35 Challenging Rehabilitation Environment for older persons During inpatient rehabilitation, patient-regulated exercise is another effective way to increase therapy time without increasing staff levels. Patients were positive about this form of therapy, although treatment fidelity remains a challenge. Increasing autonomy is important to regain self-confidence and improve patients’ active participation in rehabilitation.40-42,44 One included study contradicted the others regarding the effectivity of patient-regulated exercise, by showing no significant benefits after four weeks of patient-regulated exercise; however, this study had a very small population with a high dropout.43 Moreover, since two later studies showed positive effects of patient-regulated exercise, it seems to be an important part of rehabilitation and suitable to increase therapy time. When patient-regulated exercise is recommended, the exercises need to be stimulating and appropriate for the patient’s individual level. Also, evaluation and feedback will help to increase the therapy fidelity of patient-regulated exercise. Studies reported the importance of caregivers in the rehabilitation process; moreover, the availability of caregivers is an important predictor for discharge home. Additional practice with caregivers leads to increased exercise time, leading to improved body function, activities and participation, better quality of life for both patient and caregiver, shorter length of stay, and reduced levels of caregiver burden.46-52 Caregivers should be trained and involved in therapies, not only to increase therapy time, but also to increase knowledge of common (stroke-related) problems and their prevention, and to acquire lifting/handling techniques tailored to the needs of the individual patient. Rehabilitation wards need to stimulate caregivers to be part of the rehabilitation process and to teach caregivers about the health problems of their loved ones. Multiple trials and reviews have investigated task-oriented training after stroke and all reported benefits for functional outcomes compared with traditional therapies. Task-oriented training has proven effective for improving body functions and activities, and quality of life.38,53-56 Task-oriented training is already part of the current therapy approach during stroke rehabilitation. It is important to involve nurses in task-oriented training; they can create opportunities to practice meaningful functional tasks outside regular therapy sessions. 2
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