Empowering older patients
Facilitating family members to participate in rehabilitation empowered them to increase opportunities for physical activity, providing physical and psychosocial beneﬁts. Kate Lawler discusses this qualitative study, which is in the latest issue of the Journal of Physiotherapy.
Can you start by explaining the Transition Care Program?
Transition care is for older people who have been in hospital and need more time to get back on their feet and return home, or perhaps enter residential aged care for the ﬁrst time. It looks different from state to state, depending on other services available, but it will generally include nursing or personal care and low intensity therapy. What is meant by low intensity therapy has not been well deﬁned but usually there is a physiotherapy presence along with other allied health professionals and case managers.
Transition care might be delivered in the home, or in institutional settings such as hospital wards or residential aged care facilities. It is partly funded federally, so an aged care assessment team/service is required for entry. The time limit is 12 weeks, but the average length of stay is around ﬁve weeks.
Your first paper describes a randomised trial of family-assisted therapy where family members assisted with rehabilitation. How was that study designed?
We wanted to investigate whether family-assisted therapy would help improve physical outcomes for patients in transition care. People in the residential program are often sitting doing nothing, so we conducted the study there. The control group received usual care and the experimental group received family-assisted therapy in addition to usual care, over a four-week period.
Family-assisted therapy was tailored to patient goals. An initial session with patient, family member and a physiotherapist was used to deﬁne a main goal and choose one or two safe and speciﬁc exercises or activities that a family member could assist with. Depending on the circumstances of the participants—some patients were quite independent and cognitively intact, some family members were experienced caregivers or registered nurses— initial training was followed by another session a few days later, or a visit once a week, or even text messages and phone calls. Often walking was the activity of choice.
Outcomes were measured before and after the intervention and included falls during the intervention period, the Short Falls Efﬁcacy Scale- International, physical activity measured with an accelerometer ﬁxed to the thigh, the Modiﬁed Barthel Index, and health-related and capability-related quality of life. We also used the Modiﬁed Caregiver Strain Index to try and capture the impact on family members.
What were the results of the trial?
Seventeen patients and 20 of their family members participated in the experimental group, and 18 patients and 20 family members in the control group. Family-assisted therapy in addition to usual physiotherapy care increased daily steps taken, increased functional independence and may have reduced falls without increasing caregiver strain. There were no changes in falls-related self-efﬁcacy or quality of life.
The trial was small but it can give us conﬁdence that involving families in physiotherapy, with appropriate training and support, is likely to be a safe intervention for older people in this setting. It also looks like an effective intervention, which is something I’ve always worried about when considering involving busy family members in therapy.
And your second paper, published in the Journal, was linked to that paper. Can you explain how?
Families bring more to the table than an extra pair of hands. We knew it would be difﬁcult to capture this in a quantitative study, so we conducted interviews with patients and family members from the experimental group of the randomised trial, at the end of the intervention period. The Journal of Physiotherapy paper is an analysis of these interviews.
What were the views of the patients and family members about family-assisted therapy?
I had hoped participants would say that family-assisted therapy is the most fabulous way to increase physical activity. They did see both physical and psychosocial beneﬁts as an important part of the intervention. However, the greatest impact was that family-assisted therapy empowered families in what is usually a very disempowering setting. This approach gave family members a legitimate place in the healthcare team. It helped them to contribute to their family member’s recovery, helping with things like walking, without getting ‘in trouble’ from staff. It also enabled them to bring their lifetime history with the patient to help with things like motivation.
So they didn’t find it a chore; it was more of a welcome opportunity because it allowed them to contribute something to their family member’s recovery?
That’s right. Some families try to help anyway, but don’t know what to do, or are not permitted to do anything. So, having training and support was seen as valuable. However, I should point out that family-assisted therapy is not for everyone. We are planning to write a paper describing the barriers and facilitators to this approach.
Were any data collected in the trial that could be compared to the qualitative data?
Yes, for sure. We have included a table in the qualitative paper doing just that. We compared qualitative themes and subthemes with clinical outcomes and compliance with the trial method. The only aspect that didn’t ﬁt was around psychosocial beneﬁts to patients. Qualitative ﬁndings indicated that family-assisted therapy led to improvements in conﬁdence and independence. However, we found no difference in quality of life or falls self-efﬁcacy in the trial. This highlights the importance of choosing the right outcome measures, and decent follow-up periods. It also suggests that some things are best understood through qualitative approaches.
Kate Lawler is a physiotherapist with 20 years of experience working across acute, subacute and aged care settings. She completed her PhD through La Trobe University in 2019 investigating family- assisted therapy for people in transition care. She is passionate about the rights of older people to excellent care and is now a lecturer at the Wicking Dementia Research and Education Centre in Hobart.
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