

31

0.98

0.79, 1.18*

Caregiver included

0.016

Yes

37

0.92

0.71, 1.13*

Unclear

12

0.48

0.20, 0.77*

Environment alteration

0.714

Yes

22

0.77

0.57, 0.98*

Unclear

27

0.84

0.55, 1.12*

Assessment of methodological quality Random sequence generation

0.005

Low risk

25

0.57

0.36, 0.79*

High and unclear risk

24

1.05

0.80, 1.30*

Allocation concealment

<0.001

Low risk

18

0.33

0.14, 0.51*

High and unclear risk

31

1.07

0.84, 1.29*

Blinding of outcome assessment

< 0.001

Low risk

15

0.23

0.11, 0.35*

High and unclear risk

34

1.07

0.84, 1.31* *

Incomplete outcome data addressed

*

0.025

Low risk

28

0.97

0.74, 1.19

High and unclear risk

21

0.59

0.34, 0.83*

p< 0.05 for within studies

+

p value for between studies

Identification

Records identified through database searching (n = 20575) PubMed (n = 3559) CINAHL (n = 694) Cochrane Library (n = 10799) Embase (n = 3129) CEPS (N=1194) CNKI (N=1200)

Additional records identified through reference lists of the included articles (n = 16)

Screening

Records after duplicates removed (n = 8440)

Eligibility

Full-text articles assessed for eligibility (n=68)

Included

Records screened (n=12151)

Studies included in quantitative synthesis (meta-analysis) (n=49) English (n=23) Chinese (n=26)

Records excluded (n=12083) Non-RCT (n=429) Non stroke patients (n=5092) Non home-based rehabilitation (n=6519) Non interesting outcome (n= 38) Review article (n=5) Full-text articles excluded, with reasons (n=19) Protocol (n=2) Only abstract published (n=3) Control group received home-based care (n=6) Unclear intervention program (n=3) Unclear control group (n=1) Unavailable data (n=4)

Figure 1 Preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2009 flow diagram

Figure 2a. Forest plot comparing the intervention and control groups in physical function (n=49)

Figure 2b. Sensitivity analysis examining the effect of home-based rehabilitation on physical function without a large effect size (≧2). (n=43)

References of included studies 1. Anderson, C., Rubenach, S., Mhurchu, C., Clark, M., Spencer, C., & Winsor, A. (2000). Home or hospital for stroke rehabilitation? results of a randomized controlled trial : I: health outcomes at 6 months. Stroke, 31(5), 1024-1031. 2. Baskett, J. J., Broad, J. B., Reekie, G., Hocking, C., & Green, G. (1999). Shared responsibility for ongoing rehabilitation: a new approach to home-based therapy after stroke. Clin Rehabil, 13(1), 23-33. doi: 10.1191/026921599701532090 3. Bjorkdahl, A., Lundgren, N. A., Grimby, G., & Stibrant, S. K. (2006). Does a short period of rehabilitation in the home setting facilitate functioning after stroke? A randomized controlled trial. Cerebrovascular diseases, 19 (Suppl 2), 27. 4. Cao, Q., Feng, S., Huang, S., Li, X., Lin, X., Tan, Y., & Xu, C. (2016). Study of home rehabilitation model and effectiveness analysis on stroke patients in rural area. Chinese Journal of Rehabilitation, 31(3), 190-192. 5. Chaiyawat, P., Kulkantrakorn, K., & Sritipsukho, P. (2009). Effectiveness of home rehabilitation for ischemic stroke. Neurology international, 1(e10), 36-40. 6. Chen, X. (2006). Effect of community-based-rehabilitation on activities of daily life and cognitive fuction in stroke patients. Chinese Journal of Clinical Rehabilitation, 10(32), 4-6. 7. Chen, H., Jing, S., & Pan, H. (2015). Evaluation of the effect of the community intervention on the ADL in the patients with cerebral apoplexy hemiplegia. Shanghai Medical & Pharmaceutical Journal, 36(10), 57-59. 8. Donnelly, M., Power, M., Russell, M., & Fullerton, K. (2004). Randomized controlled trial of an early discharge rehabilitation service. Stroke, 35(1), 127-133. 9. Duncan, P., Richards, L., Wallace, D., Stoker-Yates, J., Pohl, P., Luchies, C., . . . Studenski, S. (1998). A randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke. Stroke, 29(10), 2055-2060. 10. Fan, W., Ni, C., Wang, T., Chen, J., Chen, J., & Han, R. (2009). Long-tren effects of community-based rehabilitation on upper extremity function and activities of daily living in stroke patients Chinese Journal of Rehabilitation Medicine, 24(1), 68-71. 11. Fang, R., & Wang, Z. (2017). Influence of normative community-based rehabilitation treatment for motor fuction of stroke patients. Journal of Mathematical Medicine, 30(3), 325-327. 12. Gao, F., Huang, S., Yu, C., Fang, J., & Chou, H. (2015). Effect analysis of home nursing in patients with stroke. Medical Innovation of China, 12(31), 78-81. 13. Gilbertson, L., Langhorne, P., Walker, A., Allen, A., & Murray, G. D. (2000). Domiciliary occupational therapy for patients with stroke discharged from hospital: randomised controlled trial. BMJ, 320(7235), 603-606. 14. Gjelsvik, B. E. B., Hofstad, H., Smedal, T., Eide, G. E., Næss, H., Skouen, J. S., . . .

Strand, L. I. (2014). Balance and walking after three different models of stroke rehabilitation: Early supported discharge in a day unit or at home, and traditional treatment (control). BMJ Open, 4(5). doi: 10.1136/bmjopen-2013-004358 15. Gladman, JR, Lincoln, NB, Barer, DH. A randomised controlled trial of domiciliary and hospital-based rehabilitation for stroke patients after discharge from hospital. Journal of neurology, neurosurgery, and psychiatry 1993;56(9):960-966. 16. Hu, Y., Chen, Q., Wei, M., Huang, Z., & Ma, L. (2015). Effect of community rehabilitation education and family rehabilitation guidance on the daily living activities of stroke patients. Chinese Community Doctors, 31(33), 166-169. 17. Huang, H. (2014). Effect evaluation of rehabilitation nursing model of hospital-community-family in rehabilitation of patients with stroke. Medical Innovation of China, 11(11), 128-130. 18. Huang, C., Sun, J., Peng, A., Dong, Y., & Gao, Y. (2011). The effect of self-management mode on rehabilitation of patients with cerebral stroke in community nursing. Chinese Nursing Management, 11(3), 36-39. 19. Koç, A. (2015). Exercise in patients with subacute stroke: a randomized, controlled pilot study of home-based exercise in subacute stroke. Work, 52(3), 541-547. 20. Li, X. (2013). Analysis of brain patients discharged from follow-up care effect. Guide of China Medicine, 11(17), 459-461. 21. Li, X., Wang, L., Zhang, Q., Huang, W., & Lai, G. (2011). Effectiveness study of nursing by rehabilitation collaboration network among the stroke family in urban community. Journal of Nurses Training, 26(9), 773-776. 22. Liao, Y. (2014). Discussion of the role of two kinds of discharge follow-up in patients with stroke. The Medical Forum, 18(27), 3680-3681. 23. Lin, J. H., Hsieh, C. L., Lo, S. K., Chai, H. M., & Liao, L. R. (2004). Preliminary study of the effect of low-intensity home-based physical therapy in chronic stroke patients. Kaohsiung J Med Sci, 20(1), 18-23. doi: 10.1016/s1607-551x(09)70079-8 24. Lincoln, NB, Walker, MF, Dixon, A, et al. Evaluation of a multiprofessional community stroke team: a randomized controlled trial. Clinical rehabilitation 2004;18(1):40-47. 25. Liu, D., Liu, Y., Zou, W., & He, R. (2017). Effect of community rehabilitation on motor function and activities of daily living in patients with stroke. China's rural health, 2 , 82-83. 26. Luo, F., Cao, W., & Ma, D. (2011). 3 Models of rehabilitation service on stroke patients following hemiplegia in community. Chinese Journal of Rehabilitation Theory and Practice, 17(5), 473-475. 27. Mao, J., & Tang, F. (2016).The Effect of Community Rehabilitation Nursing in Patients with Stroke Sequelae. Today Nurse,9, 102-103. 28. Mayo, N., Wood-Dauphinee, S., Côté, R., Gayton, D., Carlton, J., Buttery, J., & Tamblyn, R. (2000). There's no place like home : an evaluation of early supported discharge for

stroke. Stroke, 31(5), 1016-1023. 29. Morgan, S., Kelkar, R., & Vyas, O. (2002). Client-centered occupational therapy for acute stroke patients. Indian Journal of Occupational Therapy, 34(1), 7-12. 30. Özdemir, F., Birtane, M., Tabatabaei, R., Kokino, S., & Ekuklu, G. (2001). Comparing stroke rehabilitation outcomes between acute inpatient and nonintense home settings. Arch Phys Med Rehabil, 82(10), 1375-1379. 31. Pan, X., Li, Q., Zhai, H., & Wang, Y. (2017). The effect study of community-based rehabilitation in improving the daily living ability and quality of life of patients with stroke sequelae. Medical Innovation of China, 14(13), 19-22. 32. Rasmussen, R., Ostergaard, A., Kjaer, P., Skerris, A., Skou, C., Christoffersen, J., . . . Overgaard, K. (2016). Stroke rehabilitation at home before and after discharge reduced disability and improved quality of life: a randomised controlled trial. Clin Rehabil, 30(3), 225-236. 33. Roderick, P., Low, J., Day, R., Peasgood, T., Mullee, M. A., Turnbull, J. C., . . . Raftery, J. (2001). Stroke rehabilitation after hospital discharge: a randomized trial comparing domiciliary and day‐hospital care. Age and Ageing, 30(4), 303-310. 34. Santana, S., Rente, J., Neves, C., Redondo, P., Szczygiel, N., & Larsen, T. (2017). Early home-supported discharge for patients with stroke in Portugal: a randomised controlled trial. Clin Rehabil, 31(2), 197-206. 35. Shan, S., Gao, L., Ge, X., & He, Q. (2015). Effect of community rehabilitation on activity of daily living in stroke patients. Heilongjiang Medicine Journal, 28(4), 887-889. 36. Walker, M., Gladman, J., Lincoln, N., Siemonsma, P., & Whiteley, T. (1999). Occupational therapy for stroke patients not admitted to hospital: a randomised controlled trial. Lancet, 354(9175), 278-280. 37. Wang, L. (2005). Neurologist participates in the community intervention for the functional prognosis convalescent patirnts with stroke. Chinese Journal of Clinical Rehabilitation, 9(17), 4-5. 38. Wang, A., Xu, G., Wu, Q., Liu, Y., & Ge, X. (2010). Influence of comprehensive nursing intervention on quality of life and activity of daily living in community patients with convalescent stroke. China Journal Practice Nursing, 26, 11-14. 39. Wang, T., Tsai, A., Wang, J., Lin, Y., Lin, K., Chen, J., . . . Lin, T. (2015). Caregiver-mediated intervention can improve physical functional recovery of patients with chronic stroke: a randomized controlled trial. Neurorehabilitation and neural repair, 29(1), 3-12. 40. Wang, F., Chen, X., Yan, X., Liu, W., Sun, X., Wang, L., & Sun, T. (2016). Effect of extended care on the rehabilitation of discharged stroke patients: a randomized controlled trial. China Journal Practice Nursing, 32(19), 1457-1461. 41. Widen Holmqvist, L., von Koch, L., Kostulas, V., Holm, M., Widsell, G., Tegler, H., . . . de Pedro-Cuesta, J. (1998). A randomized controlled trial of rehabilitation at home after

stroke in southwest Stockholm. Stroke, 29(3), 591-597. 42. Wolfe, CD, Tilling, K, Rudd, AG. The effectiveness of community-based rehabilitation for stroke patients who remain at home: a pilot randomized trial. Clinical rehabilitation 2000;14(6):563-569. 43. Xia, W., & Zhu, P. (2004). The effect of community rehabilitation on motor function of post-stroke patients. Clinical Journal of Medical Officer, 32(5), 97-98. 44. Xiao, X. (2013). Effects of community rehabilitation on recovery in patients with stroke and quality of life China Modern Medicine, 20(26), 162-163. 45. Yang, M. (2011). Effect of community rehabilitation on activity of daily living in stroke patients. Heilongjiang Medicine Journal, 24(3), 466-467. 46. Yang, Q., Mo, C., & Zheng, H. (2016). Influence of rehabilitation of nursing home guide to patients with sequelae of stroke in community. China Medicine and Pharmacy, 6(12), 128-130. 47. Young, J. B., & Forster, A. (1992). The Bradford community stroke trial: results at six months. BMJ, 304(6834), 1085-1089. 48. Zhang, Q., Li, J., & Luo, S. (2012). The effect evaluation of the family rehabilitation nursing intervention on the patients with stroke. International Journal of Nursing, 31(1), 56-57. 49. Zhang, R., Dong, X., Wu, C., Hao, L., Shao, J., & Ma, H. (2012). Influence of integrated community rehabilitation intervention on the activities of daily living and life satisfaction in stroke patients. Journal of Nursing (China), 19(1A), 67-70.