Professional Documents
Culture Documents
Protocol
Occupational Therapy
i
Stroke Rehabilitation Protocol – Occupational Therapy
Members of the Stroke Working Group
Coordinating Committee for Occupational Therapists
(OTCOC), HA (2007/8)
Coordinator
Teresa Leung, Occupational Therapist I (SH, NTE Cluster)
Members
Cecilia Sum, Department Manager (Occupational Therapy), (SH, NTE Cluster)
Christina Yau, Senior Occupational Therapist (TWH, HKW Cluster)
Dora Chan, Senior Occupational Therapist (KH, KC Cluster)
Grace Yuen, Occupational Therapist I, (RHTSK, HKE Cluster)
Joyce Cheung, Occupational Therapist I, (POH, NTW Cluster)
Kathy Chow, Occupational Therapist I, (KH, KC Cluster)
Cheung Sau Han, Occupational Therapist I (KH, KC Cluster)
Albert Tsai, Occupational Therapist I, (HHH, KE Cluster)
Sharron Leung, Occupational Therapist I, (CMC, KW Cluster)
Acknowledgement:
The Stroke Working Group (OTCOC) would like to give special acknowledgement
to the Stroke Rehabilitation Protocol Working Group of the New Territories East
Cluster of the Hospital Authority for providing their protocol (12/2002) as our basis
of work to extend it as this protocol at OTCOC level in 2007.
Members
Brian Au, Occupational Therapist I, Tai Po Hospital (TPH)
Amy Chan, Occupational Therapist I, Shatin Hospital (SH)
Raymond Ching, Occupational Therapist I, North District Hospital (NDH)
Teresa Leung, Occupational Therapist I, Shatin Hospital (SH)
Dawn Poon, Occupational Therapist I, Prince of Wales Hospital (PWH)
Ewert Tse, Occupational Therapist I, Alice Ho Mui Ling Nethersole Hospital
(AHNH)
ii
Stroke Rehabilitation Protocol – Occupational Therapy
Table of Contents
Page
1. Background……………………………………………………………………. 1
1.1 Introduction………………………………………………………………… 1
1.2 Objectives of Occupational Therapy in Stroke Rehabilitation…………….. 2
1.3 Objectives of Stroke Protocol……………………………………………… 3
iii
Stroke Rehabilitation Protocol – Occupational Therapy
4. Occupational Therapy Treatment Interventions…………………….. 23
6. Documentation………………………………………………………………. 32
7. Appendices......................................................................................................... 33
iv
Stroke Rehabilitation Protocol – Occupational Therapy
1. Background
1.1. Introduction
Stroke care is a major healthcare issue in Hong Kong. In 2005, it was the third
leading cause of death and first leading cause of disability. The age-specific
mortality rate was 2,974 per 100,000 population among patients age ≥ 65 and
377 per 100,000 for age 45 to 64 in year 2004 (Hospital Authority Statistical
rehabilitation.
protocols” refers to the precise and detailed plans for a medical or biomedical
2005. This clinical protocol for stroke rehabilitation is based on the evidence
with stroke and improving the communication among colleagues in the care
process.
1
Stroke Rehabilitation Protocol – Occupational Therapy
1.2. Objectives of Occupational Therapy in Stroke Rehabilitation
1.2.5 To assist patients and their families in adjusting to disability and life
changes, so as to reintegrate into community and live a meaningful
life of their choice.
2
Stroke Rehabilitation Protocol – Occupational Therapy
1.3. Objectives of Stroke Protocol
1.3.3 To enhance the continuity of care from one setting to another through
colleagues.
3
Stroke Rehabilitation Protocol – Occupational Therapy
2. Stages of Occupational Therapy Management for Patients with Stroke
2.1 Occupational Therapy Service Network for Different Stages of Stroke Rehabilitation in Hospital Authority
Clusters
Stages NTE NTW KC KW KE HKW HKE
Acute Phase PWH, NDH TMH QEH CMC, KWH UCH QMH PYNEH
AHNH PMH, YCH TKOH RHTSK
Rehabilitation SH POH KH CMC UCH TWH RHTSK
Phase TPH TMH BH OLMH HHH FYKH TWEH
PMH (LKB) MMRC CCH
WTSH GH
YCH
Ambulatory PWH (OPD) TMH (OPD & GDH) KH (OPD) CMC (GDH & OPD) YFS (OPD & GDH ) TWH (DRC & GDH) PYNEH (GDH)
Phase SH (GDH) POH (OPD) YMT (GDH) KWH (GDH & OPD) HHH (DRC & OPD) MMRC(ARC) RHTSK (GDH)
AHNH (DRC & OPD) OLMH (OPD) TKOH (OPD) FYKH (GDH) TWEH (GDH)
NDH (DRC & OPD) PMH (GDH & OPD) DTRC (OPD) SJH (OPD)
WTSH (GDH)
YCH (OPD)
Community All settings (HV) All settings (HV) All settings (HV) All settings (HV) All settings (HV) All settings (HV) All settings (HV)
Phase (COST) for NTE TMH (CGAT ) KH (CMRS & COT) CMC (CGAT) HHH (CGAT) FYKH (CGAT) RHTSK (CGAT)
cluster KH (CGAT) KWH (COT, CGAT & YFS (CGAT) MMRC (ECS)
COST) DTRC (COT)
PMH (COT & CGAT)
Note:
OPD – outpatient service DRC –Day Rehabilitation Center
GDH – Geriatric Day Hospital ARC- Ambulatory Rehabilitation Center
COST – Community Outreach Service Team ECS – Extended Care Service
CMRS – Community Medical Rehabilitation Service CGAT – Community Geriatric Assessment Team
COT – Community Occupational Therapy HV – pre and post discharge home visits
Rehabilitation
These goals are references that apply to all stages of stroke rehabilitation depends on the needs,
ability and support system of the patient at a particular time, and it is not exhaustive either as
special goals may arise in particular patients with that specific background.
In-patient Rehabilitation
Acute Phase (OT Goals):
1. Prevent complications.
2. Improve foundation skills
3. Maximize ADL and IADL function.
4. Facilitate adjustment to disability
5. Provide caregiver education.
6. Facilitate safe discharge
7. Recommend on the need of further rehabilitation.
8. Provide recommendation on level of care needed upon
discharge.
Community
In acute phase of stroke rehabilitation, occupational therapist will act as assessor and trainer to
As an assessor, Occupational Therapists will evaluate the individual potential and needs for
rehabilitation in order to have a tailor-made rehabilitation plan for each patient. On the other
the same time, Occupational Therapists will provide functional training to minimize patient’s
disability by enabling patient to perform relevant daily life tasks. Ultimately, our patient can
receive the most appropriate Occupational Therapy service in acute setting and can be
2.4.1.1 To evaluate client’s potential and triage for different tracks of rehabilitation.
2.4.1.5 To assist patient and family in adjusting to disability and life changes.
ii. Educate on positioning of affected limbs and the use of assistive positioning
subluxation or deformity.
when necessary.
Assess cognitive-perceptual function, upper limb function, and ADL function with
(CMMSE), Albert’s Test (AT) / Behavioural Inattention Test (BIT), Functional Test
for Hemiplegic Upper Extremity (FTHUE), Barthel Index (BI) / Modified Barthel
Index (MBI) and Lawton Instrumental Activities of Daily Living (Lawton IADL)
ii Provide self care training, to improve bedside self-care skills such as feeding,
iii Improve patient’s ability to feed safely by use of proper positioning and the use
of assistive device.
iv Provide Upper limb training to increase voluntary use of the involved upper
extremity.
rehabilitation process.
ii. Provide training in caring skills and educate caregivers in the use of adaptive
equipment as necessary.
2.4.3.1 Patients with mild disability will usually be discharged from acute wards.
Occupational Therapists will ensure the safe discharge of patients with the
2.4.3.3 If discharged patients are indicated for further ambulatory care, Occupational
Therapists will refer patients to attend OPD/ GDH for a short course of training
community re-integration.
hospitals to continue the stroke rehabilitation process. The multi-disciplinary team will
regularly review the progress of the cases. Occupational Therapists help in triaging patients
to different tracks of rehabilitation and set realistic goals to optimize patient’s function and
2.5.1.2 To improve foundation skills in: sensory-motor, limbs and postural control
2.5.1.8 To recommend any needs for further training at discharge from in-patient
care.
This group of patients is dependent in the majority of ADL. Their sitting balance
had little or no return in the rehabilitation period, or the cognitive level indicated
poor learning ability to comply with functional training. Patients in the severe
prevent shoulder pain or pressure sores; basic feeding and grooming tasks training;
institution.
balance during functional tasks. Patients’ cognitive level is able to comply with
intensive retraining of foundation skills and ADL training, and has a better rehab
potential.
improving the limb function, sitting and standing balance during functional tasks,
dressing upper garment) to more complex ADL tasks (lower garment dressing,
toileting, bathing and related transfers). For patients who will be discharged home,
transfer safety, fall prevention, IADL (e.g. cooking and other simple household
performed if applicable.
provide service to enhance safety of patient in the community after discharge with
the use of assistive devices. They may perform on-site assessment and
discharge from in-patient care. For patients require further training in specific
intensive rehabilitation, they will usually attend a full day rehabilitation program
ensuring proper use of assistive devices, and indicating community resource etc.
Upon discharge from hospital settings, patients in need of further training/ intervention will
be referred for ambulatory care, i.e. day hospitals/rehabilitation centres and Occupational
Therapy Out-Patient Department (OPD). The role of Occupational Therapy in this phase of
rehabilitation is to act as a bridge and fill up the gap between a hospital setting and a
approach and the setting provides a one-stop service for patients. The patients can receive
intensive and comprehensive training without going from place to place and the skills
learnt in in-patients phase are reinforced and strategies for adaptation to community living
The duration and types of intervention are varied according to the specific needs of
individual patients. When conditions progress and needs change, patients will be
2.6.1.8 To empower patients with knowledge of life style re-design towards a more
meaningful life.
When stroke patients enter the ambulatory phase, Occupational Therapists review patients’
medical history (e.g. diagnosis, CT Brain, past and present medical history, premorbid
functional level, social support, etc.) through medical record and / or patient / caregivers
provided in previous phases will be reviewed and followed up. Appropriate interventions
different settings, assessments may focus on essential areas and interventions will be
prioritized.
2.6.2.1 Functional training will focus on independence and safety in ADL, IADL
2.6.2.2 Patients’ support systems will be enhanced and carers will be empowered to
and the therapeutic environment will gradually shift from hospital-based settings
2.6.2.4 Education for more balanced way of living for primary prevention and
requirement.
Patients will be discharged from the ambulatory phase with the fore-mentioned goals
achieved. For patients who have risk of new life maladjustment, deterioration, community
community services.
In the stroke rehabilitation program, the phase of community care is considered to be the
stage in which the client has been discharged from hospital as well as other sort of formal
rehabilitation system. In this phase, client lives in the community (alone or with family) or
lives in institutions such as grouped home, aged hostel, private or subvented aged home.
Community Occupational Therapy tackles patients with wide range of disability level with
patients who are frail and of high risk, also focus on collaboration with health care workers
In this phase, patients and caregivers may have risks of maladjustment to new life,
ramp, furniture re-arrangement, etc.) to improve access, minimize risk of fall and
2.7.2.2 On-site assessment and training for patients and care givers to overcome
living skills training and application of assistive devices fall in this category.
groups, etc.) and empowerment of both patients and caregivers will facilitate
(Please refer to Appendix IV for the work flow of community occupational therapy
intervention for stroke patients post discharge from in-patient rehabilitation)
3.1.2 Past medical history: date of previous stroke and resulting functional limitations,
other medical history including physical and psychological aspects, any medical
3.2.3 Home environment: for simulated environmental training of ADL and early
modification.
3.3.1 Vital signs: conscious level, blood pressure, pulse, other discomfort complains at
3.3.3 Strength
3.3.4 Coordination
3.3.7 Functional balance: relate the static and dynamic sitting and standing balance in
3.3.9 Presence of abnormal reflex and reactions: clonus, associated reactions etc.
3.4.3 Stereognosis
3.5.2 Apraxia
3.5.3 Visual spatial perception e.g. position in space, figure-ground, depth perception
3.5.4 Somatoagnosia
3.6.2 Orientation
3.6.3 Memory
3.6.5 Sequencing
3.6.6 Problem-solving
3.7.2 Grooming
3.7.3 Dressing
3.7.5 Transfers
3.7.6 Toileting
3.7.7 Bathing
3.8.1 Cooking
3.8.7 Shopping
3.8.8 Laundry
3.9.1 Mood
patients who have potential to resume previous work role or change work role.
3.11.3 Productivity
condition to see his/her coping and integration in the community, and how well his/her
risk-taking behavior, the home and outdoor access environment in relations with the
patient’s cognitive and physical functional level. Moreover, overall assessment on the
4.1.2 Normalize muscle tone and inhibit abnormal reflexes which interfere normal
functional use of the affected upper limb according to the 7 functional levels of
provided either through visual assistance and relearning from the unaffected side
4.1.6 Enhance postural and lower limb motor relearning in functional activities.
including:
ADL activities.
4.1.7.3 Furniture and cushion support system to support forearm and shoulder in
proper alignment.
available.
trunk and limb alignment while assisting patients in daily functional tasks.
4.2.1 Remediate and relearn the perceptual function, and apply functionally in daily
living.
4.2.2 Minimize the risk or disability in daily living due to the perceptual problems
4.3.1 Improve the patient’s tracking and scanning abilities across midline and
4.3.2 Reduce the risk caused by unawareness of the unilateral neglect problem.
4.3.3 Teach patient to use adaptive skills when performing routine tasks by
4.4.1 Remediate and relearn the cognitive skills and integrate them in daily
activities.
4.4.2 Minimize the risk or disability in daily living that caused by cognitive
problems.
4.4.3 Conduct therapeutic groups such as problem solving group, memory group,
social skills training group, ad hoc party preparation group and craft group. The
groups are well structured and aim to facilitate patient’s learning on specific
These include personal ADL and instrumental ADL, for example, bathing, to
4.4.5 Virtual Reality and computer based remedial activities may be applied to
allow patients to pre-learn some real life situation with a programmed real life
situation in computer, which the patient can re-learn the steps and problem
solving skills step by step. Suitable training topics include road crossing, value
4.5.2 Use of facilitation techniques and provide assistive devices to protect shoulder
4.5.3 Advice on the proper position of limbs for patients in supine, side lying,
4.6.2 Generalize the use of normal motor pattern to perform functional tasks.
4.6.3 Functional training follows the clinical reasoning steps of the Motor Relearning
Theory:
task.
4.6.3.3 Practice of the task: apply the skills learned in step ii to actual practice on
functional task.
4.6.4 Transfer of training: to generalize the skills in functional tasks in step iii in
other similar functional tasks (lateral transfers) or more advance tasks (vertical
transfer).
(The ADL Training Manual written by the Stroke Working Group of OTCOC, May 2005
will be adopted as the guideline of retraining ADL skills for patients with stroke with the
4.6.5 Adaptive approach will be applied if indicated, therapist will provide adapted
steps or techniques (one hand techniques) according to the maximum return level
of the affected limb or balance function, and the residual cognitive or perceptual
dysfunctions.
4.7.1 Ensure safe discharge of patient back home and reduce re-hospitalization.
re-arrangement.
4.7.3.3 Identify risk factors e.g. slippery floor mat, unstable furniture, or soft and
low seat for patients and recommended patient / care giver to take necessary
action.
4.7.3.5 Provide home program for better continuation of therapy after discharge.
independence.
4.7.4 Education of fall prevention and home safety knowledge to patients and
caregivers.
4.7.5 Post-discharge home visit will be provided for cases who have risks of potential
assistive device or who are living alone. The post discharge home visit aims to
4.8.1 Increase the patient’s and the caregiver’s knowledge of the stroke
rehabilitation process.
4.8.3 Educate the importance of and techniques recommended for involving the
subluxation.
4.8.6 Use of proper body mechanics by the caregiver when assisting the patient, to
minimize injury.
stress.
problem.
4.9.3 Safety education should be started at the very beginning of the rehabilitation
program since self care training started which educate patient to turn / pivot
4.9.5 Identify and remove hazards for risk of fall, e.g. remove mats, proper footwear,
4.10.5 Training Skills in taking public transport e.g. Taxi, minibus, train etc
4.11.1 Maximize patients’ physical and cognitive function to resume work role, either
4.11.2 Work adaptation: one handed typing technique, equipment and work
environment modification.
4.12.1 Explore interests and assess adaptations needed to allow the patient to continue
to participate.
4.12.2 Evaluate the patient’s leisure interests, and integrate the patient’s physical,
4.13.2 Provide psychological support throughout the rehabilitation process and after
4.13.3 Provide support and encouragement for the patient and the family to verbalize
Self-Management Group.
Hospital Authority.
stagnant or very slow, for safety and maximization of functional level, OT will
4.14.2 Provide user friendly assistive device for patient to maximize independence level
in daily live.
4.14.3 Avoid forceful effort in strength and manipulation required tasks, which may
induce associated reaction and increase tone of the affected limb in long run.
(Please refer to Appendix III for Assistive Devices for Daily Living)
4.15.1 Anti-spasticity hand and wrist splint: to prevent hypertonicity and contracture
4.15.2 Resting paddle: to prevent mal-alignment and hand and wrist at flaccid stage.
4.15.4 Shoulder sling : full shoulder forearm support, shoulder and humeral support to
4.15.6 Thumb opponents splint: it can be of static or dynamic design with help to
4.15.7 Pressure Therapy: application should be monitored with blood pressure and
4.15.7.1 Hand and arm tubigrip to control oedema and prevent development of
4.15.7.2 Pressure stocking for hypotension condition of patients or for deep vein
(The details of splint designs can be referred to the Splint Manual (HKOTA)
¾ Neurodevelomental Therapy
¾ Neuro-Integrative Functional Rehabilitation And Habilitation
¾ Motor Relearning
¾ Functional Approach
¾ Biomechanical
¾ Rehabilitative
¾ Adaptive
6. Documentation
Clear and concise documentation are important for team communication of the patient’s
problems, treatment, progress, and further rehabilitation plan. The documentation should
follow the basic guidelines in clinical records and also covers the relevant points to reflect
the patient’s condition in respect to the types of documentation. Good records are also for
protecting the right of patient to have detail retrospective enquiry of their clinical
Stroke Rehabilitation
Pre-discharge Planning
No
Refer for OPD or GDH to continue OT Post-discharge follow-up by
Follow –up
COT
required
Feeding aids: Easy scooping bowl or plate, adapted chopsticks require less manipulation
Dressing: Elastic shoelaces, specific steps in dressing upper and lower garment without
Bed-side transfers: Adapt bed and chair to same height for easy transfers, and use of firm
Toileting and toilet transfers: Commode chair, buttock washing devices, toilet seat, hand
rails etc.
Bathing and bathing transfers: Commode shower chair, bath board, hand rail, foot brush,
standard wheelchair or one arm drive wheelchair will increase the functional mobility
Kitchen tasks: Jar opener or fixator, nailed chopping board, suction bottle brush to wash
glass etc.
Home making: Long handle self-wringing sponge mops, free standing dustpans, light
Writing: Occupational Therapist will provide progressive training to patient for writing,
adaptive tripod pen-holder will facilitate better writing effect for patients.
Pressure Sores prevention: Heel protectors to prevent heel sores, ripple bed to prevent
YES
Assessment on
Any problem
Self care, caregiver skills,
needed to be
compliance of home Close case
solved
program and use of assistive
devices and home visit
report
Follow up
Problem identified
visit and
under the service
re-evaluation
scope Refer to OPD or
GDH OT service
if indicated for
Arrange next rehabilitation
Plan and implement
follow up visit due to
intervention:
deterioration or
-caregiver education
new problems.
-functional training
-aids prescription
-home modification
Perceptual assessment
¾ Rivermead Perceptual Assessment
Battery (RPAB)
¾ Behavioral Inattention Test- Hong
Kong Version (BIT-HKV)
¾ Albert’s Test
¾ Árnadóttir Occupational Therapy
Neurobehavioral Evaluation
(A-ONE)
¾ Loewenstein Occupational Therapy
Cognitive Assessment (LOTCA)
¾ SAFER
Home Environment
Chinese Patient ‘s global Chiu et al., 1994 Chiu et al., Hong Kong
Mini-Mental State cognitive 1994 Chinese version
Examination performance Chiu et al., 1994
Cognistat 5 major areas Kiernan et al Kiernan et al Cognistat
Neurobehavioral -Language (2002) (2002) Neurobehavioral
Cognition Status -Constructional Northern Northern Cognition Status
Exam (NCSE) ability California California Exam (NCSE)
-Memory Neurobehaviora Neurobehav Kiernan et al
-Calculation skills l Group (1998) ioral Group (2002)
-Reasoning/ (1998) Northern
judgment California
Neurobehavioral
Group (1998)
Rivermead Assess memory ( RBMT ) ( RBMT ) Rivermead
Behavioural skills related to Wilson et al Wilson et al Behavioural
Memory Test everyday (1989) (1989) Memory
situations. Useful Test( RBMT )
to predict Wilson et al (1989)
everyday life task
memory problems.
Modified Rankin Status of disability van Swieten et van Swieten Culture free
Scale in patients with al. (1988) et al. (1988);
stroke de Haan et
al., (1995);
Uyttenboog
aart et al.
(2005)
Chinese Patient ‘s global Chiu et al., 1994 Chiu et al., Hong Kong
Mini-Mental State cognitive 1994 Chinese version
Examination performance (Chiu et al., 1994)
Barthel Index 20 Basic activities of Wade (1992); Wade Original version
daily living for Novak et al. (1992); with minor
patients with (1996) Novak et al. adaptation of “use
stroke (1996) of chopsticks” in
feeding item
Chinese Version To assess Tong and Man, Tong and Chinese Version of
of the Lawton independent living 2002 Man, 2002 the Lawton
Instrumental skills for older Instrumental
Activities of Daily adults in Hong Activities of Daily
Living Scale Kong Living Scale
The Safety Safety and Letts et al., 1998 Oliver et al., SAFER
Assessment of function within the 1993; SAFER-Home
Function and the home environment Letts &
Environment for Marshall,
Rehabilitation 1995;
(SAFER) Letts et al.,
1998