Physiotherapy Practice

Guidelines

for Stroke Rehabilitation

PTCOC

May 2000

ii

Preface

Physiotherapy has been advocated in the management of stroke patients as an integral and important

essence. (AHCPR 1995, RCP 1998 and SIGN 1998). As a responsible and proactive profession, we

are constantly striving to upgrade the quality standard of our care; to broaden the scope of our service

and to optimise the efficiency of our treatment. Within these framework, it is essential to develop an

acceptable set of standards in this area of specialism. This document is developed from the standards

recommended by AHCPR, RCP, SIGN and the physiotherapy service standard in Neurology 1998. It

is intended that this Physiotherapy Practice Guidelines booklet will be used throughout the HA

hospitals and organizations to assure quality of care in the management of stroke patients. We hope

that through the awareness and process of quality management the profession can be excelled towards

the summit of excellence. This document will be reviewed in one year.

Members of the PPG working group:

George Au (co-ordinator) CMC

Raymond Lo POH

Elsy Chan RH

Robin Tsim OLMH

Harold Ng CMC

Cedric Chow CMC

Hazel Ip CMC

Mabel Yu CMC

iii

TABLE OF CONTENTS

Page I. Goals of Guidelines

1

II. Epidemiology of Stroke 1 A. Definition 1 B. Incidence 1

C. Classification

2

III. Physiotherapy Management in Stroke Rehabilitation 2 A. Goals of Physiotherapy 4 B. Assessment 5 C. Interventions 9 D. Outcome 23 E. Discharge 25 F. Community 27

G. Service Evaluation

30

III. References

31

IV. Appendices

40

1

I. Goals of Guidelines The goals of developing the physiotherapy practice guidelines for stroke are to provide evidence-based

supports to physiotherapy practice in stroke management within the H.A. It is an exercise of literature

search evaluation on related practice and aims to cover common physiotherapy assessment and

treatment interventions used and studied in the field. There are several evidence-based clinical practice

guidelines available providing management stroke condition (AHCPR, 1995; National Clinical

Guideline for Stroke, RCP 1998; SIGN, 1998). Although these documents are not physiotherapy

specific, they form the cornerstone of the overall management model.

II. Epidemiology of Stroke A. Definition Stroke, also known as cerebro-vascular accident (CVA), is an acute disturbance of focal or global

cerebral function with signs and syndromes lasting more than 24 hours or leading to death presumably

of vascular origin (World Health Organization, 1989).

B. Incidence In United States, the incidence of stroke is approximately 550,000 new cases annually, leaving 300,000

with disability (Stineman, 1997). An estimate of 30 billion of US dollars was spent on the direct

medical cost (17 billion) and indirect cost (13 billion) due to productivity loss in 1993. In United

Kingdom, the incidence rate is 1.7 to 2.0 per 1,000 population per year (Riddoch, 1995). It is reported

that the incidence rate in China is 219 per 100,000 population per year from a 1982 survey (Kay, 1993).

In Hong Kong, the exact incidence of stroke is unknown as no community-based study was ever done.

However, Hong Kong Hospital Authority has reported that there is about 20,000 of stroke patients

admitted into the public hospitals for the stroke condition annually and about 3000 of them were dead

in their annual statistical report (HKHA, 1997). Stroke is now the fourth leading cause of death in

Hong Kong and has been identified as one of the ten priority health areas by Hospital Authority (Ho,

2000).

2C. Classification Stroke can be classified into haemorrhagic or ischemic in origin. The common causes of brain

haemorrhage include uncontrolled hypertension, ruptured aneurysm, arteriovenous malformation,

cavernous angioma, drug abuse with cocaine, anticoagulant therapy and brain tumor. Ischaemic stroke

is related to thrombotic, embolic or haemodynamic factors.

Two hospital-based studies have been conducted in Hong Kong and published in the Stroke journal

(Huang, Chan, Yu, Woo, and Chin, 1992) and in the Neurology journal (Kay, Woo, Kreel, Wong,

Teoh, and Nicholls, 1992). In these two studies, 86% and 96% of the entire stroke patients admitted

respectively received CT scanning of brain. Both studies clearly established that cerebral haemorrhage

constituted about 30% of all stroke occurring in Hong Kong Chinese. This proportion is significantly

different from those found in Caucasian populations constituting approximately 10% of all strokes. According to the Bamford study in 1991, ischaemic stroke can be further classified clinically into total

anterior circulation infarcts (TACI), partial anterior circulation infarcts (PACI), posterior circulation

infarcts (POCI) and lacunar infarcts (LACI) (Appendix 2).

III. Physiotherapy management in stroke rehabilitation Physiotherapy plays an important role in the process of stroke rehabilitation. As a part of the

interdisciplinary team, physiotherapists work in concert with the managing doctor and other

rehabilitation specialists to provide stroke patients with a comprehensive rehabilitation program.

The physiotherapy stroke rehabilitation program involves a dynamic process of assessment,

goal-setting, treatment and evaluation; its coverage spans from the acute stage, through the

rehabilitation stage, to the community stage. The whole rehabilitation program is predicated on two

general components. The first includes preventive measure targeted at maintaining physical integrity

and minimizing complications that will prevent or prolong functional return. These measures should

begin immediately poststroke and continue as long as necessary. The second component is restorative

treatment aimed at promoting functional recovery. This phase should begin as soon as the patient is

medically and neurologically stable and has the cognitive and physical ability to participate actively in

a rehabilitation program. In brief, the aims of physiotherapy interventions are to promote motor

recovery, optimize sensory functions, enhance functional independence, and prevent secondary

complications.

3Recommendations:

Assessments

Clinicians should use assessments or measures appropriate to the needs (i.e., to help make a

clinical decision). (Level of evidence = IV, Recommendation = Grade C)

Where possible and available, clinicians should use assessments or measures that have been

studied in terms of validity and reliability. (Level of evidence = IV, Recommendation = Grade C)

Routine assessments should be minimised, and each considered critically. (Level of evidence = IV,

Recommendation = Grade C)

Patients should be reassessed at appropriate intervals. (Level of evidence = IV, Recommendation

= Grade C)

Teamwork

All members of the healthcare team should work together with the patient and family, using an

agreed therapeutic approach (Stroke Unit Trialists' Collaboration, 1998). (Level of evidence = III,

Recommendation = Grade B)

All staff should be trained to place patients in positions to reduce the risk of complications such as

contractures, respiratory complications and pressure sores. (Carr and Kenney, 192; Lincoln et al.,

1996). (Level of evidence = III, Recommendation = Grade B)

Goal setting

Goals should be meaningful, challenging but achievable (Bar-Eli et al., 1994, 1997; VanVliet et al.,

1995) (Level of evidence = III, Recommendation = Grade B), and there should be both short- and

long-term goals. (Level of evidence = IV, Recommendation = Grade C)

Goal setting should involve the patient (Blair,1995; Blair et al., 1995; Glasgow et al., 1996) (Level

of evidence = III, Recommendation = Grade B), and the family if appropriate. (Level of evidence

= IV, Recommendation = Grade C)

Therapy approach / interventions

Any of the current exercise therapies should be practised within a neurological framework to

improve any patient function. (Basmajian et al., 1987; Jongbloed et al., 1989; Richards et al., 1993;

Nelson et al., 1996; Dean & Shepherd, 1997).

(Level of evidence = Ib, Recommendation = Grade A)

Intensity / duration of therapy

Patients should see a therapist each working day if possible. (Rapoport and Eerd, 1989). (Level

of evidence = IIb, Recommendation = Grade B)

4 While they need therapy, patients should receive as much as can be given and they find tolerable.

(Kwakkel et al., 1997, 1999; Lincoln, 1999; Parry et al., 1999). (Level of evidence = Ia,

Recommendation = Grade A)

Patients should be given as much opportunity as possible to practise skills. (Smith et al., 1981;

Langhorne et al., 1996). (Level of evidence = Ia, Recommendation = Grade A)

A. Goals of Physiotherapy According to AHCPR, SIGN, RCP, management of stroke patients begins as the acute care during

acute hospitalization and continues as rehabilitative care as soon as patient’s medical & neurological

status has stabilized. Moreover, community reintegration of patients continues during the community

care stage (AHCPR, 95).

1. Acute Care

Aims :

1) Prevent recurrent stroke

2) Monitor vital signs, dysphasia adequate nutrition, bladder & bowel function.

3) Prevent complications

4) Mobilize the patient

5) Encourage resumption of self-care activities

6) Provide emotional support & education for patient & family

7) Screen for rehabilitation and choice of settings 2. Rehabilitation care

Aims :

1) Set rehabilitation goals; develop rehabilitation plan and monitor progress

2) Manage sensori-motor deficits

3) Improve functional mobility & independence

4) Prevent & treat complications

5) Monitor functional health conditions

6) Discharge planning (safe residence recommendation, patient & caregivers education & continuity

of care)

7) Community – reintegration

53. Community care

Aims :

1) Assist patient to reintegrate into community

2) Enhance family and caregivers functioning

3) Co-ordinate continuity of patient care.

4) Promote health and safety and prevent further hospitalization

5) Give advice on community supports, valued activities and vocational reintegrate

B. Assessment The objectives of assessment are to (AHCPR, 1995):

- document the diagnosis of stroke, its etiology, area of the brain involved, and

clinical manifestations.

- identify treatment needs during the acute phase.

- identify patients who are most likely to benefit from rehabilitation.

- select the appropriate type of rehabilitation setting.

- provide the basis for creating a rehabilitation treatment plan.

- monitor progress during rehabilitation and facilitate discharge planning.

- monitor progress after return to a community residence.

1. Timing

There is a strong correlation between poor outcome and delay in acute medical care and rehabilitation

care. It is expected to start rehabilitation as soon as possible. Screening for post-stroke rehabilitation

is performed when the patient is medically and neurologically stable. The initial physiotherapy

assessment forms the basis of treatment planning, permitting goals to be set in conjunction with the

patient, carer and other members of the multidisciplinary team. The assessment allows the selection of

the most appropriate intervention strategies to resolve problems and achieve goals. A complete

baseline assessment by physiotherapists should be completed for patients within 3 working days after

admission to an rehabilitation program in an inpatient rehabilitation setting or within three visits for an

outpatient or home rehabilitation program (AHCPR,1995). All information should be fully

documented in the patient record.

6Recommendation:

• A baseline assessment by physiotherapists should be completed for patients within 3 working days

after joining an inpatient rehabilitation program or within three visits for an outpatient or home

rehabilitation program (Level of evidence = IV, Recommendation = Grade C).

2. Stages of assessment

Assessment begins at the time of admission to acute care hospital. Screening for poststroke

rehabilitation for patient who is medically and neurologically stable. Baseline assessment at time of

admission to a rehabilitation program. Finally, periodic reassessment during rehabilitation documents

progress and provides the information needed to adjust treatment and eventually to plan for discharge

or transfer to another type of rehabilitation setting. After discharge from rehabilitation setting,

assessment is performed to monitor adaptation to a community residence and maintenance of

functional gains made during rehabilitation.

Recommendations:

• Periodic assessment should be done. (Level of evidence = IV, Recommendation = Grade C)

• Screening for possible admission to a rehabilitation program should be performed as soon as the

patient's neurological and medical conditions permit. (Level of evidence = IV, Recommendation =

Grade C)

3. Principles of assessment

Problems of patients can be assessed according to the ICIDH-2 model of disablement. There are four

dimensions represented in the ICIDH-2, three levels of functioning and contextual factors. The three

levels of functioning (at the body, person and social levels) in interaction with contextual factors yield

as outcomes either positive or negative levels of functioning, and both can be classified in the ICIDH2.

The negative levels of functioning are the three kinds of disablement: impairments, activity limitations

and participation restrictions.

7 Impairments Activities Participation Contexual

Factors Functioning at body level at person level at social level in interaction with

environmental factors and personal factors

Characteristics Body function Body structure

Person’s daily activities

Involvement in the situation

Features of the physical, social attitudinal world

Positive Aspect Functional and structural integrity

Activity Participation Facilitators

Negative Aspect Impairment Activity limitation Participation restriction

Barriers

4. Contents

Physiotherapy assessment includes:

a) Patient characteristics

Demographics (age, gender).

History of illness.

Prior activity level (low to very high).

Prior socialization (isolated to outgoing).

Expectations regarding stroke outcomes and need for assistance.

b) Family and caregiver characteristics

Members of household and relationship to patient.

Other potential caregivers.

Capacity to provide physical, emotional, instrumental support.

c) Impairments

e.g. speech, seeing, tone, muscle strength, balance, and co-ordination.

d) Activities

e.g. communication, movement, use of assistive devices and technical aids.

e) Participation

e.g. mobility, personal maintenance, social relationships, work, leisure, hobby, economic life

f) Environment factors

e.g. personal support and assistance, social and economic institutions, physical environment such as

access to building and key facilities within living quarters, safety considerations, access to resources

and activities in community.

8Recommendation:

• The contents of assessment should include patient characteristics, family and caregiver

characteristics, impairments domain, activities domain, participation domain, and environment

domain (Level of evidence = IV, Recommendation = Grade C).

5. Special consideration

Shoulder assessment

Shoulder subluxation and pain is a major and frequent complication in patients with hemiplegia.

(Joynt, 1992; Grossen-Sils, and Schenkman, 1985). As many as 80% of patients with cerebrovascular

accident has been reported to show shoulder subluxation. Clinical examination of shoulder should

include thorough evaluation of pain , range of movement, motor control, and shoulder subluxation.

Recommendation:

• Shoulder assessment should be done in the initial assessment (Level of evidence = IV,

Recommendation = Grade C).

6. Setting rehabilitation goals

Both short-term and long- term goals need to be realistic in terms of current levels of disability and the

potential for recovery. Goals should be mutually agreed to by the patient, family, and rehabilitation

team and should be documented in the medical record in explicit, measurable terms. (Level of evidence

= IV, Recommendation = Grade C).

7. Developing the rehabilitation management plan

The rehabilitation management plan should indicate the specific treatments planned and their sequence,

intensity, frequency, and expected duration. Measures to prevent complications of stroke and recurrent

strokes should be continued. (Level of evidence = IV, Recommendation = Grade C).

9

C. Interventions 1. Improving motor control

a. Neurofacilitatory Techniques

These therapeutic interventions use sensory stimuli (e.g. quick stretch, brushing, reflex stimulation and

associated reactions) ,which are based on neurological theories, to facilitate movement in patients

following stroke (Duncan,1997). The following are the different approaches: -

i. Bobath Berta & Karel Bobath’s approach focuses to control responses from damaged postural reflex

mechanism. Emphasis is placed on affected inputs facilitation and normal movement patterns (Bobath,

1990).

ii. Brunnstrom Brunnstrom approach is one form of neurological exercise therapy in the rehabilitation of stroke

patients. The relative effectiveness of Neuro-developmental treatment (N.D.T.) versus the Brunnstrom

method was studied by Wagenaar and colleagues (1990) from the perspective of the functional

recovery of stroke patients. The result of this study showed no clear differences in the effectiveness

between the two methods within the framework of functional recovery.

iii. Rood Emphasise the use of activities in developmental sequences, sensation stimulation and muscle work

classification. Cutaneous stimuli such as icing, tapping and brushing are employed to facilitate

activities (Goff, 1969).

iv. Proprioceptive neuromuscular facilitation (PNF)

Developed by Knott and Voss, they advocated the use of peripheral inputs as stretch and resisted

movement to reinforce existing motor response (Kidd et al., 1992). Total patterns of movement are

used in treatment and are followed in a developmental sequence.

It was shown that the commutative effect of PNF is beneficial to stroke patient (Wong, 1994).

Comparing the effectiveness of PNF, Bobath approach and traditional exercise, Dickstein et al (1986)

demonstrated that no one approach is superior to the rest of the others (AHCPR, 1995).

10

b. Learning theory approach

i. Conductive education

Conductive education is one of the methods in treating neurological conditions including hemiplegic

patients. Cotton and Kinsman (1984) demonstrated a neuropsychological approach using the concept

of CE for adult hemiplegia. The patient is taught how to guide his movements towards each task-part

of the task by using his own speech - rhythmical intention.

ii. Motor relearning theory

Carr & Shepherd, both are Australian physiotherapists, developed this approach in 1980. It

emphasises the practice of functional tasks and importance of relearning real-life activities for patients.

Principles of learning and biomechanical analysis of movements and tasks are important. (Carr and

Shepherd, 1987)

There is no evidence adequately supporting the superiority of one type of exercise approaches over

another. However, the aim of therapeutic approach is to increase physical independence and to

facilitate the motor control of skill acquisition and there is strong evidence to support the effect of

rehabilitation in terms of improved functional independence and reduced mortality.

Recommendation:

• Physiotherapists with expertise in neuro-disabilty should co-ordinate therapy to improve movement

performance of patients with stroke (AHCPR, 1995). (Level of Evidence = IV, Recommendation =

Grade C)

c. Functional electrical stimulation (FES) FES is a modality that applied a short burst of electrical current to the hemiplegic muscle or nerve.

FES has been demonstrated to be beneficial to restore motor control, spasticity, and reduction of

hemiplegic shoulder pain and subluxation. It is concluded that FES can enhance the upper extremity

motor recovery of acute stroke patient (Chae et al., 1998; Faghri et al., 1994; Francisco, 1998). Alfieri

(1982) and Levin et al (1992) suggested that FES could reduce spasticity in stroke patient. A recent

meta- analysis of randomized controlled trial study showed that FES improves motor strength (Glanz

1996). Study by Faghri et al (1994) have identified that FES can significantly improve arm function,

electromygraphic activity of posterior deltoid, range of motion and reduction of severity of subluxation

and pain of hemiplegic shoulder.

11

Recommendations:

• Functional electrical stimulation should not be used as a routine after stroke (RCP, 1998). (Level

of evidence = Ib, Recommendation = Grade A)

• FES should be considered in improving upper extremities functional (Faghri et al., 1994), (Level of

evidence = Ib, Recommendation = Grade A), strength (Glanz, 1996) (Level of evidence = Ia,

Recommendation = Grade A), reduction of hemiplegic shoulder pain and subluxations (Faghri et

al.,1994) (Level of evidence = Ib, Recommendation = Grade A) and motor recovery (Chae et

al.,1998), (Level of evidence = Ib, Recommendation = Grade A), (Franciso, 1998), (Level of

evidence = Ib, Recommendation = Grade A); (Faghri et al., 1994) (Level of evidence = Ib,

Recommendation = Grade A).

d. Biofeedback Biofeedback is a modality that facilitates the cognizant of electromyographic activity in selected

muscle or awareness of joint position sense via visual or auditory cues. The result of studies in

biofeedback is controversial. A meta-analysis of 8 randomized controlled trials of biofeedback therapy

demonstrated that electromyographic biofeedback could improve motor function in stroke patient

(Schleenbaker, 1993). Another meta-analysis study on EMG has showed that EMG biofeedbcak is

superior to conventional therapy alone for improving ankle dorsiflexion muscle strength (Moreland et

al., 1998. Erbil and co-workers (1996) showed that biofeedback could improve earlier postural control

to improve impaired sitting balance. Conflicting meta-analysis study by Glanz et al (1995) showing

that biofeedback was not efficacious in improving range of motion in ankle and shoulder in stroke

patient. Moreland (1994) conducted another meta-analysis concluded that EMG biofeedback alone or

with conventional therapy did not superior to conventional physical therapy in improving upper-

extremity function in adult stroke patient.

Recommendations:

• Biofeedback should not be used on a routine basis (RPC, 1998). (Level of evidence = Ia,

Recommendation = Grade A)

• Biofeedback should be considered as an additional therapy in sitting balance retraining.

(Level of evidence = IIa, Recommendation = Grade B)

12(2) Hemiplegic shoulder management

Shoulder subluxation and pain of the affected arm is not uncommon in at least 30% of all patient after

stroke (RCP, 1998) ,whereas subluxation is found in 80% of stroke patients (Najenson et al., 1971). It

is associated with severity of disability and is common in patients in rehabilitation setting.

Suggested interventions are as follows:

a) Exercise

Active weight bearing exercise can be used as a means of improving motor control of the affected arm;

introducing and grading tactile, proprioceptive, and kinesthetic stimulation; and preventing edema and

pain. Upper extremity weight bearing can be used to lengthen or inhibit tight or spastic muscles while

simultaneously facilitating muscles that are not active (Donatelli, 1991) (Level of evidence = IV,

Recommendation = Grade C). According to Robert (1992), the amount of shoulder pain in hemipelgia

was related most to loss of motion. He advocated that the provision of ROM exercise (caution to avoid

imprigement) as treatment as early as possible. AHCPR (1995) recommended ROM exercise should

not carry the shoulder beyond 900 of flexor and abduction unless there is upward rotation of scapular

and external rotation of the humeral head.

Recommendation:

• Range of motion exercise should carry out as early as possible and caution

to avoid excessive shoulder flexion (Level of evidence = III, Recommendation = Grade B).

b) Functional electrical stimulation

Functional electrical stimulation (FES) is an increasingly popular treatment for the hemiplegic stroke

patient. It has been applied in stroke rehabilitation for the treatment of shoulder subluxation (Faghri et

al.,1994), spasticity (Stefanovska et al., 1991) and functionally, for the restoration of function in the

upper and lower limb (Kralji et al., 1993). Electrical stimulation is effective in reducing pain and

severity of subluxation, and possibly in facilitating recovery of arm function (Faghri, et al., 1994; Linn,

et al., 1999).

Recommendation: • Functional electrical stimulation should be used to prevent shoulder pain and subluxation ( Faghri

et al.,1994). (Level of evidence = Ib, Recommendation = Grade A)

13c) Positioning & proper handling

Proper positioning and handling of hemiplegic shoulder, whenever in bed, sitting and standing or

during lifting, can prevent shoulder injury is recommended in the AHCPR & SIGN guidelines for

stroke rehabilitation. Moreover, positioning can be therapeutic for tone control and neuro-facilitation

of stroke patients (Davies, 1991). Braus et al 94 found shoulder hand syndrome reduced from 27% to

8% by instruction to every one including family on handling technique.

Recommendations :

• Positioning can be used to prevent shoulder pain and subluxation.

(Level of evidence =IV, Recommendation = Grade C)

• Education on staff & carers on correct handling of hemiplegic arms. (Level of evidence = III,

Recommendation = Grade B)

• All staff involved in rehabilitation should be trained by a named senior physiotherapist in

techniques of handling and positioning to prevent the onset of painful shoulder (SIGN, 1998).

(Level of evidence = IV, Recommendation = Grade C)

• The prevention of shoulder injuries should emphasize proper positioning and support and

avoidance of overly vigorous range-of-motion exercise (AHCPR, 1995). (Level of evidence = IV,

Recommendation = Grade C)

d) Neuro-facilitation

Recommendations:

• Based on the Bobath's approach, muscle tone that stabalises the shoulder can be facilitated and

shoulder movement patterns, especially the scapula movements, can be enhanced by the various

Bobath's techniques. Shoulder subluxation can then be reduced and development of painful

shoulder can be prevented (Davies, 1991). (Level of evidence = IV, Recommendation = Grade C)

• Brunnstrom advocated the activation of the cuff muscles of shoulder, especially the supraspinatus

to prevent the subluxation of shoulder (Kathryn, 1992). (Level of evidence = IV, Recommendation

= Grade C)

e) Passive limb physiotherapy

Maintenance of full pain-free range of movement without traumatising the joint and the structures can

be carried out. At no time should pain in or around the shoulder joint be produced during treatment.

(Davies, 1991).

14Recommendation :

• Range-of-motion exercises should not carry the shoulder beyond 90 degrees of flexion and

abduction unless there is upward rotation of scapula and external rotation of the humeral head.

(AHCPR, 1995). (Level of evidence = IV, Recommendation = Grade C)

f) Pain relief physiotherapy

Passive mobilisation as described by Maitland, can be useful in gaining relief of pain and range of

movement (Davies, 1991).

Other treatment modalities such as thermal, electrical, cryotherapy etc. can be applied for shoulder

pains of musculoskeletal in nature.

Recommendation :

• Leandri et al. (1990) found high intensity TENS led to prolonged pain relief and increase ROM of

hemiplegic shoulder. High intensity TENS should used to treat shoulder pain. (Level of evidence

= Ib, Recommendation = Grade A)

G) Reciprocal pulley/ OP

The use of reciprocal pulley appears to increase risk of developing shoulder pain in stroke patients. It

is not related to the presence of subluxation or to muscle strength. (Kumar et al., 1990)

Recommendation :

• Avoid the use of overhead pulley to prevent shoulder injury and pain. (Level of evidence = Ib,

Recommendation = Grade A)

H) Sling

The use of sling is controversial. No shoulder support will correct glenohumeral joint subluxation.

However, it may prevent the flaccid arm from hanging against the body during functional activities,

thus decreasing shoulder joint pain. They also help to relieve downward traction on the shoulder

capsule caused by the weight of the arm (Hurd, Farrell, and Waylonis, 1974 ; Donatelli ,1991).

Recommendation :

• Shoulder sling should not be used as routine.

(Level of evidence = III, Recommendation = Grade B)

15 (3) Limb physiotherapy

Limb physiotherapy includes passive, assisted-active and active range-of-motion exercise for the

hemiplegic limbs. This can be an effective management for prevention of limb contractures and

spasticity and is recommended within AHCPR (1995). Self-assisted limb exercise is effective for

reducing spasticity and shoulder protection (Davis, 1991).

Adams and coworkers (1994) recommended passive full-range-of-motion exercise for parlysed limb

for potential reduction of complication for stroke patients.

Recommendation :

• Limb physiotherapy should be performed for prevention of contractures and spasticity of

hemiplegia limbs (AHCPR, 1995). (Level of evidence = IV, Recommendation = Grade C)

(4) Chest physiotherapy

Evidence shows that both cough and forced expiratory technique (FET) can eliminate induced

radioaerosol particles in lung field. Directed coughing and FET can be used as a technique for

bronchial hygiene clearance in stroke patient.

Recommendation

• Directed coughing can maintain the bronchial hygiene clearance in stroke patients. (Bennet, 1981;

Hasani et al., 1991). (Level of evidence = II, Recommendation = Grade B)

(5) Positioning

Consistent “reflex-inhibitory” patterns of posture in resting is encouraged to discourage physical

complication of stroke and to improve recovery (Bobath, 1990).

Meanwhile, therapeutic positioning is a widely advocated strategy to discourage the development of

abnormal tone, contractures, pain and respiratory complications. It is an important element in

maximizing the patient's functional gains and quality of life.

Recommendation :

• Physiotherapists should position patients to minimize the risk of complications such as contractures,

respiratory complication, shoulder pain & pressure sores (RCP, 1998). (Level of evidence = IV,

Recommendation = Grade C)

16(6) Tone management

A goal of physical therapy interventions has been to “normalize tone to normalize movement.”

Therapy modalities for reducing tone include stretching, prolonged stretching, passive manipulation by

therapists, weight bearing, ice, contraction of muscles antagonistic to spastic muscles, splinting, and

casting. Research on tone-reducing techniques has been hampered by the inadequacies of methods to

measure spasticity (Knutsson and Martensson, 1980) and the uncertainty about the relationship

between spasticity and volitional motor control (Knutsson and Martensson, 1980; Sahrmann and

Norton, 1977). Manual stretch of finger muscles, pressure splints, and dantrolene sodium do not

produce apparent long-term improvement in motor control (Carey, 1990; Katrak, Cole, Poulus, and

McCauley, 1992; Poole, Whitney, Hangeland, and Baker, 1990). Dorsal resting hand splints reduced

spasticity more than volar splints, but the effect on motor control is uncertain (Charait, 1968) while

TENS stimulation showed improvement for chronic spasticity of lower extremities (Hui-Chan and

Levin, 1992).

Recommendation:

• Electrical Stimulation could be used for tone management (Level of evidence = Ia,

Recommendation = Grade A)

(7) Sensory re-education

Bobath and other therapy approaches recommend the use of sensory stimulation to promote sensory

recovery of stroke patients.

Recommendation:

• Yekutiel et al (1993) had demonstrated in a controlled study that statistically significant

improvement in sensory recovery after 6 weeks of sensory retraining. (Level of evdence = IIa,

Recommendation = Grade B)

8. Balance retraining

Reestablishment of balance function in patients following stroke has been advocated as an essential

component in the practice of physiotherapy (Nichols, 1997). Some studies of patients with

hemiparesis revealed that these patients have greater amount of postural sway, asymmetry with greater

weight on the non-paretic leg, and a decreased ability to move within a weight-bearing posture

(Dickstein, Nissan, Pillar, and Scheer, 1984; Horak, Esselman, Anderson, and Lynch, 1984).

Meanwhile, research has demonstrated moderate relationships between balance function and

parameters such as gait speed, independence, wheelchair mobility, reaching, as well as dressing

17(Dickstein et al., 1984; Horak et al., 1984; Bohannon, 1987; Fishman, Nichols, Colby, and Sachs,

1996; Liston and Brouwer, 1996; Nichols, Miller, Colby and Pease, 1996).

Some tenable support on the effectiveness of treatment of disturbed balance can be found in studies

comparing effects of balance retraining plus physiotherapy treatment and physiotherapy treatment

alone.

Recommendations:

• Improvement in weight distribution of lower limbs, or better standing symmetry, has been

demonstrated in study of Winstein and coworkers (1989) (Level of evidence = IIa,

Recommendation = Grade B) and that of Shumway-Cook and colleagues (1988). (Level of

evidence = Ib, Recommendation = Grade A).

• Moreover, some researchers found that not only the standing symmetry but also the stance stability

are improved after balance retraining (Hocherman, Dickstein, and Pillar, 1984). (Level of evidence

= IIa, Recommendation = Grade B)

9. Fall prevention

Falls are one of the most frequent complications in stroke rehabilitation ( Dromerick and Reading,

1994), and the consequences of which are likely to have a negative effect on the rehabilitation process

and its outcome. According to the systematic review of the Cochrane Library (1999), which evaluated

the effectiveness of several fall prevention interventions in the elderly, there was significant protection

against falling from interventions which targeted multiple, identified, risk factors in individual patients

(odds ratio 0.77; 95% CI 0.64 to 0.91). The same is true for interventions which focused on

behavioural interventions targeting environmental hazards plus other risk factors (odds ratio 0.81; 95%

CI 0.71 to 0.93).

The effect of the exercise component in fall prevention was also evaluated in that systematic review.

Based on the analysis of four trials, exercise alone did not establish protection against falling (odds

ratio 1.05; 95% CI 0.74 to 1.48). (Level of evidence = Ib, Recommendation = Grade A) Likewise,

there was also no evidence to support exercise in conjunction with health education classes for the

prevention of falls (odds ratio 1.72; 95% CI 0.78 to 3.75) (Level of evidence = Ib, Recommendation =

Grade A). Despite having such non-significant findings, the results have to be viewed with caution

given the variation in the participants and in the research methodology of these clinical trials.

18Recommendations:

• It is concluded that an effective fall prevention programme should consist of a health screening of

at risk elderly people, followed by interventions which are targeted at both intrinsic and

environmental risk factors of individual patients.

(Level of evidence = Ib, Recommendation = Grade A)

(10) Gait re-education

Recovery of independent mobility is an important goal for the immobile patient, and much therapy is

devoted to gait-reeducation. Bobath assume abnormal postural reflex activity is caused of dysfunction

so gait training involved tone normalization and preparatory activity for gait activity. In contrast Carr

and Shepherd advocates task-related training with methods to increase strength, coordination and

flexible MS system to develop skill in walking while Treadmill training combined with use of

suspension tube. Some patient’s body weight can effective in regaining walking ability, when used as

an adjunct to convention therapy 3 months after active training (Visintin et al., 1998; Wall and Tunbal

1987; Richards et al., 1993).

Recommendations :

• Treadmill training with partial (<40%) bodyweight support should be considered as an adjunct to

conventional therapy in patients who are not walking at 3 months after stroke. (Level of evidence

= Ib, Recommendation = Grade A)

• Gait re-education to improve walking ability should be offered. (Level of evidence = III,

Recommendation = Grade B)

(11) Functional Mobility Training

To handle through the functional limitations of stroke patients, functional tasks are taught to them

based on movement analysis principles. These tasks include bridging, rolling to sit to stand and vice

versa, transfer skills, walking and stairing etc (Mak et al., 2000).

Published studies report that many patients improve during rehabilitation. The strongest evidence of

benefit is from studies that have enrolled patients with chronic deficits or have included a no-treatment

control group (Wade et al., 1992; Smith and Ashburn et al., 1981).

Meanwhile, early mobilization helps prevent compilations e.g. DVT, skin breakdown contracture and

pneumonia. Evidence have shown better orthrostatic tolerance (Asberg, 1989) and earlier ambulation

(Hayes and Carroll, 1986).

19

Recommendations :

• Patients who have functional deficits and at least some voluntary control over movements of the

involved arm or leg should be encouraged to use the limb in functional tasks and offered exercise

and functional training directed at improving strength and motor control, relearning sensorimotor

relationship and improving functional performance (AHCPR, 1995). (Level of evidence = III,

Recommendation = Grade B)

• The patient with an acute stroke should be mobilized as soon after admission as is medically stable

(Level of evidence = III, Recommendation = Grade B).

(12) Upper limb training

By 3 months poststroke, approximately 37% of the individuals continues to have decreased upper

extremities (UE) function. Recovery of UE function lags behind that of the lower extremities because

of the more complex motor skill required of the UE in daily life tasks. That means many individuals

who have a stroke are at risk for lowered quality of life.

Many approaches to the physical rehabilitation of adults post-stroke exist that attempt to maximize

motor skill recovery. However the literature does not support the efficacy of any single approach. The

followings are the current approaches to motor rehabilitation of the UE.

a) Facilitation models

They are the most common methods of intervention for the deficits in UE motor skills including

Bobath, proprioceptive neuromuscular facilitation, Brunnstrom’s movement therapy and Rood’s

sensorimotor approach. There is some evidence that practice based on the facilitation models can

result in improved motor control of UE ( Dickstein et al,1986, Grade A; Wagenaar et al, 1990 ).

However, intervention based on the facilitation models has not been effective in restoring the fine hand

coordination required for the performance of actions ( Kraft, Fitts & Hammond, 1992; Butefisch et al,

1995 ).

Recommendation:

• Practice based on facilitation models can improve upper limb motor skills of stroke patient. (Level

of evidence = Ib, Recommendation = Grade A ).

20b) Functional electric stimulation

Functional electric stimulation (FES) can be effective in increasing the electric activity of muscles or

increased active range of motion in individuals with stroke ( Dimitrijevic et al., 1996; Fields, 1987;

Faghri et al., 1994,; Kraft, Fitts and Hammond, 1992 ). Some evidence shown that FES may be more

effective than facilitation approaches ( Bowman, Baker and Waters, 1979; Hummelsheim, Maier-Loth

and Eickhof, 1997 ).

Recommendation :

• Functional electric stimulation can improve the arm function of stroke patient. ( Level of evidence

= Ib, Recommendation = Grade A )

c) Electromyographic biofeedback

Intervention using biofeedback can contribute to improvements in motor control at the neuromuscular

and movement levels ( Kraft, Fitts and Hammond, 1992; Moreland and Thomson, 1994; Wissel et al.,

1989; Wolf and Binder-MacLoed, 1983; Wolf, LeCraw and Barton,1989; Wolf et al., 1994 ). Some

studies have shown improvments in the ability to perform actions during post-testing after biofeedback

training ( Wissel et al.,1989; Wolf and Binder-MacLoed, 1983; Moreland and Thomson, 1994).

However, the ability to generalize these skills and incorporate them into daily life is not measured.

Recommendation:

• Improvement shown in upper limb performing actions ability after biofeedback training. (Level of

evidence = Ib, Recommendation = Grade A )

d) Constraint-induced therapy

Constraint-Induced (CI) therapy was designed to overcome the learned nonuse of the affected UE. In

the most extreme form of CI therapy, individual post-stroke are prevented from using the less affected

UE by keeping it in a splint and sling for at least 90% of their waking hours. Studies have found that

the most extreme of CI therapy can effect rapid improvement in UE motor skill ( Nudo et al., 1996;

Taub and Wolf, 1997; Taub et al., 1993; Wolf et al., 1989 ) and that is retained for at least as long as 2

years ( Taub and Wolf, 1997 ). However, CI therapy, currently are effective only in those with distal

voluntary movement ( Taub and Wolf, 1997 ).

21Recommendation :

• Constraint-induced therapy is effective on improvement of upper limb motor skill of stroke patient

( Level of Evidence = IIa, Recommendation = Grade B ).

(13) Mobility appliances and equipment

Small changes in an individual's local 'environment' can greatly increase independence, use of a

wheelchair or walking stick. However, little research has been done for these 'treatments'. It is

acknowledged that walking aids and mobility appliances may benefit selected patients.

Tyson and Ashburn (1994) showed that walking aids had effect in poor walkers - a benefical effect on

gait (Level of evidence = III, Recommendation = Grade B). Lu and coworkers (1997) concluded that

wrist crease stick is better than stick measured to greater trochanter. (Level of evidence = IIb,

Recommendation = Grade A)

Recommendations :

• A walking stick may increase standing stability in patients with severe disability. (Level of

evidence = III, Recommendation = Grade B)

• Length of walking stick should better measured to wrist crease. (Level of evidence = IIb,

Recommendation = Grade A)

• A wheelchair prescription for patient with severe motor weakness or easy fatigability should be

based on careful assessment of the patient and the environment in which the wheelchair will be

used. Wheelchair selection should have the full support of the patient and family / involved others

(AHCPR, 1995). (Level of evidence = IV, Recommendation = Grade C)

(14) Acupuncture

The World Health Organisation (WHO) has listed acupuncture as a possible treatment for pariesis after

stroke. Studies had sown its beneficial effects in strike rehabilitation.

Chen et al. (1990) had performed a controlled clinical trial of acupuncture in 108 stroke patients. They

stated that the total effective rate of increasing average muscle power by at least one grade was 83.3%

in the acupuncture group compared with the controlled group which was 63.4% (p<0.05).

Hua et al. (1993) had reported a significant difference in changes of neurological score between the

acupuncture group and the control group after 4 weeks of treatment in a RCT and no adverse effects

were observed in patients treated with acupuncture.

22Recommendation:

• Clinical study shown that accupuncture had beneficial effect in stroke rehabilitation. ( Level of

evidence = Ib recommendation = Grade A )

(15) Vasomotor training

Early stimulation of the muscle pump can reduce the venous stasis and enhance the general circulation

of the body. It then hastens the recovery process.

Recommendation:

• Vasomotor training should start in the early stage of rehabilitation (Level of evidence = IV

Recommendation = Grade C )

(16) Oedema management

Use of intermittent pneumatic pump, elastic stocking or bandages and massage can facilitate the

venous return of the oedematous limbs. Therefore, the elasticity and flexibility musculoskeletal

system can be maintained and enhance recovery process and prevent complications like pressure ulcer.

( Level of evidence = IV, Recommendation = Grade C )

23D. Outcome Physiotherapy treatment outcome can be reflected by measures of impairments, disabilities, and

handicaps (World Health Organization, 1980).

1. International classification of impairments, disabilities, and handicaps

(ICIDH)

a. Impairment

.The ICIDH definition of impairment is ‘. . . any loss or abnormality of psychological, physiological,

or anatomical structure or function’. And the ICIDH also notes that impairment represents

exteriorisation of a pathological state, . . .’.

There are many detailed charts available for recording neurological impairments. These are often

designed for specific circumstances. The classification used is primarily anatomical, and this suits

diagnostic purpose. The systems are best for localizing lesions in the brain-stem, spinal cord and

peripheral nerves. A second way to approach the measurement of impairments is to start from the

pathology, and to construct measures which concentrate upon those impairments that are specific to the

disease.

Examples of impairment measurement:

- for spasticity: Modified Ashworth Scale (Appendix 3)

- for balance: Functional reach, Berg’s balance scale, timed up-and-go test

- for co-ordination: Finger-to-nose test, heel-shin test, Purdue pegboard

Recommendation:

• Common assessment scales should be used in hospitals. For assessing balance, Berg’s balance

scale is recommended as it is well validated. (Level of evidence = III, Recommendation = Grade

B).

Approximate Time to Name and Source Administer Strengths Weaknesses Uses Berg 10 min Simple, well None observed formal Balance established with assessment Assessment stroke patients, monitoring (Berg, 1989) sensitive to change, (Berg et al., 1989) validity, reliability (Appendix 4) & sensitivity tested

24b. Disability

The ICIDH definition of disability is ‘. . . any restriction or lack of ability to perform an activity within

the range considered normal for a human being.’ The ICIDH also notes that disability represents

objectification of an impairment, and as such represents disturbances at the level of the person. It

refers to the effect pathology or impairment has upon actions which have some meaning to the person.

World Health Organization (WHO 1980) categories disabilities into behaviour; communication;

personal care; locomotion; body disposition (domestic activities and body movements); dexterity; and

specific situations.

There are some examples of disability scales for measuring stroke outcome.

Approximate Time to Name and Source Administer Strengths Weaknesses Uses Barthel Index 5-10 min Widely used for Low sensitivity screening, (Appendix 5) stroke; for high-level formal excellent functioning, assessment, validity and ceiling effects monitoring, reliability maintenance Functional 40 min Widely used for ceiling” and screening, Independence stroke; measures floor” effects formal Measure mobility, use of at upper & assessment, (FIM) (Winaknder et al., T-point scale lower ends of monitoring, 1998) increases function maintenance sensitivity, ADL, cognition, (Appendix 6) functional communication, validity & reliability tested Motor 15-30 min Good, brief Reliability assessed formal Assessment assessment only in stable assessment, Scale of movement patients sensitivity monitoring and physical not tested mobility, validity & reliability tested (Appendix 7) Elderly 5-10 min Simple, validity & Ceiling effect formal Mobility scale reliability tested, assessment local validation done (Tsim, 1998; Yu ,1998)

25(Appendix 8) Recommendation:

• Common assessment scales should be used in hospitals. For assessing mobility, Elderly Mobility

Scale is recommended as it is validated locally. (Level of evidence = III, Recommendation =

Grade B).

c. Handicap

The ICIDH definition for handicap is ‘. . . a disadvantage for a given individual, resulting from an

impairment or a disability that limits or prevents the fulfilment of a role that is normal for that

individual.’ The ICIDH also notes that handicap represents socialisation of an impairment or disability,

and as such it reflects the consequences for the individual cultural, social, economic, and

environmental that stem from the presence of impairment and disability.

The World Health Organization recognized six areas of handicap. They are orientation; mobility;

physical dependence; economic self-sufficiency; occupation; and social integration.

Examples: SF-36, Sickness Impact Profile

E. Discharge 1. Indications for discharge

The term “reasonable treatment goals” is used to emphasize the importance of not underestimating or

overestimating the patient’s capabilities. When reasonable goals have been achieved, the patient is

better served by moving to the next stage of recovery.

Lack of objective evidence of progress at two successive evaluations (i.e., over a period of 2 weeks in

an intense program and 4 weeks in a less intense program) often indicates that a functional ceiling has

been reached. Unless there is a good reason for the plateau in functional gain, transfer to a different

level of care may be in the patient’s best interests, and may also represent cost-effective use of

rehabilitation resources.

Recommendations:

• Discharge from a rehabilitation program should occur when reasonable treatment goals have been

achieved. Absence of progress on two successive evaluations should lead to reconsideration of the

treatment regimen or the appropriateness of the current setting.

(Level of evidence = IV, Recommendation = Grade C)

262. Assessment prior to discharge

The predischarge assessment provides essential information for discharge planning, both about the

patient and about the environment to which the patient will return. The assessment also provides a

summary measure of gains achieved during the rehabilitation program and a baseline for monitoring

subsequent progress.

Recommendation:

• Assessment prior to discharge should include the patient’s functional status, the proposed living

environment, the adequacy of support by family or involved others, financial resources, and the

availability of social and community supports. (Level of evidence = IV, Recommendation = Grade

C)

3. Discharge planning

Discharge from a rehabilitation program marks a critical point on the trajectory of post-stroke recovery

and an important transition to new challenges. Discharge planning should begin on the day of

admission to a rehabilitation program. At this time, initial information is obtained on the extent of

family or caregiver support available and the potential places of residence after rehabilitation (in the

case of inpatient programs). Goals of discharge planning are to:

- identify a safe place of residence.

- ensure that the patient and family / caregiver are adequately trained in essential skills.

- arrange for continued medical care.

- arrange for continued rehabilitation services.

- arrange for needed community services.

Recommendation:

• Discharge planning should begin at the time of admission; should be a systematic, interdisciplinary

process, coordinated by a single health provider; should intimately involve the patient and family;

and should include assessment of the patient’s living environment, family/ caregiver support,

disability entitlements, and potential for vocational rehabilitation. To the maximum extent possible,

all decisions should reflect a consensus among the patient, family / caregivers, and rehabilitation

team. (Level evidence = IV, Recommendation = Grade C)

27

4. Patient and family education

Education and training of the patient and family prior to discharge should emphasize issues that will be

most relevant during transition. These need to be individualized to the patient but may include:

- preventing recurrent stroke.

- signs and symptoms of potential complications.

- techniques required for specific tasks (e.g. transfers).

- home exercises.

Attention to family / caregiver education and counseling has been shown to increase knowledge, help

stabilize some aspects of family functioning (Evans et al., 1988), and contribute to the maintenance of

rehabilitation gains (Garraway et al., 1981; Strand et al., 1985).

5. Continuity of care

All patients will require continued medical care after discharge from a rehabilitation program, and

many patients will require continued rehabilitation services. Discharge planning includes making

explicit arrangements for these services and ensuring that full information on the patient’s medical and

neurological status, the patient’s responses to rehabilitation interventions, and recommendations for

future medical and rehabilitation treatments are transmitted to future providers at the time of discharge.

Effective communication will help avoid gaps in care and lay the groundwork for future progress.

6. Community Services

Home care and other services from community agencies can help to supplement or substitute for

services provided by family or caregivers. Stroke groups, if available, may be particularly helpful to

the patient and family. Every rehabilitation facility should maintain an up-to-date inventory of local,

regional and national services. These should be reviewed with the patient and family prior to discharge,

and linkages should be established for services that are both needed and desired.

F. Community

1. Transition to the community

Living with disabilities after a stroke is lifelong challenge during which people continue to seek and

find ways to compensate for or adapt to persisting neurological deficits. For many stroke survivors

and their families, the real work of recovery begins after formal rehabilitation. One of the most

28important tasks of a rehabilitation program is to help those involved to prepare for this stage of

recovery.

Many people live on their own after a stroke. Others live with family members who will need to

provide various kinds of support. The impact of every stroke is intensely individual, and each person

and family has to chart a pathway to recovery. This focuses mainly on the patient who lives with

caregivers and on common themes that arise after return to a community residence.

2. The transition experience

The first few weeks after discharge from a rehabilitation program are often difficult, as the stroke

survivor attempts to use newly learned skills without the support of the rehabilitation environment.

Later on, other problems may emerge when the full impact of stroke becomes apparent as the person

attempts to resume self-care activities and family relationships. Psychological and social effects of the

stroke, such as communication disorders or limitations of short-term memory, are likely to become

more obvious over time and may have profound effects on daily life.

3. Family and caregiver functioning

Clinicians need to be sensitive to potential adverse effects of caregiving on family functioning and the

health of thecaregiver. They should work with the patient and caregivers to avoid negative effects,

promote problem solving, and facilitate reintegration of the patient into valued family and social roles.

(Evan et al., 1988). (Level of evidence = Ib, Recommendation = Grade A)

4. Continuity and coordination of patient care

The stroke survivor’s continuing care needs should be coordinated by a single physician or health care

provider with the stroke survivor and the principal caregiver. (Level of evidence = IV,

Recommendation = Grade C)

An initial visit with the stroke survivor’s principal physician or health care providers should be

scheduled within 1 month of discharge from an inpatient rehabilitation program or sooner if necessary.

(Level of evidence = IV, Recommendation = Grade C)

5. Postdischarge monitoring

The stroke survivor’s progress should be evaluated within 1 month after return to a community

residence and a regular intervals during at least the first year, consistent with the person’s condition

29and the preferences of the stroke survivor and family. Monitoring of physical, cognitive, and

emotional functioning and integration into family and social roles is especially important.

(Level of evidence = IV, Recommendation = Grade C)

6. Continued rehabilitation services

Continued rehabilitation services should be considered to help the stroke survivor sustain the gains

from the rehabilitation program and to build on patient and family strengths and interests as that patient

becomes reintegrated into the home and community. Services should be phased out as measurable

benefit diminishes. (Level of evidence = IV, Recommendation = Grade C)

7. Community supports

Acute care hospitals and rehabilitation facilities should maintain up-to-date inventories of community

resources, provide this information to stroke survivors and their families/ caregivers, and offer

assistance in obtaining needed services. (Level of evidence = IV, Recommendation = Grade C)

8. Safety and Health Promotion during Transition

a. Fall Prevention

Fall prevention after the stroke survivor returns to a community residence should emphasise

identifying patient, treatment, and environmental risk factors, and steps to reduce these risks

(Rubenstein et al., 1990). (Level of evidence = III, Recommendation = Grade B)

b. Health promotion

High priority should be given to the prevention of stroke recurrence and stroke complications and to

health promotion more generally, after the survivor returns to the community. (Level of evidence = IV,

Recommendation = Grade C)

9. Resuming valued activities

Valued leisure activities should be identified, encouraged and enabled (MacNeil et al., 1982)

(Level of evidence = III, Recommendation = Grade B)

Stroke survivors who worked prior to their strokes should, if their condition permits, be encouraged to

be evaluated for the potential to return to work. Vocational counseling should be offered when

appropriate. (Level of evidence = IV, Recommendation = Grade C)

30G. Service Evaluation Service evaluation needs to cover not only the individual professions and departments but also the

quality of the whole service including care in the community.

In order to provide and monitor an adequate clinical service, information is required. Matters that may

need to be considered include: sources of data, documentation outcome assessment; measuring

structure and process.

Recommendations:

• Physiotherapy documentation is clear, accurate and up-to-date, to facilitate optimal patient care,

enhance communication and satisfy legal requirement. (Physiotherapy Service Standard in

Neurology (PSSIN), 1998). (Level of evidence = IV, Recommendation = Grade C)

• Physiotherapists involved in neurological care are responsible for evaluation of service provided

(PSSIN, 1998). (Level of evidence = IV, Recommendation = Grade C)

• Local guidelines or evidence based protocols should he discussed and agreed for common

problems (Naylor et al., 1994). (Level of evidence = Ia, Recommendation = Grade A)

31

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40

Appendix 1

This adopted guideline from Scottish Intercollegiate Guidelines Network originates from the US

agency for Health Care Policy and Research and is set out in the following table.

Level Type of Evidence

Ia Evidence obtained from meta-analysis of randomised controlled trails.

Ib Evidence obtained from at least one randomised controlled trail.

IIa Evidence obtained from at least one well-designed controlled study without

randomisation.

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.

III Evidence obtained from well-designed non-experiemntal descriptive studies, such as

comparative studies, correlation studies and case studies.

IV Evidence obtained from expert committee reports or opinions and/ or clinical experiences

of respected authorities.

Grade Recommendation

A Required - at least one randomized controlled trial as part of the body of literature of

overall good quality and consistency addressing specific recommendation.

B Required - availability of well conducted clinical studies but no randomized clinical trials

on the topic of recommendation.

C Required - evidence obtained from expert committee reports or opinion and/ or clinical

experiences of respected authorities. Indicates absence of directly applicable clinical

studies of good quality.

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Appendix 2 Classification of ischaemic stroke According to the Bamford study in 1991, ischaemic strokes can be classified clinically into: Total anterior circulation infarcts (TACI), Partial anterior circulation infarcts (PACI), Posterior circulation infarcts (POCI) and Lacunar infarcts (LACI). Different groups have different clinical presentation and different prognosis. Involvement Involvement Functional

outcome TACI Cortical and sub-cortical

territories of MCA 1. Weakness ± sensory deficit of at

least 2 of 3 body areas : face/ arm /leg

2. Homonymous hemianopia 3. Higher cerebral dysfunction

( dysphasia, dyspraxia etc)

Poor

PACI Mainly cortical involvement of either division of MCA or ACA

Either 2 of the above Better

POCI Vertibrobasilar arterial territory, associated with brain stem, cerebellum, occipital lobes

Varied, may include : bilateral deficit, ipsilateral cranial nerve palsy, disordered eye movement, isolated homonymous hemianopia etc

Best chance

LACI Territories of deep perforating arteries, mostly of Basal Ganglia and Pons

Pure motor stroke Pure sensory stroke Sensori-motor stroke Ataxic hemiparesis

Can be very handicapped

Prognostic value of classification TACI: poor function and high mortality PACI: early recurrent stroke POCI: later recurrent stroke in 1st year LACI: poor function and low mortality

42

Appendix 3

Modified Ashworth Scale

0 = No increase in muscle tone

1 = Slight increase in muscle tone, manifested by a catch and release or by minimal

resistance at the end range of motion when the part is moved in flexion or extension/

abduction or adduction, etc.

1+ = Slight increase in muscle tone, manifested by a catch, followed by minimal resistance

thoughtpout the remainder (less than half) of the ROM.

2 = More marked increase in muscle tone through most of the ROM, but the affected part is

easily moved.

3 = Considerable increase in muscle tone, passive movement is difficult.

4 = Affected part is rigid in flexion or extension (abduction or adduction etc)

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Appendix 4 Berg's Balance Scale

ITEM DESCRIPTION SCORE (0-4) 1. Sitting to standing __________ 2. Standing unsupported __________ 3. Sitting unsupported __________ 4. Standing to sitting __________ 5. Transfer __________ 6. Standing with eye close __________ 7. Standing with feet together __________ 8. Reaching forward with outstretched arm __________ 9. Retrieving object from floor __________ 10. Turning to look behind __________ 11. Turning 360 degrees __________ 12. Placing alternate foot on stool __________ 13. Standing with one foot in front __________ 14. Standing on one foot __________ TOTAL __________ GENERAL INSTRUCTIONS Please demonstrate each task and/ or give instructions as written. When scoring, please record the lowest response category that applies for each item. In most items, the subject is asked to maintain a given position for specific time. Progressively more points are deducted if the time or distance requirements are not met, if the subject's

performance warrants supervision, or if the subject touches an external support or receives assistance

from the examiner. Subjects should understand that they must maintain their balance while attempting

the tasks. The choices of which leg to stand on or how far to their reach are left to the subjects. Poor

judgement will adversely influence the performance and the scoring.

Equipment required for testing are a stopwatch or watch with a second hand, and a ruler or other

indicator of 2, 5, and 10 inches (5, 12, and 25cm). Chairs used during testing should be of reasonable

height. Either a step or a stool (of average step height) may be used for items #12.

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Appendix 5 Barthel ADL Index

Bowels 0=incontinent (or needs to be given enemata) 1=occasional accident (once a week) 2= continent Baldder 0=incontinent, or catherized and unable to manage alone 1= occasional accident (maximum once per 24 hours) 2=continent Grooming 0=needs help with personal care 1=independent face/ hair/ teeth/ shaving (implements procided) Toilet use 0= dependent 1=needs some help, but can do something alone 2-independent (on and off, dressing, wiping) Feeding 0=unable 1=needs help cutting, spreading butter, etc. 2=independent Transfer (bed to chair and back) 0=unable 1=major help (one or two person, physical), can sit 2=minor help (verbal or physical) 3=independent Mobility 0=immobile 1=wheelchair independent, including corners 2=walks with help of one person (verbal or physical) 3=independent (but may use any aids; for example, stick) Dressing 0=dependent 1=needs help but can do about half unaided 2=independent (including buttons, zips, laces, etc.) Stairs 0=unable 1=needs help (verbal, physical, carrying aid) 2=independent Bathing 0=dependent 1=independent

45

45

Appendix 7 Motor Assessment Scale

0 1 2 3 4 5 6

1. supine to side lying

2. Supine to sitting over side of bed

3. Balance sitting

4. Sitting to standing

5. Walking

6. Upper-arm function

7. Hand movement

8. Advanced hand activities

9. General tonus

Detail of scoring criteria, go to Carr et al. (1985). Investigation of a new assessment scale for stroke patients. Physical Therapy, 65, 178-179.

46

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APPENDIX 8

The Elderly Mobility Scale

Elderly Mobility Scale (Smith, 1994) was developed in respond to the use of Barthel Index (Mahoney and Barthel, 1965) as the core clinical assessment package in elderly medicine recommended by the Royal College of Physicians and British Geriatric Society (1992). The EMS is clinically applicable for busy medical professionals in Hong Kong due to its simplicity of administrative make-up. In rehabilitation, bed mobility, transfer and walking ability of patient covered by the EMS are physiotherapists' intervention. The EMS is a performance based test. The elderly are rated with respect to the tasks specified in seven items including ‘lying to sitting’, ‘sitting to lying’, ‘sitting to standing’, ‘standing’, ‘gait’, ‘timed walk’ and ‘functional reach’. Performance of each of the tasks is rated against a Likert scale. Each item carries different scores. The items ‘lying to sitting’ and ‘sitting to lying’ range from 0 to 2. The items ‘sitting to standing’, ‘standing’, ‘gait’ and ‘timed walk’ range from 0 to 3. The item ‘functional reach’ ranges from 0 to 4. Standardized scoring criteria is set for all items. The scoring criteria are: i) ‘Lying to sitting’/ ‘Sitting to lying’ 2 Independent (without verbal or physical help) 1 Needs help of 1 person 0 Needs help of 2+ people ii) ‘Sitting to standing’

3 Independent in under 3 seconds (whether or not the upper limbs are used) 2 Independent in over 3 seconds

1 Needs help of 1 person (verbal or physical help, uses assisting device, pulls up using upper limb) 0 Needs help of 1 person Remark: Timing commences when the patient begins the task. The chair height is 19”. The chair should be firm and straight backed. iii) ‘Standing’ 3 Stand without support and able to reach 2 Stand without support but needs to reach 1 Stand but need support 0 Stand only with physical support Remark: Maximum score 3 is achieved if the person can stand without holding on with upper limb or leaning against something, and move arms forward and sideways as if to reach for something within arm’s length ( i.e. not reaching so far so center of gravity is shifted). They must be safe and steady while performing this test. Score 1 is achieved if they need assistance to steady themselves e.g. frame, stick or furniture ( not parallel bars ) whilst standing.

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iv) ‘Gait’ 3 Independent (including use of sticks/ Quadripod) 2 Independent with frame 1 Mobile with walking aid but erratic/ unsafe 0 Needs physical help to walk or constant supervision Remark: Score 3 if the person walks independently and safely, is able to turn, change direction, stop and start. Use of a walking stick is acceptance. Score 2 if the person walks safely, is able to turn, change directions, stop and start using a frame/ rollator/ crutches/ 2 sticks. Score 1 if the person requires supervision at times, e.g. when turning, but not all the time. v) ‘Timed walk’ (6 meters) 3 Under 15 seconds 2 16-30 seconds 1 Over 30 seconds 0 Unable to cover 6 meters Remark: Walking speed is timed over 6 meters, with the person walking as fast as they can. Timing should be done with a stop watch, and commences as the leading foot swings across the start line. vi) ‘Functional reach’ 4 Over 20 cm (8”) 2 10-20 cm (4-8”) 0 Under 10 cm (4”) or unable to reach because of poor balance/ inability to stand