Professional Documents
Culture Documents
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.
Page
I. Goals of Guidelines 1
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.
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).
2
C. 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).
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
5
3. 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.
6
Recommendation:
• 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
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.
8
Recommendation:
• 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).
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).
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
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)
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).
Recommendation:
• Functional electrical stimulation should be used to prevent shoulder pain and subluxation ( Faghri
et al.,1994). (Level of evidence = Ib, Recommendation = Grade A)
13
c) 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)
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
Recommendation :
• Limb physiotherapy should be performed for prevention of contractures and spasticity of
hemiplegia limbs (AHCPR, 1995). (Level of evidence = IV, Recommendation = Grade C)
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.
18
Recommendations:
• 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)
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)
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).
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 ).
20
b) 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 ).
21
Recommendation :
• Constraint-induced therapy is effective on improvement of upper limb motor skill of stroke patient
( Level of Evidence = IIa, Recommendation = Grade B ).
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.
22
Recommendation:
• Clinical study shown that accupuncture had beneficial effect in stroke rehabilitation. ( Level of
evidence = Ib recommendation = Grade A )
Recommendation:
• Vasomotor training should start in the early stage of rehabilitation (Level of evidence = IV
Recommendation = Grade C )
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
24
b. 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
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)
26
2. 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
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
28
important 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.
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
29
and 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)
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)
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)
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
References
Adams, H.P., Jr, Broh, T.G., Crowll, R.M., Furlan, A.A.J., et al. Guidelines for the management of
patients with acute ischertion stroke. American Heart Association stroke 1994, 25, pp.1901-1914.
Agency for Health Care Policy and Research (1995) Post- stroke Rehanilitation, Clinical Practice
Guideline . No. 16 Rockville, MD: US Dept of Health and Human Services.
Alfieri, V. (1982). Electrical treatment of spasticity. Scandinavian Journal of Rehabilitation Medicine,
14, 177-182.
Asberg, K.H. (1989). Orthostatic tolerance training of stroke patients in general medical wards: An
experimental study. Scandinavian Journal of Rehabilitation Medicine, 21(4), 179-85.
Bamford, J., Sandercock, P., Dennis, M., Burn, J., & Warlow, C. (1991). Classification and natural
history of clinically identifiable subtypes of cerebral infarction. Lancet, 337,1521-26.
Bar-Eli, M., Hartman, I., & Levy-Kolker, N. (1994). Using goal setting to improve physical
performance of adolescents with behaviour disorders: the effects of goal proximity. Adapted Physical
Activity Quarterly, 11, 86-97
Bar-Eli, M., Tenenbaum, G., Pie, J.S. et al. (1997). Effect of goal difficulty, goal specificity and
duration of practice time intervals on muscular endurance performance. Journal of Sports Sciences, 15,
125-35.
Basmajian, J.V., Gowland, C.A., Finlayson, M.A. et al. (1987). Stroke treatment: comparison of
integrated behavioural physical therapy vs traditional physical therapy programs. Archives of Physical
Medicine and Rehabilitation, 68, 267-72.
Blair, C.E. (1995). Combining behaviour management and mutual goal setting to reduce physical
dependency in nursing home residents. Nursing Research, 44, 160-5.
Blair, C.E., Lewis, R., Vieweg, V., & Tucker, R. (1996). Group and single-subject evaluation of a
programme to promote self-care in elderly nursing home residents. Journal of Advanced Nursing, 24,
1207-13.
Bennett, WD., Foster, WM., & Chapman W.F. (1990). Cough-enhanced mucus clearance in normal
lung. Journal of Applied Physiology, 69(5), 1670-1675.
Bohannon, R.W. (1987). Gait performance of hemiparetic stroke patients: selected variables. 68,
777 - 781.
Bobath, B. (1990). Adult Hemiplegia: Evaluation and Treatment (3rd ed). Oxford,UK: Heinemann
Medical Books.
32
Bowman, B., Baker, L., & Waters, M. (1979). Positional feedback and electrical stimulation: An
automated treatment for the hemiplegic wrist. Archives of Physical Medicine and Rehabilitation, 60,
pp. 497.
Bsus, D.F., Kraus, J.K., & Strobel, J. (1994). The Shoulder-hand syndrome after stroke: a prospective
clinical trial. Annals of Neruology, 36, T 28-33.
Butefisch, C., Hummelsheim, H., & Denzler P, et al (1995). Repetitive training of isolated movements
improves the outcome of motor rehabilitation of centrally paretic hand. J Neurol Sci 130, 59.
Carey, JR (1190) Manual Stretch: Effect and force control in stroke subjects with spastic extrinsic
finger flexor muscles. Archives of Physical Medicine and Rehabilitation 71(11), 889-894
Carr, E.K., Kenney, F.D. (1992). Positioning of the stroke patient: a review of the literature.
International Journal of Nursing Studies, 29, 355-69.
Carr, J., & Shepherd, R. (1987). A motor relearning programme for stroke. London: Heinemann.
Chae, J., Bethoux, F., Bohini, T., Dobos, L., Davis, T., & Frieddl A.. (1998). Neuromuscular
stimulation for upper extremity motor and functional recovery in acute hemiplegia. Stroke, 29, 975-
979.
Chen, Y.M, & Fang, Y.A. (1990). “108 cases of hemiplegia caused by stroke: The relationship
between CT scan results, clinical findings and the effect of acupuncture treatment.” Acupuncture &
Electro-therapeutics Res. Int. J., 15, 9-17.
Cotton, E., & Kinsman, R. (1983). Conductive education and adult hemiplegia. Edinburgh
Churchill Livingstone.
Davies, P.M. (1991). Steps to Follow. Berlin: Springer-Verlag.
Dean, C.M., & Shepherd, R.B. (1997). Task-related training improves performance of seating
reaching tasks after stroke: a randomised controlled trial. Stroke, 28, 722-8.
Dickstein, R., Hocherman, S., Pillar, T., et al. (1986). Stroke rehabilitation: Three exercise therapy
approaches. Physical Therapy, 66, pp. 1233.
Dickstein, R., Nissan, M., Pillar, T., & Scheer, D. (1984). Foot-ground pressure pattern of standing
hemiparetic patients: Major characteristics and patterns of movement. Physical Therapy, 64, 19 - 23.
Dimitrijevic, M., Stokic, D., Wawro A, et al. (1996). Modification of motor control of wrist extension
by mesh-glove electrical afferent stimulation in stroke patients. Archives of Physical Medicine and
Rehabilitation,77, 252.
Donatelli, R.A. (1991). Physical Therapy of the Shoulder, pp117- 149.
Dromerick, A., & Reading, M. (1994). Medical and neurological complications during inpatient
stroke rehabilitation. Stroke, 25, 358-361.
33
Duncan, P.W. (1997). Synthesis of intervention trials to improve motor recovery following stroke.
Top Stroke Rehabilitation, 31 (4), 1-20.
Erbil, D., Nigar, H., Semra, D., Onder, T., & Aytul, C. (1996). Angular biofeedback device for sitting
balance of stroke patients. Stroke, 27,1354-1357.
Evans, R.L., Matlock, A.L., Bishop, D.S., Stranahan, S., & Pederson, C. (1988). Family intervention
after stroke: does counselling or education help? Stroke, 19 (10), 1243-1249.
Falghri, P.D., Rodgers, M.M., Glaser, R.M., Bors, J.G., Ho, C. & Akuthota, P. (1994). The effects of
functional electrical stimulation an shoulder subluxation arm function recovery, and shoulder pain in
hemiplegic stroke patients. Archives Physical Medicine and Rehabilitation, 75, 73-79.
Fields, R. (1987). Electromyographically triggered electric muscle stimulation for chronic hemiplegia.
Archives of Physical Medicine and Rehabilitation,68,407, 1987
Fishman, M.N., Nichols, D.S., Colby, L.A., & Sachs, L. (1996). Comparison of functional upper
extremity tasks and dynamic standing balance in hemiparesis. Physical Therapy, 76, S79 [Abstract].
Franciso, G., Chae, J., Chawla, H., Kershblum, S., Zorowitz, R., Lewis, G., & Pang, S. (1998).
Electromygram-triggered neuromuscular stimulation for improving the arm function of acute stroke
survivor: a randomized pilot study. Archives Physical Medicine and Rehabilitation, 79, 570-575.
Garraway, W.M, Walton, M.S, Akhar, A.J., & Prescott, R.J. (1981). The use of health and social
services in the management of stroke in the community : results from a controlled trail. Age & ageing
10(2) ,95-104
Gillespie, L.D., Gillespie, W.J., Cumming, R, Lamb, S.E., & Rowe, B.H. (1999). Interventions for
preventing falls in the elderly. In: The Cochrane Library, Issue 3. Oxford: Update Software.
Glanz, M., Klawansky, S., Stason, W., Berkey, C., & Chalmers, T. (1996). Functional electro-
stimulation in poststroke rehabilitation: a meta-analysis of randomized controlled trials. Archives of
Physical Medicine and Rehabilitation, 77, 549-553.
Glanz, M., Klawansky, S., Stason, W., Berkey, C., Shah, N., Phan, H., & Chalmers, T.C. (1995).
Biofeedback therapy in pststroke rehabilitation: a meta-analysis of randomized controlled trials.
Achieves of Physical Medicine and Rehabilitation, 76(6), 508-515.
Glasgow, R.E., Toobert, D.J., & Hampson, S.E. (1996). Effects of a brief office-based intervention to
facilitate diabetes dietary self-management. Diabetes Care, 19, 835-42.
Goff, B. (1969). Appropriate afferent stimulation. Physiotherapy, 55, 9-17
Grossen-sils, J., & Schenkman M. (1985) Analysis of shoulder pair range of motion and subluxation
in patients with hemiplegia Physical Therapy 65-182.
34
Hasani, A., Pavia, D., Agnew, F., Clarke, S.W. (1991). The effect of unproductive coughing / FET
on regional mucus movement in the human lungs. Respiratory Medicine, 85(suppl A), 23-26.
Hayes, S.H. & Carroll, S.R. (1986). Early intervention care in the acute stroke patient. Archives of
Physical Medicine and Rehabilitation, 67(5), 319-21
Hocherman, S., Dickstein, R., & Pillar, T. (1984). Platform training and postural stability in
hemiplegia. Archives of Physical Medicine and Rehabilitation, 65(10), 588 - 592.
Horak, F., Esselman, P., Anderson, M., Lynch, M. (1984). The effects of movement velocity, mass
displaced, and task certainty on associated postural adjustments made by normal and hemiplegic
individuals. Journal of Neurology and Neurosurgical psychiatry, 47, 1020 - 1028.
Hong Kong Hospital Authority. (1997). Hospital Authority Statistical Report 1995/96. The author:
Hong Kong.
Ho, W.S.W. (2000). Development of Case Model for Stroke. Symposium on Stroke Rehabilitation,
Hong Kong.
Hua, H.H., Chung, C., et al. (1993). A randomized controlled trial on the treatment for acute partial
ischemic stroke with acupuncture. Neuroepidemiology, 12, 106-113.
Huang, C.Y., Chan, F.L., Yu, Y.L., Woo, E., & Chin, D. (1990). Cerebrovascular disease in Hong
Kong Chinese. Stroke, 21, 230-5.
Hummelsheim, H., Maier-Loth, M., & Eickhof, C. (1997). The functional value of electrical muscle
stimulation for the rehabilitation of the hand in stroke patients. Scandinavian Journal of Rehabilitation
Medicine, 29, pp. 3.
Hurd, M.M., Farrell K.H. & Waylonis G.W. (1974). Shoulder sling for hemiplegia: friend or foe?
Archives of Physical Medicine & Rehabilitation, 55, 519-522.
Jongbloed, L., Stacey, S., & Brighton, C. (1989). Stroke rehabilitation: sensorimotor integrative
treatment versus functional treatment. American Journal of Occupational Therapy 43, 391-7.
Kay, R. (1993). Cerebrovascular disease in Hong Kong. Journal of Hong Kong Medical Association,
45, 3-6.
Joynt, R. (1992). The source of shoulder pain in hemiplegia. Archives of Physical Medicine &
Rehabilitation 73(5) ,409-13
Kathryn, A., Sawer-Jeanne, M., & La Vigne. (1992). Burnnstorn's movement therapy in hemiplegic
Lippincott.
Katrak, P.H., Cole, A.M.D., Ponlus, C.J., & McCauley, J.CK. (1992). Objective assessment of
spasticity, strength and function with early exhibition of dantrolene sodicem after cerebrovascular
accident: A randomized double-blind study. Archives of Physical Medicine and Rehabilitation 73, 4-9
35
Kay, R., Woo, J., Kreel, L., Wong, H.Y., Teoh, R., & Nicholls, M.G. (1992). Stroke subtypes
among Chinese living in Hong Kong: the Shatin Registry. Neurology, 42, 985-7.
Kidd, G., Lawer, N., & Musa, I. (1992). A critical review of contemporary therapies. Understanding
neuromuscular plasticity; a basis for clinical rehabilitation. London: Edward Arnold.
Knutsson E, & Martensson A (1980). Dynamic Motor capacity in spastic paresis and its relation to
primary motor dysfunction: spastic reflexes and antagonist co-activation. Scandinavia Journal of
Rehabilitation Medicine 12(3), 93-106
Kraft, G., Fitts, S., Hammond, M. (1992). Techniques to improve function of the arm and hand in
chronic hemiplegia. Archives of Physical Medicine and Rehabilitation, 73, 220.
Kralji A, Acimoric R, stanic U 1993. Enhancement of hemiplegic patient rehabilitation by means of
functional electrical stimulation Prosthetics and Orthotics International 17:107-114
Kumar, R., Metter, E.J., Mehta A.J. & Chew T. (1990). Shoulder pain in hemiplegia: The role of
exercise. American Journal of Physical Medicine & Rehabilitation 69, 205-208.
Kwakkel, G., Wagenaar, R.C., Koelman, T.W. et al. (1997). Effects of intensity of rehabilitation after
stroke: a research synthesis. Stroke, 28, 1550-6.
Langhorne, P., Wagenaar, R., & Partridge, C. (1996). Physiotherapy after stroke: more is better?
Physiotherapy Research International, 1,75-88.
Leanclri, M., Parodi, C.1., Corriers, N., & Rigards. (1990). Comparision of TENS treatments in
hemiplegic shoulder pain. Scandinavian Journal of Rehabilitation Medicine, 22, 69-72
Levin, M.F., Hui, Chan, C.W. (1992). Relief of hemiplegic spasticity by TENS is associated with
improvement in reflex and voluntary motor functions. Electroencephalography and Clinical
Neurophysiology, 85(2), 131-142.
Lincoln, N.B., Parry, R.H., & Vass, C.D. (1999). Randomized, controlled trial to evaluate increased
intensity of physiotherapy treatment of arm function after stroke. Stroke, 30,573-79.
Lincoln, N.B., Willis, D., Philips, S.A. et al. (1996). Comparison of rehabilitation practice on hospital
wards for stroke patients. Stroke, 27,18-23.
Linn, S.L., Granat, M.H. et al. (1999). Prevention of shoulder subluxation after stroke with electrical
stimulation, Stroke 30, 963 - 968.
Liston, R., & Brouwer, B. (1996). Reliability and validity measures obtained from stroke patients
using the Balance Master. Archives of Physical Medicine and Rehabilitation, 77, 425 - 430.
Lu, C.L., Yu,B., Basford, J.R. et al. (1997). Influence of care length on the stability of stroke patients.
Journal of Rehabilitation Research and Development, 34, 91-100.
36
MacNeil, R.D., & Pringnitz, T.D. (1982). The role of therapeutic recreation in stroke rehabilitation.
The Rec J Qu 4, 26-34.
Mahoney, F.I., & Barthel, D.W. (1965). Functional evaluation: the Barthel Index. Maryland State
Medical Journal, 14, 61-65.
Mak, M., & Au-Yeung, S. (2000). A handbook on Neuro-rehabilitation (Physiotherapy). Hong Kong :
Hong Kong Polytechnic University.
Moreland, J.D., & Thomson, M.A. (1994). Efficacy of electromyographic biofeedback compared with
conventional physical therapy for upper-extremity function in patients following stroke: a research
overview and meta-analysis. Physical Therapy, 74(6), 534-547.
Moreland, J.D., Thomson, M.A., & Fuoco, A.R. (1998). Electromyographic biofeedback to improve
lower extremity function after stroke: a meta-analysis. Archives of Physical Medicine and
Rehabilitation, 79, 134-140.
Najenson T, Pilcoelny SS, Malalignment of the Genohumeral joint following hemiplegia Archives of
Physical Medicine and Rehabilitation 1965; 8:96-99
Naylor, et al. (1994). Comprehensive discharge planning for the hospitalised elderly: a randomised
clinical trial. Annals of Internal Medicine, 120, 999-1006
Nichols, D.S. (1997). Balance training after stroke using force platform biofeedback. Physical
Therapy, 77, 553 - 558.
Nelson, D.L., Konosky, K., Fleharty, K. et al. (1996). The effects of an occupationally embedded
exercise on bilaterally assisted supination in persons with hemiplegia. American Journal of
Occupational Therapy, 50, 639-46.
Nichols, D.S., Miller, L., Colby, L.A., & Pease, W.S. (1996). Sitting balance: Its relation to function
in individuals with hemiparesis. Archives of Physical Medicine and Rehabilitation, 77, 865 - 869.
Nudo, R.J., Wise, B.M., SiFuentes, F. et al. (1996). Neural substrates for the effects of rehabilitative
training on motor recovery after ischemic infarct. Science 272, pp. 1791.
Parry, R.H., Lincoln, N.B., & Vass, C.D. (1999). Effect of arm impairment on response to additional
physiotherapy after stroke. Clinical Rehabilitation, 13, 187-98.
Neurology Special Interest Group. (1998). Physiotherapy Service Standard in Neurology. Hong
Kong: Hong Kong Physiotherapy Association.
Poole, JL., Whitney SL Hangeland, & Baker, C (1990) The effectiveness of inflatable pressure splints
on motor function in stroke patients. Occupational Therapy Journal Research 10(6), 360-366.
Rapoport, J., & Eerd, M.J. (1989). Impact of physical therapy weekend coverage on length of stay in
an acute care community hospital. Physical Therapy, 69, 32-7.
37
Richards, C.L., Malouin, F., Wood-Dauphinee, S. et al. (1993). Task-specific physical therapy for
optimisation of gait recovery in acute stroke patients. Archives of Physical Medicine and
Rehabilitation, 74,612-20.
Riddoch, M.J., Humphreys, G.W., & Bateman, A. (1995). Stroke: Issues in recovery and
rehabilitation. Physiotherapy, 81, 689-694.
Royal College of Physicians. (1998). National Clinical Guidelines for Stroke.
Royal College of Physicians and British Geriatric Society. (1992). Standardized assessment scales for
elderly people, London: RCP and BGS.
Rubenstein, L.E, Robbins, A.S, Josephson, K.R., Schulman, R.L., & Osterweil, D. (1990). The value
of assessing falls in and elderly population: a randomized clinical trail. Annals of Internal Medicine,
131, 308-16.
Sahrmann, S., & Norton, B.J. (1997). The relationship of voluntary movement to spasticity in the
upper motor neuron syndrome. Annals of Neurology, 2, 460-465.
Scheenbaker, R.F., & Mainous, A.G. (1993). Electromygraphic biofeedback for neuromuscular re-
education in hemiplegic stroke patient: A meta-analysis. Archives of Physical Medicine and
Rehabilitation, 74(12), 1301-1304.
Scottish Intercollegiate Guidelines Network. (1998). Management of patients with stroke. Edinburgh:
The author.
Shumway-Cook, A., Anson, D., & Haller, S. (1988). Postural sway biofeedback: its effect in
reestablishing stance stability in hemiplegic patients. Archives of Physical Medicine and
Rehabilitation, 69(6), 395 - 400.
Smith, R. (1994). Validation and Reliability of the Elderly Mobility Scale. Physiotherapy, 80 (11),
744-747.
Smith, D.S., Goldenberg, E., Ashburn, A. et al. (1981). Remedial therapy after stroke: a randomised
controlled trial. British Medical Journal, 282, 517-20.
Stefanovska, A., Rebersek, S., Bajd, T., & Vodovnik, L. (1991). Effects of electrical stimulation on
spasticity. Critical Reviews in Physical and rehabilitation Medicine 3(1), 59-99
Stineman, M.G., & Maislin, G. (1997). A prediction model for functional recovery in stroke. Stroke,
28, 550-556.
Strand, T., Asplundk, S., Hagg, E., Lithna, F., & Wester, P. (1985). A non-intensive stroke unit
reduces functional disability and the need for long term hospitalization. Stroke, 16(1), 29-34
Stroke Unit Trialists' Collaboration. (1998). Organised inpatient (stroke unit) care for stroke
(Cochrane Review). In: The Cochrane Library, Issue 3, 1999. Oxford: Update Software.
38
Taub, E., Miller, N., Novack, T., et al. (1993). Technique to improve chronic motor deficit after
stroke. Archives of Physical Medicine and Rehabilitation 74, 347.
Taub, E., & Wolf, S. (1997). Constraint induced movement techniques to facilitate upper extremity
use in stroke patients. Topics in Stroke Rehabilitation 3, 38.
Tsim, R. (1998). Validity of elderly mobility scalein assessing mobility of elderly patients in hospitals.
Unpublished master thesis. Hong Kong: Hong Kong Polytechnic University.
Tyson, S.F., & Ashburn, A. (1994). The influence of walking aids on hemiplegic gait. Physiotherapy
Theory and Practice, 10, 77-86.
van Vliet, P., Sheridan, M., Kerwin, D.G., & Fentem, P. (1995). The influence of functional goals on
the kinematics of reaching following stroke. Neurology Report 19, 11-6.
Visintin, M., Barbeau, H., Korner-Bitenslcy, N., & Mayco, N.E. (1998). A new approach to retrain
gait in stroke patients through body weight support and treadmill stimulation. Stroke, 29, 1122-8
Wade, D.T., Collen, F.M., Robb, G.F., & Warlow, C.P. (1992). Physiotherapy intervention later after
stroke and mobility. British Medical Journal 304, 609-13.
Wade, D.T. (1998). Evidence relating to assessment in rehabilitation. Clinical Rehabilitation, 12,
183-6.
Wagenaar, R., Meijer, O., van Wieringen, P., et al. (1990). The functional recovery of stroke: A
comparison between neuro-developmental treatment and the Brunnstrom method. Scandinavian
Journal of Rehabilitation Medicine 22, pp. 1-8.
Wall, J.C., & Turnbill, G. (1987). Evaluation of Out-patient physiotherapy and home exercise
program in the management of gait asymmetry in residual stroke. Journal of Neurologic Rehabilitation
1, 115-23.
Wikander, B., Ekelund, P., & Milsom, I. (1998). An evaluation of multidisciplinary intervention
governed by Functional Independence Measure (FIM) in incontinent stroke patients. Scandinavian
Journal of Rehabilitation Medicine, 30, 15-21.
Winstein, C.J., Gardner, E.R., McNeal, D.R., Barto, P.S., & Nicholson, D.E. (1989). Standing
balance training: Effect on balance and locomotion in hemiparetic adults. Archives of Physical
Medicine and Rehabilitation, 70(10), 755 - 762.
Wissel, J., Ebersbach, G., Gutjahr, L., et al. (1989). Treating chronic hemiparesis with modified
biofeedback. Archives of Physical Medicine and Rehabilitation, 70, 612.
Wolf, S., & Binder-MacLoed, S. (1983). Electromyographic biofeedback applications to the
hemiplegic patient. Physical Therapy 63, 1393.
39
Wolf, S., LeCraw, D., & Barton, L. (1989). Comparison of motor copy and targeted biofeedback
training techniques for restitution of upper extremity function among patients with neurologic
disorders. Physical Therapy, 69, 719.
Wolf, S., Catlin, P., Blanton, S. et al. (1994). Overcoming limitations in elbow movement in the
presence of antagonist hyperactivity. Physical Therapy, 74, 826.
Wolf, S., LeCraw, D., Barton, L. et al. (1989). Forced use of hemiplegic upper extremities to reverse
the effect of learned nonuse among chronic stroke and head-injured patients. Exp Neurol 104, pp. 125.
Wong, R.Y. (1994). Effect of proprioceptive Neuromuscular facilitator on the gait of patients which
hemiplegic of long and short duration. Physical Therapy, 74, 1108-1115.
Woodspuncan, P. (1997). Synthesis of Intervention Trials to improve Motor Recovery following
Stroke. Top Stroke Rehabilitation, 3(4), 1-20.
Yekutiel, M., & Guttman, E. (1993). A controlled trial of the retraining of the sensory function of the
hand in stroke patients. Journal of Neurology, Neurosurgery and Psychiatry, 56, 241-244.
Yu, M. (1998). Validity of the elderly mobility scale in placement decision. Unpublished master
thesis. Hong Kong: Hong Kong Polytechnic University.
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.
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.
41
Appendix 2
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.
44
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
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
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.
45
46
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:
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.
46
47
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.
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.
47