Knowledge Translation and
Implementation Special Series

J. Richardson, PhD, School of
Rehabilitation Science, Faculty of
Health Science, McMaster University, IAHS Room 403, 1400 Main
St W, Hamilton, Ontario, Canada
L8S 1C7. Address all correspondence to Dr Richardson at:
jrichard@mcmaster.ca.

A. Officer, MScPT, School of
Rehabilitation Science, Faculty of
Health
Science,
McMaster
University.
S. Wilkins, PhD, School of Rehabilitation Science, Faculty of Health
Science, McMaster University.
L. Letts, PhD, School of Rehabilitation Science, Faculty of Health Science, McMaster University.
J. Bosch, PhD, School of Rehabilitation Science, Faculty of Health
Science, McMaster University.
L. Wishart, PhD, School of
Rehabilitation Science, Faculty of
Health
Science,
McMaster
University.
[Richardson J, DePaul V, Officer A,
et al. Development and evaluation
of Self-Management and Taskoriented Approach to Rehabilitation Training (START) in the
home: case report. Phys Ther.
2015;95:934 –943.]
© 2015 American Physical Therapy
Association

Julie Richardson, Vincent DePaul, Alexis Officer, Seanne Wilkins, Lori Letts,
Jackie Bosch, Laurie Wishart

Background. The incidence of stroke and subsequent level of disability will
increase, as age is the greatest risk factor for stroke and the world’s population is
aging. Hospital admissions are too brief for patients to regain necessary function.
Research to examine therapy delivered within the home environment has the potential to expedite relearning of function and reduce health care expenditures.
Purpose. This case report describes the use of the knowledge-to-action cycle
(KTA) to develop and evaluate an evidence-based approach for rehabilitation in the
home that incorporates self-management and task-oriented functional training
(TOFT) for people with stroke.

Case Description. The KTA cycle was used to guide adaptation of evidence
from self-management and TOFT into an approach titled START (Self-Management
and Task-Oriented Approach to Rehabilitation Training). Three stakeholder symposiums identified barriers and supports to implementation. Clinical practice leaders
were engaged as partners in the development of the intervention. An online learning
management system housed the resources to support therapist training. Therapist
focus groups were conducted and stroke outcomes were used to assess patient
response.
Outcomes. Eight therapists completed 4 workshops and applied the home intervention in 12 people with stroke. A mentoring process for therapists included
feedback from peers and experts after viewing treatment videos. Therapist response
was determined from the focus groups; patient response was measured by standardized assessments. The therapists noted that the intervention was easier to implement
with patients who were motivated and had minimal cognitive impairment.

Discussion. The KTA cycle provided a structure for the development of this
evidence-based rehabilitation intervention, which was feasible to implement in the
home. Further evaluation needs to be undertaken to assess the effectiveness of
START.

Published Ahead of Print:
February 26, 2015
Accepted: February 17, 2015
Submitted: December 22, 2013

Post a Rapid Response to
this article at:
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V. DePaul, PhD, School of Rehabilitation Science, Faculty of Health
Science, McMaster University, and
Department of Physiotherapy,
St Joseph’s Healthcare Hamilton,
Hamilton, Ontario, Canada. Dr
DePaul’s primary affiliation is currently the Toronto Rehabilitation
Institute–University Health Network, Toronto, Ontario, Canada.

Development and Evaluation of
Self-Management and Task-Oriented
Approach to Rehabilitation Training
(START) in the Home: Case Report

Development and Evaluation of START

T

The purpose of this case report is to
demonstrate how the knowledge-toaction (KTA) cycle9 was used to
adapt the best-available evidence
into a framework titled START (SelfManagement and Task-Oriented
Approach to Rehabilitation Training), an intervention that physical

* A framework, in this context, is a conceptual
organization that explains the relationship
among the key factors, concepts, or variables
in a manualized intervention.

June 2015

therapists and occupational therapists delivered to people with stroke
in their home environment. The
START intervention incorporates selfmanagement and task-oriented functional training (TOFT) principles to
address patient goals. Specifically,
the goal of the case report was to
develop an intervention to optimize
physical function and self-management skills for patients with stroke.

Case Description
The project was undertaken using
the steps outlined in the KTA cycle
(Fig. 1). The emphasis for this project was on the action phase of the
cycle because we relied on the
investigators, who were content
experts and provided the evidence
about motor learning and selfmanagement. All participants (both
therapists and patients) provided
written informed consent prior to
enrollment in this project. Hamilton
Health Sciences/Faculty of Health
Sciences Research Ethics Board
reviewed the project and granted
ethics approval (REB#08-596).
Step 1. Identification of the
Problem
Rehabilitation in the home environment is under-researched. A review
showed that HBSR improved independence in ADL; however, the nature and content of the therapy was
unclear.10 Studies have attempted to
explore the meaning and content of
HBSR from the patient’s and therapist’s perspectives.11,12 Therapists
often provide HBSR instinctively,
without explicit or propositional
knowledge.11,12 An explicit explanation rather than a tacit understanding
is imperative for communication
between therapists and students, and
for communication with patients. By
articulating the underlying concepts
and sharing knowledge about the
intervention being delivered, it can
be adapted in different contexts,
contributing to the ongoing development of the intervention itself.13

Relative to in-hospital rehabilitation,
patients in the home environment
assume responsibility, influence, and
control for the rehabilitation process
while therapists use creativity to
guide and develop each patient’s
problem-solving skills pertinent to
his or her unique environment and
roles.11,12 The use of social cognitive
theory with motor learning to
explain the therapist’s role within
the home using skilled teaching and
patient learning may further explicate the meaning and added value of
HBSR.14 The home environment may
allow for more efficient learning
through the use of meaningful taskpractice conditions to explore challenges and promote problem-solving
skills.15 The rationale for HBSR
rather than institution-based rehabilitation includes the importance of
relearning functioning within an ecologically valid environment, expedited reintegration, and potential
cost savings.
Step 2. Identify, Review, and
Select Knowledge to Adapt to
Local Context
Two investigators (J.R., L.L.) met
with the clinical leaders of Community Rehab (providers of in-home
therapy services) to explore the
components of practice in the home
and to develop an understanding
about the process of care on which
to develop HBSR. A review of evidence related to self-management
and task-oriented functional training
was undertaken by the experts on
the project team, who then developed a training manual detailing the
home-based intervention, which the
therapists received.

Available With
This Article at
ptjournal.apta.org
• eAppendix: Supplemental
Figures and Tables

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he disability associated with
stroke will increase, as age is
the strongest predictive risk
factor for stroke and the segment of
the population ⱖ65 years of age in
North America is growing quickly.1
Once medically stable poststroke,
most patients with residual deficits
in physical function and mobility
would prefer to reside at home with
access to rehabilitation services. Evidence from early supported discharge (ESD) studies is inconclusive,
and sample sizes are typically small.2
However, they have shown a reduction in length of hospital stay and
admissions to long-term care facilities, improvements in activities of
daily living (ADL), and increased satisfaction in older patients with moderate disability.3–5 A consensus document outlines team composition,
model of team work, intervention,
and criteria for success.6 A larger trial
is needed using an evidence-based
intervention to focus on whether
ESD to home is superior to hospitalization, with consideration given to
functional and economic outcomes7
and to identifying the determinants
within the home that contribute to
successful outcomes.8 A precursor to
such a study is the development of a
framework* for evidence-based
home-based stroke rehabilitation
(HBSR). In this case report, we outline the development of an evidencebased rehabilitation framework that
incorporates both self-management
and task-oriented training.

Development and Evaluation of START

Development of the Self-Management and Task-Oriented Approach to Rehabilitation Training (START) using the knowledge-toaction cycle. KT⫽knowledge translation. *Four half-day sessions: practice with standardized patients and patients with stroke.
Adapted from Graham ID, Logan J, Harrison MB, et al. Lost in knowledge translation: time for a map? J Contin Ed Health Prof.
2006;26:13–24, with permission of Wiley & Sons Inc.

Developing the START model.
The development of the START
model is illustrated in Figure 2. The
targeted patient population was able
to identify goals and participate in
the development of action plans.
The principles of both components
(self-management and TOFT) were
the same as outlined in the literature,
and the adaptation occurred in the
implementation. For example, a
patient who identified the goal of
increasing upper extremity function
chose to do this by practicing folding
clothes (TOFT), making the application ecologically valid. Patients
chose self-management strategies
that were most relevant to the issues
they were having (ie, improving
posture, managing challenging emotions, finding resources) (see Tab. S3
in the eAppendix, available at
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ptjournal.apta.org, for a complete
list of self-management strategies).
Evidence for self-management.
Secondary sequelae such as depression, fatigue, and difficulty sleeping
contribute to the burden of stroke
and are often not well addressed in
rehabilitation; they may limit the
benefits of physical rehabilitation interventions.16 The Stanford
Chronic Disease Self-Management
Program (CDSMP) was designed
to provide a generic approach to
self-management.17
The
selfmanagement component of the
intervention, based on social cognitive theory,18 addressed lifestyle
modification to manage the ongoing
sequelae of stroke (eg, fatigue, difficult emotions, lifestyle changes) and
risk factors for future stroke. Failure

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to address these issues could reduce
participation in the rehabilitation
process. A person with stroke needs
to make lifestyle changes inherent in
living with a chronic condition and
self-manage the symptoms, the treatment, and the physical and psychosocial consequences of the stroke.
Thus, a dynamic and continuous process of self-regulation is established.
Clinical trials of these programs
show significant improvement in frequency of health behaviors, health
efficacy, health status, and reduced
hospitalizations in people with
chronic
conditions,
including
stroke.19,20 Recently, a strokespecific self-management program
was pilot tested with 47 survivors of
stroke,21 and the randomized controlled trial (N⫽143) showed greater
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Figure 1.

Development and Evaluation of START
Key principles of TOFT in START
include: (1) set meaningful functional goals with the patient; (2)
practice meaningful, challenging,
and functional tasks; (3) maximize
the amount of practice; and (4) the
patient is a problem solver. (For
details about how these principles
were implemented, see Fig. A2 in the
eAppendix.)

Self-Management and Task-Oriented Approach to Rehabilitation Training (START)
model.

completion and participation rates
than with the generic program,
reduced depression and anxiety, and
greater engagement in life compared
with the standard care group. Participants reported improved community re-engagement and quality of
life.22 Other stroke-specific group
self-management programs have
been described but not evaluated.23,24
The key principles of selfmanagement in START are: (1) goal
setting and action planning, (2) problem solving, (3) self-monitoring, (4)
establishing self-efficacy, and (5)
applying strategies to break the
symptom cycle (for details about
how these principles were implemented and adapted, see Fig. A1 in
the eAppendix).
Evidence for TOFT. Task-oriented
functional training is an approach to
retraining skills to optimize function
for patients following stroke. It is
based on contemporary motor learning and motor control theories
supported
by
neuroplasticity
research.14,25,26 Movement emerges
as an interaction among different sysJune 2015

tems and is organized in response to
a behavioral goal, constrained by the
environment.15 Therefore, the focus
of therapeutic interventions to
retrain movement control is intensive practice of purposeful, challenging tasks and problem solving rather
than the restoration of movement
patterns.15 The SCORE (Stroke Canada Optimization of Rehabilitation
Through Evidence) Evidence-Based
Recommendations for the Upper
and Lower Extremities and Risk
Assessment Post-Stroke (2007)27,28
states that, according to Level I (randomized controlled trials) evidence:
• Training techniques should use the
involved limb in “repetitive and
intense use of novel functional
tasks and activities.”
• Patients should practice skills in
their daily routine.29
• Interventions should include taskspecific training and motor learning29,30 and functional training.31,32
• The target population is patients
with some voluntary movement
who have achievable functional
goals through motor remediation
and the capacity to participate in
goal setting and self-evaluation.

Learning management system.
An open source e-learning software
platform called Moodle (Modular
Object-Oriented Dynamic Learning

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Figure 2.

Resources for therapist training.
We developed a training manual that
outlined the key principles of
START, which included a summary
of the supporting literature on motor
learning principles. Based on the literature, the components of TOFT
were summarized in a guideline for
therapists (see Tab. S1 in the
eAppendix). A cue card (see Tab. S2
in the eAppendix) was developed
that outlined the components of
motor learning principles for therapists to consider when designing the
tasks and planning schedules of practice. Forms were created to record
the patient’s goals, tasks, practice
plan, action plans, and daily practice.
The self-management component of
the manual was a derivative of the
Stanford CDSMP.17 It outlined an
individualized approach to selfmanagement for people with stroke
that therapists could deliver in the
home. As an active self-manager, the
patient’s goal was to become proficient at role management (ie, carrying out normal activities such as
chores, employment, social life, and
leisure), emotional management (ie,
coping with challenging emotions as
a result of illness), and physical management (ie, taking care of the
patient’s health care problem, exercising, changing the patient’s diet).
(For details of the self-management
component of the manual, see Tab.
S3 in the eAppendix.)

Development and Evaluation of START

Step 3. Assess Barriers to Local
Use of Knowledge
The details of this portion of the KTA
process and results will be reported
elsewhere. In summary, we held 3
stakeholder symposiums in which
we described the project, received
input about the system barriers, and
discussed the implications for both
future practice and the health care
delivery of HBSR as part of the continuum of care. There were 8 stakeholders from different health care
sectors, including a provincial stroke
organization, an acute care institution providing stroke care, a regional
government organization, and a
home care service organization. The
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barriers identified at a system level
were related to the delivery of stroke
care in silos rather than as an integrated approach, the difficulty
in funding the number of visits
required to deliver the intervention,
and the allocation of funding dollars
to nursing and medicine rather than
to rehabilitation.
Step 4. Select, Tailor, and
Implement the Intervention
Involvement of PPLs. The occupational therapist and physical therapist PPLs from the partner agency
helped develop the project materials
and the intervention guidelines.
They also provided input as to how
the intervention should be applied in
the context of their regular practice.
Following 4 half-day training sessions
(which covered the background,
purpose, and methods of the project; the mode; and key principles of
the intervention), the PPLs pilot
tested the intervention with a simulated patient in her home, and videotapes were made to train the
therapists.
Therapist recruitment and training. Eight therapists (4 physical
therapists and 4 occupational therapists) were recruited by the PPLs,
forming 4 dyads each with an occupational therapist and a physical
therapist. Three physical therapists
and 1 occupational therapist withdrew from the project following the
initial training sessions, requiring the
training of 4 additional therapists.
The reasons for discontinuing were
provided by the therapists and are
shown in Figure A3 of the
eAppendix.
Therapist training sessions. Four
training sessions (each 3 hours)
were held at McMaster University
attended by the therapists and PPLs.
During the sessions, therapists were
provided with an overview of the
project (intervention rationale, evidence, principles, and interface

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between
self-management
and
TOFT), the intervention manual, a
review of the documentation processes, and instructions for using the
Web-based learning platform. Working in dyads, they practiced and
were videotaped using these principles with patients with stroke and
with a standardized patient. Investigators and PPLs provided guidance
and feedback to the therapists.
Finally, the therapist dyads delivered
the intervention in the home, selecting 2 sessions to be videotaped for
use in the mentoring process (see
Fig. A3 in the eAppendix).
Step 5. Monitor Knowledge Use
and Evaluate Outcomes
Each dyad of therapists treated 3 or 4
patients in the home, and each profession was allocated 10 visits per
patient. The first 2 in-home visits
were focused on TOFT, and selfmanagement was introduced during
the third visit. Joint visits occurred
when appropriate; both therapists
delivered the TOFT, and one therapist led the self-management component. Patients were included if they
met the following criteria: time since
stroke ⱖ6 months, diagnosed with
first ischemic stroke (preferably confirmed by computed tomography or
magnetic resonance imaging), some
active movement in the upper
extremity during recovery, able to
walk ⱖ2.44 m (8 ft) and able to transfer to a chair, cognitive function
score of 26 points on the Montreal
Cognitive Assessment, no receptive
aphasia, and able to communicate in
English. The criteria were provided
to therapists in local hospitals and in
the community who had treated or
were treating patients with stroke
either in the home or in outpatient
settings. If patients met the inclusion
criteria, were likely to have some
rehabilitation goals, and consented
to participate, they were included in
the intervention and evaluation.

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Environment) (Moodle Pty Ltd,
Perth, Western Australia, Australia)
for therapist training housed all of
the materials and forms developed
for the training manuals to allow
therapists to access the resources via
the Internet. Video clips of professional practice leaders (PPLs) applying key principles of the TOFT and
self-management intervention in the
home with simulated and “real”
patients were available on this platform. A self-assessment quiz allowed
therapists to assess their knowledge
of the intervention and to identify
gaps that could be addressed
by further learning. The website
(www.startathome.ca) was password protected. Therapists were
asked to view all video clips prior to
the therapist training sessions, and
we collected website use statistics,
including the amount of time therapists spent on the website and which
resources they accessed (see Tabs.
S4, S5, and S6 in the eAppendix),
There were 22 video clips for the
therapists to view, which included
goal setting, functional practice, and
negotiating the practice plan. The
percentage of therapists who
accessed the clips ranged from 87%
for goal setting to 25% for challenging task practice; the median was
50%.

Development and Evaluation of START

Figure 3.
Flow of patients through the project. START⫽Self-Management and Task-Oriented
Approach to Rehabilitation Training.

Table 1.
Baseline Characteristicsa
Variable

Measurements

Sex

9 men, 6 women

Age (y), X (SD) [range]

65.5 (5.49) [19–87]

Marital status

60% currently married

Years of education

13.7 (0.81)

Time since stroke (mo)

8.82 (2.27)

Length of hospital stay (d)

55.43 (10.33)

Length of time in inpatient rehabilitation (d)

63.36 (21.55)

Side of hemiparesis

Right (33.0%)

CMSA, arm

4.71 (0.54)

CMSA, hand

4.29 (0.55)

CMSA, leg

4.86 (0.36)

Outcomes

CMSA, foot

3.64 (0.56)

Other health problems in previous 6 mo

40% had one or more additional health problems

Self-rated health (5-point scale from poor
to excellent)

2.2 (0.37)

Presence of pain or discomfort

26.7% were usually not free of
pain or discomfort

a
Data are expressed as mean (SD) except as otherwise indicated. CMSA⫽Chedoke-McMaster Stroke
Assessment.

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Description of sample. A convenience sample of 15 patients participated in the feasibility assessment of
the intervention. The patients (for
baseline characteristics, see Tab. 1)
were referred from several sources:
another stroke study (n⫽9), a community agency (n⫽2), and a stroke
unit (n⫽4). Three patients withdrew
for the following reasons: back pain
(n⫽1), a fall resulting in hospitalization (n⫽1), and death (n⫽1) (Fig. 3).
The number of home visits provided
by the therapists ranged from 3 to 10
(X⫽7) for physical therapists and
from 3 to 9 (X⫽7) for occupational
therapists.

Baseline and Follow-up
Assessments
A single-group before-after design
was used. The following constructs
were evaluated: (1) self-management
skills, using the short-form Patient
Activation Measure (PAM)33; (2)
strength, hand function, mobility,
and ADL and instrumental ADL,
using the physical dimension score
of the Stroke Impact Scale-1634; (3)
physical function, using the Barthel
Index35 and the Timed “Up & Go”
Test (TUG)36; and (4) satisfaction,
using a modified version of the
Patient Satisfaction Questionnaire
(modified PSQ-18).37 Two physical
therapists not involved in the project
completed the assessments at baseline and immediately following the
intervention. Stata 10 (StataCorp LP,
College Station, Texas) was used to

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There were 2 aspects to the project:
patient improvement and therapist
learning. For the patient-focused
aspect, the objectives were: (1) to
assess the feasibility of delivery of
the intervention as reported by the
therapists and the patients, (2) to
assess the change that occurred in
function and self-management skills
by the end of the intervention, and
(3) to assess the satisfaction experienced by the participants.

Development and Evaluation of START
Table 2.
Outcome Measure Results for Participants With Stroke
Final Score
X (SD)

Difference
X (SD)

95% Confidence
Interval

P

TUG (s)

32.56 (22.65)

19.30 (12.53)

⫺13.26 (13.28)

3.76, 22.75

.01

Barthel Index
(range⫽0–100, with higher scores
indicating greater functional independence)

79.23 (15.12)

89.23 (8.13)

10 (11.55)

⫺16.98, ⫺3.02

.01

Stroke Impact Scale-16
(maximum score⫽80, with higher
scores indicating less impact of stroke
on performance of ADL/IADL)

56.77 (11.11)

64.38 (10.94)

7.62 (6.45)

⫺11.44, ⫺3.79

.001

Patient Activation Measure
(range⫽0–100, with higher scores indicating
greater patient activation)

64.8 (19.28)

71.82 (11.68)

7.01 (14.96)

⫺16.06, 2.03

.12

Modified PSQ-18

Mean Score (/5)

Subscales:

General Satisfaction

4.25

Technical Quality

4.3

Interpersonal Manner

4.7

Communication

4.6

Financial Aspects

3.8

Time Spent With Rehabilitation Professional

4.4

Accessibility and Convenience

3.6

a

TUG⫽Time “Up & Go” Test, ADL⫽activities of daily living, IADL⫽instrumental activities of daily living, modified PSQ-18⫽modified version of Patient
Satisfaction Questionnaire-18.

analyze the data. Parametric statistics
(t tests) were used to evaluate
change for all of the measures. Initial
and final scores and the mean difference between them for the 4 main
outcome measures are presented in
Table 2. Significant changes were
observed in 3 of the 4 measures: the
TUG, the Barthel Index, and the
Stroke Impact Scale-16. Patient satisfaction scores also are presented in
Table 2. Patients reported the highest levels of satisfaction on the Interpersonal Manner (X⫽4.7) and Communication (X⫽4.6) subscales and
the lowest satisfaction (X⫽3.6) on
the Accessibility and Convenience
subscale.
Mentoring of Therapists
The objective for the therapistfocused aspect of this project was
for therapists to understand the principles underlying the START intervention and learn the skills associated with delivering the intervention
in the home to people with stroke.
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Two videos were made by each
dyad, and each video was viewed by
3 members of the investigative team
(J.R., V.DP., and A.O.). Feedback was
provided to the therapists individually by email. Clips of videos that
characterized the therapy were
reviewed and discussed by the therapists and investigators as a group
using a checklist of intervention criteria. Therapists discussed the application of the intervention in these
specific clinical cases and learned
from observing colleagues’ practice.

categories. Quotes that corresponded to the established codes
and categories were extracted
(results of reflective journals and
therapist focus group questions are
shown in Fig. A3 in the eAppendix).
Briefly, the therapists reported that
the intervention enabled the patients
to set their own goals and plan and
record their practice. They were
able to utilize the home environment
to practice tasks. Limitations were
often related to the patients’ fatigue
and difficulty with problem solving.

Analysis of Reflective Journals
and Focus Groups
Conventional content analyses were
conducted on data from the focus
groups and the therapists’ reflective
journals.38 Investigators reviewed
the transcripts from all of the focus
groups (S.W. and A.O.) and the
reflective journals (L.L. and J.R.).
Independent, line-by-line analysis
was then used to generate initial
codes, which were consolidated into

Themes Emerging From the
Focus Group
Uncertainty regarding knowledge translation. Therapists initially expressed uncertainty about
the meaning, design, methods, and
outcome measures for knowledge
translation. Therapists’ comfort level
increased with increased exposure
to the intervention and practice:

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Initial Score
X (SD)

Variable

Development and Evaluation of START
They’re
basically
saying
the
researcher is doing all this work over
here, and we’re treating over here,
and there needs to be translation.

TOFT. Identifying
goals
for
patients with low upper extremity
functioning was sometimes difficult.
Some patients required support to
complete between-session practice.
Therapists gained greater proficiency as they practiced the
intervention.
Collaboration between physical
therapist
and
occupational
therapist. Therapists were less
isolated completing joint visits compared with usual practice; they were
able to brainstorm issues, which
resulted in less repetition and
increased consistency with goal
setting.
Community Care Access Centre
(CCAC) directive versus START
approach. Challenges to implementing the START approach were
encountered within the health care
delivery system. It was not usual
practice for some therapists to provide rehabilitation or remediation
in the home; their role was to
address home safety and equipment
issues. Both therapists and patients
expressed increased satisfaction in
the amount of time allocated to treatment, allowing them to address goals

June 2015

I think in our CCAC world, that would
have been somebody we would have
gone in to do. . .transfers with or stair
safety or. . .mobility aid or something,
and it would have been very much an
in-and-out type of situation.

Home environment. Therapists
reported their use of the home environment was similar to their previous practice. The home environment
made rehabilitation more applicable,
relevant, and motivating for the
patient, where barriers to functioning were more obvious to the patient
and the therapist. The caregiver’s
confidence in the patient’s ability
increased, resulting in greater
patient independence:
I couldn’t understand when a patient
came back from a weekend pass, that
when he told me he couldn’t walk in
his house, because he had been walking well in the gym.. . . So doing
something you have to do in your
home environment, that’s where you
need to practice it.

Patient
characteristics. Therapists noted that patient characteristics, such as intact memory, younger
age, and initiative, affected their
response to therapy. Older patients,
compared with younger patients,
were less engaged in problem solving, setting treatment goals and planning for discharge. Recordkeeping
was difficult for some patients.
Patients with more recent strokes
were less inclined to address
chronicity issues through selfmanagement strategies. Motivation
to change was an important characteristic to engage the patient in the
START therapy. Patients with a personal support worker to assist with
bathing or dressing were less motivated to engage in therapy.
Therapist characteristics. Some
therapists were early adopters of the

intervention, whereas others had difficulty providing less direction to the
patients. Some therapists needed
more time for training than we had
allowed:
I guess that we were there to basically
help these people learn how to manage their conditions—how to set
goals, what to do if there is a problem
instead of returning to doctors or
physio [physical therapist]—to actually empower people to take charge
of their health, their well-being, and
continue doing it independently and
seek help when it’s really necessary,
but not for the same thing that was
addressed so many times before.

Discussion
The KTA cycle9 provided an excellent sequential structure for the
development of this evidence-based
rehabilitation intervention in the
home for people with stroke. It provided the important stages in which
to engage the knowledge users in
the process. It also provided an
explicit rather than implicit description of the knowledge11 that supports the intervention. The theoretical underpinning and instrumental
approach to the therapy were articulated by outlining the evidence,
principles, resources, and training
process for the intervention.
START is a therapeutic program to
retrain physical function poststroke
and to provide self-management
skills for the ongoing management of
the underlying issues related to
stroke and changes in functional ability. This is the first detailed evidencebased program documented in the
literature that provides a framework
for rehabilitation practice in the
home environment. The 2 components of the program have complementary strategies, including goal
setting, action planning, and problem solving, to achieve patientidentified goals, which reinforced
adoption by the therapists and the
patients. START was feasible within

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Intervention: Self-management.
Therapists observed that selfmanagement involves a less instrumental approach than TOFT and
may be more difficult for patients
with cognitive issues. Women were
more engaged in self-management
than men, and caregivers also
reported the benefit of selfmanagement. Patients who were a
shorter time since stroke demonstrated less insight into the impact of
stroke on their life and had more
difficulty understanding the relevance of self-management.

not normally supported by the
CCAC:

Development and Evaluation of START
the home environment, as the therapists were able to deliver the intervention and the patients were
recruited and participated in the
intervention.

The self-management component
was based on a generic program and
engaged the patient individually.
This format provided a more tailored
intervention but lost the benefits of
group discussions of barriers and
solutions to issues and the sharing of
a common experience. A recent systematic review of the literature on
self-efficacy and self-management
poststroke concluded that the optimal format for delivering an SM intervention poststroke is not clear39;
however, therapists can successfully
engage patients about lifestyle
issues.40
Stroke-specific
selfmanagement programs have resulted
in greater participation compared
with generic programs, but these are
group programs and not adapted or
tested for individual patients.21
Delivery of self-management created
a more holistic role for therapists,
addressing issues such as fatigue that
affect the patient’s function and
ongoing reintegration into prestroke
roles.41– 43
Incorporating
selfmanagement within the home takes
a preventative approach to longerterm issues previously left to the
patient and caregiver.
In general, patients were satisfied
with the rehabilitation that they
received in the home. The low level
of satisfaction related to the Accessibility and Convenience subscale of
the PSQ-18 was an unanticipated
finding. One possible explanation
for this finding might be that patients
942

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This project was funded through an Operating Grant from the Ontario Stroke Strategy.

The use of standardized patients during initial practice sessions may have
enabled therapists to gain greater
proficiency before engaging with
an actual patient. The therapists
expressed greater satisfaction using
the START intervention to deliver
rehabilitation in the home, as it
enabled them to have more visits and
to make observations and offer solutions about the patients’ functioning
earlier in their recovery.

2 Chaiyawat P, Kulkantrakorn K. Effectiveness of home rehabilitation program for
ischemic stroke upon disability and quality
of life: a randomized controlled trial. Clin
Neurol Neurosurg. 2012;114:866 – 870.

This project was limited to the adoption of the START intervention by
professionals rather than integration
within a health system. A randomized design with an economic analysis is needed to determine whether
the START intervention versus usual
care results in improved functional
outcomes and more efficient and satisfying community reintegration.
Dr Richardson, Dr DePaul, Dr Wilkins, Dr
Letts, Dr Bosch, and Dr Wishart provided
input to concept/idea/project design. Dr
Richardson wrote the original draft of the
manuscript, and Dr DePaul, Dr Wilkins, Dr
Letts, and Dr Bosch provided comments and
editing. Dr Richardson, Dr DePaul, and Dr
Wilkins provided data collection. Dr Richardson, Dr Wilkins, Dr Letts, and Dr Bosch provided data analysis. Dr Richardson and Ms
Officer provided project management. Dr
Richardson provided fund procurement. Dr
DePaul provided consultation (including
review of manuscript before submission).
The authors acknowledge the contribution
of the Professional Practice Leaders Kristen
Parise and Cynthia King and the therapists
from Community Rehab who participated in
the project.

Number 6

DOI: 10.2522/ptj.20130617

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