Physiotherapy Practice Guidelines for Stroke Rehabilitation

PTCOC May 2000

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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) Raymond Lo Elsy Chan Robin Tsim Harold Ng Cedric Chow Hazel Ip Mabel Yu

CMC POH RH OLMH CMC CMC CMC CMC

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TABLE OF CONTENTS
I. Goals of Guidelines Page 1 1 1 1 2 2 4 5 9 23 25 27 30 31 40

II. Epidemiology of Stroke A. Definition B. Incidence C. Classification III. Physiotherapy Management in Stroke Rehabilitation A. Goals of Physiotherapy B. Assessment C. Interventions D. Outcome E. Discharge F. Community G. Service Evaluation III. IV. References Appendices

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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).

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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).

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.

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Recommendations: 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)

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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

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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.

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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.

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Contexual Factors at body level at person level at social level Functioning in interaction with environmental factors and personal factors Person’s daily Involvement in the Features of the Characteristics Body function Body structure activities situation physical, social attitudinal world and Activity Participation Facilitators Positive Aspect Functional structural integrity Activity limitation Participation Barriers Negative Aspect Impairment restriction 4. Contents Physiotherapy assessment includes: a) Patient characteristics

Impairments

Activities

Participation

       

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.

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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).

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).

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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).

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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.

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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 upperextremity 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)

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(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)

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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)

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).

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Recommendation : • 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)

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(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)

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(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

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(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.

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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)

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

(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).

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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 ).

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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 ).

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Recommendation : • 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.

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Recommendation: • 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 )

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D. 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’. 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 And the ICIDH also notes that impairment represents

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 Administer Strengths 10 min Simple, well established with stroke patients, sensitive to change, validity, reliability & sensitivity tested

Name and Source Berg Balance Assessment (Berg, 1989) (Berg et al., 1989) (Appendix 4)

Weaknesses None observed

Uses formal assessment monitoring

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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 Administer Strengths 5-10 min Widely used for stroke; excellent validity and reliability 40 min Widely used for stroke; measures mobility, use of T-point scale increases sensitivity, ADL, cognition, functional communication, validity & reliability tested 15-30 min Good, brief assessment of movement and physical mobility, validity & reliability tested

Name and Source Barthel Index (Appendix 5)

Weaknesses Low sensitivity for high-level functioning, ceiling effects

Uses screening, formal assessment, monitoring, maintenance screening, formal assessment, monitoring, maintenance

Functional Independence Measure (FIM) (Winaknder et al., 1998)

ceiling” and floor” effects at upper & lower ends of function

(Appendix 6)

Motor Assessment Scale

Reliability assessed only in stable patients sensitivity not tested

formal assessment, monitoring

(Appendix 7) Elderly 5-10 min Mobility scale local validation done (Tsim, 1998; Yu ,1998) Simple, validity & reliability tested, Ceiling effect formal assessment

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(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)

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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)

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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

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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.

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. 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) (Level of evidence = IV,

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

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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)

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)

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G. 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)

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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 Ia Ib IIa

Type of Evidence Evidence obtained from meta-analysis of randomised controlled trails. Evidence obtained from at least one randomised controlled trail. Evidence obtained from at least one well-designed controlled study without randomisation.

IIb III

Evidence obtained from at least one other type of well-designed quasi-experimental study. 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 Required - at least one randomized controlled trial as part of the body of literature of overall good quality and consistency addressing specific recommendation.

A

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 1. Weakness ± sensory deficit of at Poor territories of MCA least 2 of 3 body areas : face/ arm /leg 2. Homonymous hemianopia 3. Higher cerebral dysfunction ( dysphasia, dyspraxia etc) PACI Mainly cortical Either 2 of the above Better involvement of either division of MCA or ACA POCI Vertibrobasilar arterial Varied, may include : Best chance territory, associated with bilateral deficit, ipsilateral cranial brain stem, cerebellum, nerve palsy, occipital lobes disordered eye movement, isolated homonymous hemianopia etc LACI Territories of deep Pure motor stroke Can be very perforating arteries, Pure sensory stroke handicapped mostly of Basal Ganglia Sensori-motor stroke and Pons Ataxic hemiparesis 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

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Appendix 3
Modified Ashworth Scale

0 1

= =

No increase in muscle tone 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 4

= =

Considerable increase in muscle tone, passive movement is difficult. Affected part is rigid in flexion or extension (abduction or adduction etc)

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Appendix 4
Berg's Balance Scale

ITEM DESCRIPTION 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

SCORE (0-4) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________

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

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Appendix 7
Motor Assessment Scale

0 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

1

2

3

4

5

6

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

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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

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