Study design and participants

This retrospective study was conducted at the National Center for Geriatrics and Gerontology (NCGG), Aichi, Japan after obtaining approval from the local Ethics Review Committee (No. 1582–2). Medical records of outpatients who had received HBR from the NCGG between June 2016 and September 2022 were screened. Of these, individuals who were discharged from the convalescent rehabilitation ward and community-based integrated care ward of the hospital and had started HBR within one month after discharge which continued for at least six months were considered for inclusion into the study. Patients who could not be regularly assessed for motor function, ADL evaluation, and whose caregivers could not be evaluated for the burden of care during the period of HBR due to hospitalization or other reasons were excluded from the study. Regarding informed consent, opt-out consent procedures were adopted wherein the study protocol was disclosed via the hospital’s website and posters within the hospital to provide the patients with the opportunity to refuse participation.

Home-based rehabilitation program

Physical and occupational therapists provided the HBR program. Each patient received 1–2 sessions per week on average (40–60 min/session) for at least 6 months. At the beginning of each visit, vital signs, pain, edema, appetite, sleep status, and recent falls were assessed. Subsequently, each patient was provided with a personalized HBR program. Each program invariably provided functional training, promoted practice of ADLs and instrumental ADLs (IADLs), provided information and instruction regarding the use of assistive devices, encouraged social participation and setting further rehabilitation goals, provided instruction on daily exercises, and provided caregiver support (Table 1), with the proportion of time spent on each item varying depending on the patients’ characteristics and needs. The program was organized based on each patient’s goals and action plan, as assessed by the Canadian Occupational Performance Measure (COPM) [18], in collaboration with the physician and care manager.

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Table 1. Home-based rehabilitation program.

https://doi.org/10.1371/journal.pone.0316163.t001

Assessment of outcome measures

Basic characteristics collected from medical records included age, gender, disease, Japanese version of the Mini-Mental State Examination (MMSE-J), time from injury or disease onset to discharge from the hospital (hospitalization period), time from discharge to the start of HBR, and the number of people living with the patient. The data were accessed for research on December 23, 2022. The authors did not access any personally identifiable participant information during or after data collection.

The primary outcome was instrumental ADLs assessed using the Frenchay Activities Index (FAI) [19, 20], which consists of 15 items on ADLs, including social activities [0 (most inactive) to 45 (most active)]. The secondary outcomes included basic ADLs assessed using the 18-item Functional Independence Measure (FIM) [each scored 1 (severely dependent) to 7(independent), with total scores ranging 7–135] [21–23]; motor function assessed using grip strength [24]; the 5-repetition sit-to-stand test (5-rep STS test) [25] for muscle strength and Standing test for Imbalance and Disequilibrium (SIDE) for postural balance ability [0 (unable to stand), 1, 2a, 2b, 3, 4 (able to stand on one foot)] [26]; and caregiver burden measured using the 22-item Zarit Caregiver Burden Interview (J-ZBI) [0 (lightest) to 88 (heaviest)] [27, 28]. These outcome measures were assessed at baseline and after 3 and 6 months.

Statistical analysis

Scores for each indicator were compared at the three time points using repeated measures one-way ANOVA for continuous variables and the Friedman test for ordinal variables. Two-tailed Student’s t-test and Wilcoxon signed rank test were used for post-hoc analysis, respectively, with Bonferroni adjustment to correct for p-values (p-values were multiplied by the number of tests). All statistical analyses were performed using SPSS (version 26; IBM Corp., Armonk, NY, USA). Statistical significance was set at p < 0.05.

Impact on motor function

We observed significant improvements in all measures of motor function after 6 months of HBR, which concurs with the results of previous studies on elderly people living in the community [29, 30]. HBR, including functional training of the upper and lower limbs and postural balance exercises for 40 weeks, in stroke patients at least 6 months after stroke onset, led to significant improvements in the 5-rep STS test and Tinetti’s Balance Scale [29]. In another study, physical therapists visited patients with hip fractures approximately 9.5 months after the injury, distributed an exercise program, asked them to record their exercise, and conducted regular monitoring for 6 months [30]. They noted improvements in the Short Physical Performance Battery and the Activity Measure for Post-Acute Care, both of which assess motor function and mobility. The participants included in this study had a shorter post-onset/injury period than those in the aforementioned studies. Given that motor recovery is generally more evident in the early post-onset/injury period, it can be reasonably assumed that continued HBR would promote improvement in motor function. Notably, the current study showed that the effects of HBR on motor function persist after intensive inpatient rehabilitation, during which the maximum possible extent of rehabilitation is provided. Presumably, encouraging frequent performance of exercises in daily life, including days where the therapist does not visit—an essential component of the HBR program—may effectively improve motor function.

Impact on ADLs and IADLs

Significant improvements in independence in ADLs and IADLs were observed, which began as early as 3 months after initiating HBR. Similar findings have been reported in previous studies on the effects of HBR on ADLs and IADLs for chronic patients which advocate for tailored rehabilitation programs designed according to the patient’s condition and goals [2, 4, 31–33]. The present study further corroborates that patients can regain independence in ADLs earlier with HBR immediately after discharge. This result can be attributed to the HBR program designed according to the patient’s condition and goals. Environmental adjustments, such as the installation of nursing beds, shower chairs, chairs for dressing and undressing shoes, handrails near steps and doors, evaluation and suggestion of walking aids, and reduction of steps and thresholds in the room are some of the characteristic features of HBR that cannot be attained only with inpatient rehabilitation [34]. Therefore, these interventions tend to facilitate functional recovery even in patients who have undergone intensive inpatient rehabilitation.

Impact on caregiver burden

Another important effect of HBR is the reduction in the caregiver burden. Our findings showed an improvement in the J-ZBI score after 6 months of HBR. Although similar results have been reported with HBR programs for community-dwelling stroke patients [31], the current study emphasizes that these positive effects of HBR from the caregivers’ perspective can be attained soon after discharge from inpatient rehabilitation. Two key aspects facilitate these results. First, improvements in the patient’s motor function through functional training and environmental adjustments implemented during HBR enable early independence in ADLs and increase the frequency of participation by the patients [31, 35]. Second, family guidance provided to caregivers reinforce positive attitudes when dealing with daily problems, as is observed with patient education and motivational interviewing [36].

Benefits of HBR program early after discharge from the hospital

This study draws attention to the favorable effects of initiating HBR promptly after discharge from the hospital for patients who received inpatient rehabilitation. Notably, even after receiving inpatient rehabilitation for approximately 3 months, HBR immediately after discharge helped regain functional recovery. Given that previous studies have reported functional decline in the medium to long term after discharge [12, 16, 37], our findings carry tremendous significance for patients’ lives after discharge. Overall, our results showed that implementation of HBR early after discharge could be effective for two reasons. First, making environmental adjustments and sharing rehabilitation goals and progress with family members could help patients cope with “over-care by caregivers” and “refraining from activities to prevent falls,” which are the primary reasons for the decline in ADLs [16]. Second, evidence has shown that patients cannot completely regain their pre-onset/injury functional state even after intensive inpatient rehabilitation [38, 39]. This could be possibly considered as a potential for further improvement. Therefore, continuous HBR among patients who could not be sufficiently convalesced during hospitalization may have promoted functional recovery, which ultimately reduced caregiver burden.

The study had certain limitations. First, according to our hospital’s protocol, it was not possible to have a control group that did not receive HBR, so the results could not be compared with the natural follow-up after discharge from the hospital. Second, the exact number of total HBR visits or sessions on certain activities (e.g., functional training or ADL training) per participant could not be obtained from the existing data. Hence, future studies should analyze the relationship between the total time spent on a specific training and its effectiveness. Lastly, because the study was conducted at a single hospital, potential bias due to the hospital’s environment and characteristics cannot be ruled out. Nevertheless, this study offers clinically meaningful results to verify the effects of continuous HBR immediately after discharge. The results of this study suggest that immediate and subsequent HBR should be provided even after intensive inpatient rehabilitation. The next step would be to identify the characteristics of patients who are more or less likely to benefit from HBR.