Clinical Practice Guidelines Occupational Therapy

Stroke Rehabilitation

Clinical Practice Guidelines Jan 2005

Updated by Stroke Working Group, &

Endorsed by the Service Development Subcommittee, Coordinating Committee in Occupational Therapy, Hospital Authority

Members of the Stroke Working Group

Coordinating Committee for Occupational Therapists (OTCOC), HA (2004/5):

Coordinator

Dora Chan, Senior Occupational Therapist (KH, KC cluster)

Members

Cecilia Sum, Department Manager (Occupational Therapy), (SH, NTE cluster) Christina Yau, Senior Occupational Therapist (TWH, HKW cluster)

Grace Yuen, Occupational Therapist I, (RH, HKE cluster)

Joyce Cheung, Occupational Therapist I, (POH, NTW cluster)

Kathy Chow, Occupational Therapist 1. (KH, KC cluster)

Roy Yuen, Occupational Therapist II, (TKO, 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 Guideline Working Group of the New Territories East Cluster of the Hospital Authority for providing their guideline in 2003 as our basis of work to extend it as this guideline at OTCOC level in 2005

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Acknowledgement to

Stroke Guideline Working Group Occupational Therapy (NTE Cluster)

Coordinator

Cecilia Sum, Department Manager (Occupational Therapy), (SH)

Members

Brian Au, Occupational Therapist 1, (TPH)

Amy Chan, Occupational Therapist I, (SH) Raymond Ching, Occupational Therapist I, (NDH) Teresa Leung, Occupational Therapist I, (SH)

Dawn Poon , Occupational Therapist I, (PWH)

Ewert Tse, Occupational Therapist I, (AHNH)

For advice on evidence based practice and audit

Victoria Leung, Senior Occupational Therapist, (PWH) Alex Vue, Senior Occupational Therapist, (SH)

For medical advice

Professor Jean Woo, Chief of Service (General), (SH)

Professor Richard Kay, Professor, Dept of Medical & Therapeutics, (PWH) Professor Wong Ka Sing, Associate Professor 1I, (PWH)

Professor Timothy K wok, Duty Chief of Service (Medical & Extended Care) (TPH) Dr. Wong Kwan Keung, Chief of Service (Medicine), (NDH)

Dr. Wong Chi Keung, Senior Medical Office, (Medicine), (NOH) Dr. Sze Ka Hoi, Senior Medical Officer, (SH)

Dr. Raymond Lo, Senior Medical Officer, (SH)

Dr. Samuel Tse, Senior Medical Officer, (TPH)

Dr. Yeung Hon Ming, Senior Medical Officer, (AHNH)

Proofreading

Mr. Fung Yee wang (volunteer)

* PWH - Prince of Wales Hospital

AHNH - Alice Ho Mui Ling Nethersole Hospital

NDH - North District Hospital

SH - Shatin Hospital

TPH - Tai Po Hospital

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Table of Content

1. Background

1.1. Introduction

1.2. Objectives of guideline 1.3. Format

2. Service Scope

2.1. Objectives of occupational therapy in stroke rehabilitation 2.2. Occupational therapy in stroke rehabilitation process

2.3. Occupational therapy service network for stroke rehabilitation in the Hospital Authority

3. Executive Summary of Recommendations

4. Approaches to Rehabilitation 4.1. Assessment procedures 4.2. Teamwork

4.3. Goal-setting

4.4. Therapy approaches 4.5. Intensity of treatment

4.6. Precautions / Contraindications 4.7. Documentation requirement

5. Acute Interventions

5.1. Early disability assessment and management 5.2. Complications prevention

5.2.1. Positioning

5.2.2. Pressure sores

5.2.3. Venous thromboembolism 5.2.4. Aspiration Pneumonia

6. Rehabilitation Interventions

6.1. Upper limb function

6.1.1. Upper extremity assessment

6.1.2. Functional training of upper extremity 6.1.3. Management of shoulder complication

6.1.4. Management on the increased muscle tone of upper extremity

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6 6 6 7

8 8 9

10

11

16 16 16 17 17 17 18 18

20 20 21 21 21 21 22

23

? ... -j

23 24 26

6.2. Activities of Daily Living and Instrumental Activities of Daily Living 27

6.2.1. Functional assessments 27

6.2.2. Specific assessments 27

6.2.3. Foundation skills training 27

6.2.4. ADL and IADL training 28

6.2.5. Effects of functional training on impairments 28

6.3. Cognitive and perceptual function 29

6.3.1. Cognitive and perceptual assessments 29

6.3.2. Intervention approaches for cognitive and perceptual problems 32

6.3.3. Treatment of Unilateral Neglect 33

6.4. Psychological adjustment to the disease 34

6.4.1. Screening for depression and anxiety 34

6.4.2. Psychological support 34

7. Pre-discharge planning

7.l. Prescription of assistive devices

7.1.1. Consideration on prescriptions of assistive devices 7.1.2. Education on the use of prescribed assistive devices

7.2. Community occupational therapy! envirorunental modifications 7.2.l. Pre-discharge home visit

7.2.2. Post-discharge follow up

7.3. Fall prevention

7.3.1. Community Occupational Therapy visit can prevent falls 7.3.2. Hip protectors

7.4. Carers education

7.4.1. Mode of training

7.4.2. Information provision: content and strategies 7.5. Home program

7.6. Community re-integration

7.6.1. Occupational adaptation

7.6.2. Support program

35 35 36 36 36 37 37 38 38 39 39 39 40 41 41 42 42

8. Service Evaluation

8.l. 8.2. 8.3.

Audit of guideline Data collection Data interpretation

43 43 44 44

9. Tables of Evidence 10. References

46 71

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1. Background

1.1 Introduction

Stroke care is a major healthcare issue in Hong Kong. In 20021 2003, there was a total of 26,150 hospital admissions for stroke event (ICD-9 code 430 - 438) and it accounted for the third most common death in Hong Kong (Hospital Authority Statistical Report, 2003). The age-specific mortality rate was 2,494 per 100,000 population among patients age ~ 65 and 457 per 100,000 for age 45 to 64 in year 2000. (Hospital Authority Statistical Report, 2003). In the Hong Kong Occupational Therapist Profile Survey 2004/5, there were 34.4% of the occupational therapists participating in stroke rehabilitation. Therefore, the Stroke working Group of the Coordinating Committee for Occupational Therapists (OTCOC) targeted to provide a common protocol for all occupational therapists in different clusters.

As similar review of guideline had been done by the Occupational Therapists in the Stroke Guideline Working Group of the New Territories East Cluster (NTE)l in August 2003. The Stroke Working Group (OTCOC), Hospital Authority decided to adopt this version with enrichment of more updated evidences as indicated.

This is a local clinical guideline based on the international guidelines on stroke management 2 3 and the Occupational Therapy Program Guide (1999) developed by the Working Group on Geriatric Rehabilitation, OTCOC, Hospital Authority 4.

In developing this local guideline, all members provide their practical and expert clinical opinions, which underpin the applicability of this guideline for service users. They included the experienced occupational therapists from the 5 hospitals in the NTE cluster, and further updated by 8 occupational therapists from all clusters of the Hospital Authority.

1.2. Objectives of guideline

1.2.1. To standardize the practice among occupational therapists within the cluster, considering the best decisions and management for each stroke patient.

1.2.2. To enhance the continuity of care from one setting to another through the use of similar approaches techniques and format of documentation.

1.2.3. To employ common outcome measuring tools to determine the overall effectiveness and efficiency of services provided by occupational therapists for stroke patients in the Hospital Authority.

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1.3. Format

This guideline follows the general principles indicated by the United Kingdom National Clinical Guidelines for Stroke in the following way:

• Address important issues of occupational therapy for stroke.

• Draw upon published evidence whenever possible.

• Indicate areas of uncertainty or controversy.

• Be useful and usable.

For each topic there is a consistent format:

• A short introduction to describe the topic briefly.

• Each guideline statement accompanied by a grade of recommendation.

• References from the detailed table of evidence in Section (9).

• Considerations for specific hospitals whenever necessary.

A letter CA, B or C), indicating the strength of recommendation accompanies each guideline statement. Besides the grade of evidence, the level of evidence is demonstrated by a number (1 to IV) indicating its provenance. Table 1.1 shows the meaning of each; these levels and grades are used because they are currently the preferred ways of indicating the strength of any guideline or supporting evidence.

Table 1.1 Guideline strength: level of evidence and grade of recommendation 1

Type of evidence Level of Grade of
evidence recommendation
Meta-analysis of randomized controlled Ia A
trials (RCTs)
At lease one RCT Ib A
At least one well designed, controlled study IIa B
but without randomization
At least one well designed, lIb B
quasi-experimental study
At least one well designed, III B
non-experimental descriptive study (e.g.
comparative studies, correlation studies,
case studies)
Expert committee reports, opinions and/or IV C
experience of respected authorities 7

2. Service Scope

2.1. Objectives of Occupational Therapy in Stroke Rehabilitation

2.1.1. To assist stroke patients to achieve maximum functional level of independence at home, work and leisure.

2.1.2. To prevent secondary complications resulting from stroke.

2.1.3. To educate patients and caregivers regarding ongoing treatment and ensunng consistent home management I home programme for patients upon discharge.

2.1.4. To minimize residual disabilities and improve quality of life through appropriate prescription of aids and environmental adaptations.

2.1.5. To assist patients and their families in adjusting to disability and life changes, so as to reintegrate into community and find meaningful life of their choice.

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2.2. Occupational Therapy in Stroke Rehabilitation Process

I Medical Referral I

Acute Phase

• Early disability assessment and management

• Complication prevention

• Suggest placement & further rehabilitation

Subacute! Rehabilitation Phase

• Comprehensive assessment and training: Upper limb function, sensori-motor, ADL, foundation skills, cognitive, perceptual, and psychosocial aspects

• Prevention of secondary complication

"

Pre-discharge Phase

• Home management skills! IADL

• Advice on home modification

• Fall prevention

• Prescription of assistive devices

• Caregivers education

• Recommendation on placement & further rehabilitation

• Facilitation for community re-integration

Ambulatory Phase Community Phase

Continuous assessment & training

• Occupational adaptation

• Advice on home modification

• Advice on home program

• Follow-up & advice on home modification & prescribed assistive devices

• Education on caregivers! staff of institutions

•

Enhance the continuity of care with NGO

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2.3. Occupational Therapy Service Network for Stroke Rehabilitation in Hospital Authority

Clusters NTE NTW KC KW KE HKW HKE
Acute Phase PWH, NOH TMH QEH CMC,KWH UCH QMH PYNEH
AHNH PMH,YCH TKOH RHTSK
Rehabilitation SH POB KH CMC UCH TWH RI-ITSK
Phase TPH BH OLMH HHH FYKH TWEH
PMH (LKB) MMRC CH,CHK
WTSH GH
YCH
Ambulatory PWH (OI'D) TMH (01'0 & GOH) KH (01'0) CMC (GOH & 01'0) YFS (OPO & GOH ) TWH (ORC & GOH» PYNEH (GDH)
Phase SH (GOII) POH (OI'D) YMT(Goll) KWH (GOH & OI'D) J-H-IH (ORC & 01'0) MMRCtARC) RHTSK (GDII)
AHNH (DRC & 01'0) OLMH(opo) TKOH (OI)D) FYKH (GOI-I) TWEH (GOII)
NDH (DR C& 01'0) PMH (GOII & OpD) OTRC(OpO) SJH (01'0)
WTSH(GDH)
YCH (01'0)
Community All settings (IIV) All settings (IIV) All settings (HV) All settings (IIV) All settings (IIV) All settings (IIV) All settings (HV)
Phase (COST) for NTE TMH (CGAT) KH (CMRS & COT) CMC (CGAn HHH (CGAT) FYKH (CGAT) RHTSK (CGAT)
cluster KH «'GAT) KWH (COT, ('GAT &. YFS (CGAT) MMRC (ECS)
COST) OTRC(COT)
PMH (COT &. CGAT) Note:

Of'D - outpatient service GI)II - Geriatric Day Hospital

COST - Community Outreach Service Team

CMRS - Community Medical Rehabilitation Service COT - Community Occupational Therapy

DRC -Day Rehabilitation Center

ARC- Ambulatory Rehabilitation Center ECS - Extended Care Service

CGAT - Community Geriatric Assessment Team HV - pre and post discharge home visits

(0

3. Executive Summary of Recommendations

Approach to Rehabilitation

Assessment Procedures

~ Common validated assessments will be used at different phases of rehabilitation.

~ Formal assessment will be initiated at least 2 working days after medical referral. Continuous assessment will be carried out weekly in the rehabilitation phase and monthly in ambulatory phase.

Teamwork

~ All members of the healthcare team should work together with the patient and family, using an agreed therapeutic approach.

Goal setting

m Goals should be meaningful, challenging but achievable for the involved patients.

m Goal setting should involve the patient, the family and the team members and the goals should be revised periodically by evaluating the patient's progress.

Therapeutic approaches

!] Any of the current exercise therapies should be practiced within a neurological framework to improve patients' function.

Intensity of therapy

m Patients should receive as much therapy as can be given and as much as they can tolerate.

Documentation requirement

~ Therapists should document patients' performance and progress clearly and regularly. A comprehensive progress report should be based on the ongoing assessments.

1/

Acute Intervention

Early disability assessment and management

ilJ Acute settings should use validated assessments like: MMSE, B1 and FTHUE-HK to identify cognitive impairment, basic ADL and Upper Extremity Function.

~ Rehabilitation should be started as soon as the patient's condition permits.

Complication prevention

~ Occupational Therapists should assess patients' need before deciding to provide adapted seating (either on adapted geriatric chair or adapted wheelchair), to provide splintage if indicated and/or to position patients in order to minimize the risk of complications such as contractures, respiratory complications, shoulder pain and pressure sores.

~ Occupational Therapists should assess patients' need for pressure relieving devices (e.g. heel protectors, sheepskins, seat cushions), in order to prevent skin breakdown.

~ Full Length Compression stockings should be applied in stroke patients with DVT for the paralysed legs with careful monitoring on patient's peripheral circulation, sensation and the state of the skin.

~ Occupational therapists advise patients' and their family on postural strategies to reduce the complications.

Rehabilitation Intervention

Upper Extremity Function

ilJ Functional Test for Hemiplegic Upper Extremity (FTHUE-HK) should be used to assess the functional control of upper extremity after stroke because of its psychometric properties. Dexterity can also be further assessed by various standardized procedures.

~ Sensory assessment should be included in the evaluation of hand function after stroke because sensory deficit affects hand function.

~ There are different treatment approaches that can be used to improve upper extremity functions, especially if they are incorporated into purposeful activity.

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[D Structured sensory retraining can improve somatosensory deficit after stroke.

~ Prevention of shoulder subluxation by positioning, edema control, active and passive mobilization is effective in controlling complex regional pain syndrome.

~ Shoulder sling and ann support devices may help to reduce shoulder subluxation or shoulder pain of the flaccid upper extremity.

~ Proper techniques in facilitating the control of hemiplegic shoulder girdle is helpful in reducing shoulder pain and subluxation.

[D Patients' and carers' education on proper positioning and handling can help to prevent shoulder pain.

~ Hand splint may help to reduce the increased tone of hemiplegic upper extremity.

Activities of Daily Living & Instrumental Activities of Daily Living

LD The currently used functional assessments for stroke patients can predict the functional outcome at discharge and help to plan for the treatment realistically.

LD Patients showing unexplained persistent difficulties in ADL should be assessed specifically for perceptual impairments.

~ Foundation skills training focused on goal orientated tasks and coordinated movement may increase voluntary active range of movement.

~ Occupational therapy significantly reduces disability and handicap of patients with stroke.

[D Functional training incorporated with specialized treatment techniques can result in greater improvement of cognitive and motor ability after stroke.

Cognitive & Perceptual Function

[D The provision of information about cognitive assessment in stroke rehabilitation may decrease carer strain.

W Cantonese version ofMMSE will be used as the screening tools for cognitive

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impairment, Therapists should conduct specific validated assessments if CMMSE result revealed certain cognitive problems.

~ The A-ONE and the Behavioral Inattention Tests have been recommended as the most suitable tools for measuring perceptual and body image dysfunction.

! Assessment of Motor and Process Skills (AMPS) is recommended

for assessing clients' excessive function in carrying out BADL & IADL tasks.

[D Use of consistent strategies to accomplish functional activities can Improve cognitive-perceptual function after stroke.

W Spatiomotor cueing seems to be effective in the treatment of uni lateral neglect.

Psychosocial adjustment to the disease

~ The Geriatric Depression Scale (GDS) should be used during hospitalization, as it is reliable in predicting post-discharge depression in stroke elderly.

m Patients should be given information, advice and the opportunity to talk about the impact of illness upon their lives.

Pre-discharge Planning

Prescription of Assistive devices

~ Prescription of assistive devices and providing environmental modification promote patient's functional performance and are cost effective.

~ As patients' needs and use of assistive devices vary over time due to change in health and functional status, therapist should consider the use of aids loaning service.

m Education in the use of aids is needed. Follow up action is required to promote utilization after discharge.

Community Occupational Therapy visit / Environmental modifications

~ Patients' length of stay in the hospital for rehabilitation can be much reduced with pre-discharge community occupational therapy service.

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~ Community occupational therapy service addresses stroke patients' problems after discharged, ensures that the clients receive the necessary aids and assistance to maintain independence at home.

~ Pre-discharge education and Post-discharge follow up together improve the functional outcome and satisfaction of stroke patients and are more beneficial to them than to prolong their stay in hospital for routine rehabilitation.

Fall prevention

~ Community occupational therapy visits prevent falls among older people, facilitate higher daily activity performance as well as household and leisure engagements.

~ Hip Protectors can reduce the risk of hip fracture resulting from falls.

Care Taker Education

[D Stroke services must be alert to the likely stress on caregivers and provide appropriate level of support to different types of caregivers.

~ Information combined with educational sessions Improves knowledge and mental health of patients and/or caregivers, and is more effective than providing information only.

[D A structured education programme for patients and caregivers needs to be developed with reference to information about their ongoing needs throughout the care-giving Journey.

Community Re-integration

~ Occupational therapy demonstrates the effectiveness of improving stroke patients' participation in activities. It is recommended that the therapists use structured instruction in specific and client-identified activities, as well as appropriate adaptations to enable performance and practice within a familiar context, and give feedback to improve client performance.

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4. Approaches to rehabilitation

4.1. Assessment procedures

Assessment is central to the management of any disability. Assessment is used here to include both the collection of data and their interpretation in order to inform a decision 1. As suggested in National Clinical Guidelines for Stroke by the Royal College of Physicians, clinician should use structured assessments to help identify problems 5 6. These instruments have been tested for their validity (appropriateness for the purpose) and reliability.

OT assessment focuses mainly on self-care, work and leisure. The amount of weighting in the respective areas depends on the phases of rehabilitation that the patient is going through and the occupational roles that the patient has engaged in previously.

Common validated assessments will be used at different phases of rehabilitation.

Grade C, Level IF

Grade C, Level

Formal assessment will be initiated at least 2 working days after medical referral. Continuous assessment will be carried out weekly in rehabilitation phase and monthly in ambulatory phase.

Evidence: Table 4.1

4.2. Teamwork

Evidence strongly suggests that good stroke outcomes follow the involvement of healthcare professionals working together as a team. A team is a group of individuals working together towards a single goal or set of goals. All team members should be taught to adopt a consistent approach for any single patient 1. Weekly ward round and case conference can facilitate the communication among team members.

Grade C, Level

All members of the heaIthcare team should work together with the patient and family, using an agreed therapeutic approach.

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4.3. Goal setting

One of the specific characteristics of rehabilitation is the setting of goals. However, the tenn is used loosely and its practice varies greatly. Goal setting here refers to the identification of, and agreement on, a target which the patient, therapist or team members will work towards over a specified period of time 2. There is reasonable evidence for goal setting being practical in rehabilitation " but most of it is not specific to stroke. Although specialists in stroke care identify goal setting as good practice S <) 10. the majority of studies on goal setting are descriptive and based on small samples for other patient populations.

Goals should be meaningful, challenging but achievable for the involved patients.

II I"

Grade B, Level III -

Goal setting should involve the patient, the family and the team members and the goals should be revised by evaluating the patient's progress.

Grade B, Level III 13 14 15 16 I"

Evidence: Table: 4.3

4.4. Therapeutic approaches

All approaches focus on the modification of impairment and improvement in function within everyday activities. Differences in approaches centre around the type of stimuli used, the emphasis on task-specific practice and/or the principles of learning that followed 2, So far there is no evidence to support the superiority of one approach over another I 8. But research findings suggest that patients would benefit from therapy, which focuses on the management of disability using purposeful activity 19 20.

11 )? ?, ~4 ?~ Grade B, Level II b - -- -. - -.

Any of the current exercise therapies should be practiced within a neurological framework to improve patients' function.

Evidence: Table 4,4

4.5. Intensity of therapy

There is much debate about the amount of therapy needed. One important but unanswered question asks whether there is a minimum threshold, below which there is no benefit at all. Studies on well organized services show that it is rare for patients to

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receive more than 2 hours therapy each day. There are few trials, and the interpretation of most of them is confounded because experimental groups are often given more and better therapeutic treatments than control groups.

'( 2-; "S Grade B, Level/lb -) ,-

Patients should receive as much therapy as can be given and as much as they can tolerate.

Evidence: Table 4.5

4.6. Precautions / Contraindications

The following precautions/ contraindications are quoted from Occupational Therapy Protocol Management in Adult Physical Dysfunction :!9

1. Be aware of the patient's medical stability before initiating occupational therapy evaluations and treatment.

2. Take precautions in elevating the patient's head in acute stage (usually only a concem for patients requiring a craniotomy due to possible intracranial pressure); check with nursing staff and lor patient's medical chart.

3. Watch for signs and symptoms of blood pressure changes and transient ischemic attacks.

4. Avoid damage/pain to weak shoulder, which could result from pulling or lifting the patient by the involved ann or poor positioning.

5. Be aware of patient's balance status, choose appropriate and safe transfer techniques

6. Take appropriate environmental precautions with regard to possible visual field deficits/ unilateral neglect.

7. Avoid subjecting the patient to undue fatigue and overexertion.

S. Be aware of deficits in communication that may cause misunderstanding between patients and therapists i.e. receptive (Wernicke's) or expressive (Broca's) aphasia or both ( global), Dysarthria, oral apraxia, agraphia, or alexia.

4.7. Documentation requirement

Therapists should document all the assessments, problems identified, plan of care, treatment, progress and re-assessment in a clear and concise manner. To facilitate the efficiency of work and ease of communication, acute hospital and rehabilitation hospital should use similar assessment forms and summary of discharge respectively.

Specific assessment results and home visit reports should be attached separately in the medical records.

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Therapists should update patients' progress on regular basis. It is expected that the plan of care will be revised after the weekly discussions in the case conference/ ward round in rehabilitation hospital and the monthly reassessments in ambulatory care.

Grade C, Level /J

Therapists should document patients' performance and progress clearly and regularly. A comprehensive progress report should be based on the ongoing assessmen ts,

Other important points to be noted on clinical documentation:

1. Report on assessment and progress should be wel1 organized, legible, precise and concise.

2. Clear entry of patient's information and date on each page of the record

3. Therapist(s) should sign, rather than just initial the report, and make sure there is a date to each entry. They should also put down their names and ranks in block letters.

4. Error must be corrected by drawing a single line through an error (liquid correction fluid and erasures are not acceptable), and signed by the therapist altering the record

5. Report on facts, not opinions; avoid judgmental wordings.

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5. Acute Interventions

5.1. Early disability assessment and management

Occupational therapy uses activity to enhance function, to re-educate the affected limbs in home, work and leisure activities, and to improve function of the upper limb. Assessment at early phase will also focus on cognitive function, self-care ability and hand function. No evidence supporting particular selection criteria for more active rehabilitation or admission to a stroke unit was found. However, the results of admission assessments are commonly used for triaging the rehabilitation placement.

Acute settings should use validated assessments like: MM8E, BI and FfHUE-HK to identify cognitive impairment, basic ADL and Upper Extremity Function Grade B, Level III 30 31 32 33 34 35

Therapists should choose formal evaluations selectively based on clinical observations of the patient participating in functional activity 36, Special attention should be paid to visual neglect and mood disturbance. If therapist noticed the patient's tendencies to neglect items in the right or left visual field during ADL task, Behavioral Inattention Test (BIT) should be conducted to con finn visual neglect.

Evidence from clinical trials suggests that early rehabilitation intervention will lead to

. d h . I d c . 1 37 38 39 40 TI fi I I

Improve p ysica an Iunctiona outcomes . te irst t tree mont 1S

following stroke are seen to be the most critical period when greatest recovery is thought to occur 41. The earliest training is also beneficial for regaining functions and self care performance. The training includes bed mobility, transfer in and out of bed and tasks such as dressing, feeding and grooming. Further upgrading of program will continue in the rehabilitation phase.

Rehabilitation should be started as soon as the patient's condition permits.

Grade A, level Ib 3

Evidence: Table 5.1

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5.2. Complications prevention

5.2.1. Positioning

Therapeutic positioning of stroke patients IS a widely advocated strategy to discourage the development of abnormal tone, contractures, pain, skin breakdown. and respiratory complications. It is an important element in maximizing the patient's functional gains and quality of life.

There are few studies relating to positioning. Positioning improves with formal teaching. It has been observed that patients in stroke units are more likely to be in recommended positions 42 43 44. Use of lapboard and arm trough, which corrects vertical subluxation but not cause lateral humeral displacement, is suggested 4:' 46 47

Occupational Therapists should assess patients' need before deciding to provide adapted seating (either on adapted geriatric chair or adapted wheelchair), to provide splintage if indicated andlor to position patients in order to minimize the risk of complications such as contractu res, respiratory complications, shoulder pain and pressure sores.

5.2.2. Pressure Sores

Pressure sores (also known as pressure ulcers, bed sores and decubitus ulcers) may present as persistently hyperaemic, blistered, broken or necrotic skin, and may extend to underlying structures, including muscle and bone. The presence of pressure sores may increase the death risk of elderly people and people in intensive care unit by 200% - 400%. However, pressure sore is a marker for underlying disease severity and other comorbidities rather than an independent predictor of

I, 48

morta ity .

Grade C, Level IV

Occupational Therapists should assess patients' need for pressure relieving devices, (e.g. heel protectors, sheepskins, seat cushions), in order to prevent skin breakdown.

5.2.3. Venous Thromboembolism

Deep Vein Thrombosis (OVT) IS a common problem after stroke, and has an 21

incidence of 23% to 75% depending on the severity of the stroke. Most of the morbidity and mortality associated with DVT result from venous thromboembolism (VTE). Pulmonary embolism after stroke has an incidence of 10% to 29% and a mortality rate of 10% 49. The best approach to VTE is to prevent DVT 50

Evidence from studies in surgical patients suggests that external compression stockings reduce the risk of DVT and pulmonary embolus. although severe peripheral vascular disease is a contraindication to their use. It has became a common practice for external compression stockings to be used in patients with stroke when heparin is contraindicated or in ischaemic stroke when there are contraindications to the use of anticoagulants. Evidence is found on the use of fulllength compression stocking 51. Application of the compression stockings should be carefully measured in order to avoid over compression, which may damage the blood vessels. Prescription on compression stockings should be discussed with medical staff, to ensure no potential problems associated with heart disease.

Full Length Compression stockings should be applied in stroke patients with DVT for the paralyzed legs with careful monitoring on patient's peripheral circulation, sensation and the state of the skin.

Grade A, Levellb

5.2.4. Aspiration Pneumonia

Dysphagia, an abnormality in swallowing fluids or food, is common; it occurs in about 45% of all stroke patients admitted to hospital. It is associated with more severe strokes, and with worse outcome. The presence of aspiration may be associated with an increased risk of developing pneumonia after stroke.52

Occupational therapists advise patients' and their family on postural strategies to reduce the complications.

Grade C, Level IV ~:.

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6. Rehabilitation Intervention

6.1 Upper Extremity Function

6.1.1 Upper Extremity Assessment

6.1.1.1 Functional assessment of upper extremity

A recently validated assessment called the Functional Test for the Hemiplegic Upper Extremity (FTHUE-HK) is commonly used by occupational therapists 35. The assessment is based on Brunnstorm's developmental stages of stroke recovery in a hierarchy of seven functional levels. Grading is on a pass-fail basis of activities for each level. A training protocol has been developed accordingly.

The upper extremity dexterity can be further assessed by various standardized procedures such as Purdue Pegboard, Minnesota Manual Dexterity Test and Nine

. .;4 55 56 57

Hole Peg Test. All these tests are standardized and validated .

Functional Test for Hemiplegic Upper Extremity (FTHUE-HK) should be used to assess the functional control of upper extremity after stroke because of its psychometric properties. Dexterity can also be further assessed by various standardized procedures.

Grade B, Level III 35

6.1.1.2 Sensory assessment

The adverse effect of sensory deficits on functional outcome are repeatedly

d d 51' 59 60 'T' I h functi f h .

ocumente - .. 10 eva uate t e sensory nctron 0 t e upper extremity,

there are various assessment procedures currently used by occupational therapy, such as pin prick, light touch and tests of proprioception. The ratings used are normal, impaired and absent. These assessments seem acceptable for practical purposes. though less reliable than motor measures 61 62, Validated sensory tests are available, such as monofilaments, two-points discrimination test and Moberg

P· k T 63 64 (15 66 I h h h d k I . d . .

IC '-up est , at oug t ey nee to ta e onger time to a munster.

Moberg Pick-up Test is indicated when motor return is good but hand dexterity

67 remains impaired

Sensory assessment should be included in the evaluation of hand function after stroke because sensory deficit affects hand function.

Grade C, Level H

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6.1.2 Functional Training of Upper Extremity

The loss of upper extremity control is common after stroke: 88% of stroke survivors have some level of upper extremity dysfunction 68. Different treatment approaches are used by occupational therapists to improve hemiplegic upper extremity function, for example, neurodevelopmental approach, motor releaming, rood approach and constraint-induced movement therapy. All approaches share a common neurophysiological foundation based on two assumptions about CNS function. Firstly, the CNS is capable of plasticity in response to damage, and motor output can be modified through application of sensory stimuli 69. There are numerous studies documenting the effectiveness of these approaches 70 71 72 73 74 75 7(.

Therapists may choose to follow any specific approach. To work effectively, it should be incorporated into purposeful activity 19 24. To standardize the practice, we follow the Hemiparetic Upper Limb Training Protocol developed by Stroke Focus Group, OTCOC, HA and Department of Rehabilitation Sciences. Hong Kong Polytechnic University (2002) 77. This task specific training focused in systematic and repetitive practice within the level of upper limb function was effective in improving upper limb function."

Grade A, Levellb 19 24 78

There are different treatment approaches that can be used to improve upper extremity functions, especially if they are incorporated into purposeful activity.

6.1.2.1. Retraining of sensory function of the paralyzed hand

Somatosensory deficit can be alleviated even years after stroke and that rehabilitation for stroke patients should include sensory retraining for those with

d fi . 79 SO T ·1 h Id b d

sensory e 1C1t • reatment to restore tacu e awareness s ou e structure so

that repeated sensory inputs are provided to gain a larger cortical representation for those skin surfaces needed to perform daily tasks 81

7980 Grade B, level Ua--

Structured sensory retraining can improve somatosensory deficit after stroke.

6.1.3. Management of shoulder complications

6.1.3.1. Shoulder complications

24

Shoulder subluxation, shoulder pain and even complex regional pain syndrome type I (reflex sympathetic dystrophy) are the common upper extremity complications after stroke. Shoulder subluxation may be a causative factor for reflex sympathetic dystrophy (RSD) disorder 82. The reported incidence of Shoulder Hand Syndrome ranges from 12.5% to 25% 83. The syndrome begins with severe pain and progresses to stiffness in the shoulder and pain throughout the extremity. Other symptoms include moderate to marked swelling of the wrist and hand. vasomotor changes, and atrophy 8-1. Such complications can affect the recovery of power and function of arm as well as functional outcome 85. Therefore, prevention and appropriate treatment of glenohumeral joint subluxation should be included in the rehabilitation of hemiplegic patients. Edema can be reduced by elevation of upper extremity and pressure garment. Active and passive mobilization of the involved

. . 1 d d 86

extremity IS a so recommen e .

Grade C, Level IV

Prevention of shoulder subluxation by positioning, edema control, active and passive mobilization is effective in controlling complex regional pain syndrome.

6.1.3.2. Shoulder slings and supports

A specific design of shoulder sling may reduce the effect of gravitational pull on the

poorly supported glenohumeral joint, helping to prevent subluxation 45. Positioning

of the upper extremity is routinely highlighted as the initial focus in the treatment of heimplegic shoulder pain. For chair-bound patients, an arm trough or lap tray can

id f flaccid d ffi . I d bl . 45464768

provi e support or a acct ann an e ectrve y re uce su uxation .

Avoid the use of overhead arm slings, which encourage uncontrolled abduction 2.

Shoulder sling and arm support devices may help to reduce shoulder subluxation or shoulder pain of the flaccid upper extremity.

Grade C, Level IV

6.1.3.3. Re-education of shoulder girdle control

Early passive range exercise is generally accepted as an important measure to prevent immobility and soft tissue contracture 87. However, it should be done carefully to prevent impringement and rotator cuff tear 88. Reduction of muscle tone prior to passive elevation of the spastic shoulder is recommended. In treating

25

subluxed shoulder, the humeral heads should be relocated 111 the glenoid cavity

b C id ion d 89 90

erore movement to avoi traction amage .

Grade C, Level IF

Proper techniques in facilitating the control of hemiplegic shoulder girdle is helpful in reducing shoulder pain and subluxation.

6.1.3.4. Education on positioning and handling

Some studies suggest that trauma to the shoulder joint can be prevented by proper

'" d I dli 88 ()( P' I . I I ' h f

posinomng an tan II1g ,atIents w 10 require te p WIt trans ers are more

likely to suffer with shoulder pain 92, Stroke patients and their carers need advice about correct handling of the hemiplegic arm, and more work is required to ensure that correct handling occurs to prevent further damage to the joint.

97 9' Grade B, Level III - -

Patients' and carers' education on proper positioning and handling can help to prevent shoulder pain.

6.1.4.l\lanagemcnt on the increased muscle tone of upper extremity

6.1.4.1. Splintage

Other than proper positions or encouraging weight bearing positions, hand splints are used by occupational therapists as a method of reducing the increased muscle tone of the upper extremity following stroke, The splint may be used to maintain soft-tissue length, provide low-load prolonged stretch, place muscles at their resting lengths on both sides of the joints, and attempt distal relaxation by promoting proximal alignment 94. Finger spreader splint is found to be effective to inhibit spasticity when applied over 6 hours daily 95,

Grade C, Level Iv

Hand splint may help to reduce the increased tone of hemiplegic upper' extremity

Evidence: Table 6.1

26

6.2 Activities of Daily Living and Instrumental Activities of Daily Living (ADL & IADL)

6.2.1. Functional assessment

The original Barthel indexrBl), modified Barthel index(MBI), Functional Independence measures (FIM) and Assessment of Motor and Process Skills (AMPS) arc all widely used by occupational therapists as assessment tools for clinical decision-making and outcome measurement. All these scales were well studied and

. 96 97 98 91) Ion . .. .

validated . The scales can reflect the degree of functional disability

ft k d di h f . I fr h d . . 101 IU2 103

a er stro e an pre ret t e uncnona outcome om tea mission score .

FIM has high internal consistency and adequate discriminative capabilities for

h bili . I . d i d' I"". b d f 1()4 105

re a I nation patients, t IS a goo III icator lor ur en 0 care.

The currently used functional assessments for stroke patients can predict the functional outcome at discharge and help to plan for the treatment realistically.

Grade B, level III

6.2.2. Specific assessments

Functional disability is closely related to cognitive impairment, and cogrutrve impairment is often an indicator of the ability to lead an independent life Infl. There are evidences that overall cognitive improvement correlates with overall ADL improvement in stroke 107. Besides, cognitive function is important for motor relearning and learning the adaptive method in the rehabilitation process \08. Perceptual impairment such as unilateral neglect has been shown to be one of the major disruptive factors impeding functional recovery and rehabilitation success 109 1111. There is a significant correlation between unilateral neglect and functional ability III. Such distorted perception seriously impedes performance in daily functions. Therefore, early identification of cognitive and perceptual deficits can facilitate better treatment planning.

112 1 \3 Grade B, Level Ilb

Patients showing unexplained persistent difficulties in ADL should be assessed specifically for perceptual impairments.

6.2.3. Foundation skills training

Various studies have identified a number of factors, which are associated with the functional outcome in stroke patients. It has been found that there is a close

I' I' b h itv of I' d d' bili 114 115 P k d

re ations lip etween t e seventy 0 para ysis an isa I ity , oor trun ' an

, h k f c, k 11(, 117 us

lower extremity control are t e mar cers 0 poor outcome rrorn stro e '

Local study also explored the importance of sitting and standing functional balance training can improve ADL, IADL and community living skills for patients with stroke 11'/, Other factors include cognitive perceptual status, depression and psychological adjustment to stroke 68 120, They are possibly reversible by appropriate intervention I:! I I:!:! 123 1:!4 125, The theoretical framework of occupational therapy also has similar beliefs that these factors, or so call foundation skills, are important for an individual to perform functional tasks effectively 116, Occupational therapy programmes utilize goal-oriented remedial activities to develop the client's foundation skills, which are precursors to function 127. Foundation skills training include coordinated motor control and sensory awareness, Evidence suggests that coordinated movement may be improved using meaningful goal objects as

I"'S 129 targets and imagining functional use of the affected limb -

Foundation skills training focused on goal orientated tasks and coordinated movement may increase the voluntary active range of movement.

1"'8 Grade A, Level Ib -

6.2.4. ADL and IADL training

Early referral to occupational therapy for stroke rehabilitation is important. Occupational therapy can improve the ability in ADL and TADL after stroke 113, Functional training for stroke patient is important for better functional outcome 130 131 Care takers' stress is subsequently reduced as well 113, Specific compensatory strategies in coping with functional disability resulting from cognitive and

I" I ffecti 13"' 1'1

perceptua impairments are a so e ecnve - - - ,

Further functional training after an initial phase can also bring about improvements

ft ' , 134 I3S 1 ~6

even one year a er a stroke and can prevent deterioration -

Grade A, levellb 136

Occupational therapy significantly reduces disability and handicap of patients with stroke.

6.2.5. Effects of functional training on impairments

The advantage of functional training for stroke patient is that it can bring about a

t ' fb 1 ' , b'l' d 19 128

grea er Improvement 0 ot 1 cognitive a 1 ity an motor control ,

Functional tasks training incorporated with specialized treatment techniques can result in greater improvement of cognitive and motor ability after stroke.

Grade B, level III

28

Evidence: Table 6.2

6.3. Cognitive and perceptual function

Cognitive function refers to the ability of the brain to process, store, retrieve, and manipulate information. It also refers to attention, perception, organization, memory, high level thinking process and language 13 i. Reduced cognitive function is

. k . 138 139 C . . .. fr I ft

common III stro e patients . ogmtive impairment occurs equent y a er

stroke, commonly involving memory, orientation, language and attention 106. Cognitive function is important for motor relearning and learning the adaptive method in the rehabilitation process 108.

Perceptual problems have been shown to be common following both right and left hemiplegic stroke, such problems include visuo-spatial neglect, visual perceptual

d functi . d . 140 141 142 Th I bl ff I

ys nction, apraxia, an agnosia . ese perceptua pro ems a ect t ie

patients' responses to rehabilitation and their ability to perform activities of daily living (ADL) 142, suggesting that they should be treated if possible.

Perceptual problems are important in that they may explain an otherwise inexplicable disability in ADL 2, which is of occupational therapists' primary concern.

6.3.1 Cognitive and perceptual assessments

Occupational performance and cognition are major factors determining health and quality of life. Occupational performance encompasses human functioning in the areas of self-care, productivity and leisure 143. Cognition is a basic human trait that underlies every human function 144. Cognitive impairment can limit functional gains during inpatient rehabilitation 145. Therefore, accurate and prompt assessment of cognitive dysfunction is critical to the success of stroke rehabilitation and for prediction of rehabilitation outcome.

146 Grade B, Level JIb

The provision of information about cognitive assessment in stroke rehabilitation may decrease care taker strain.

6.3.1.1. Cognitive assessments in rehabilitation phase

The cognitive assessments commonly used by occupational therapists include:

29

CMMSE, LOTCA, RBMT, NCSE (COGNISTAT), RPAB.

The MMSE (Mini-Mental State Examination) is a reliable, and validated instrument widely used in screening for cognitive impairment as it is easy to administer 147 In Hong Kong, CMMSE (Chinese Mini-Mental State Examination) translated version was well validated with cut off score at 19 or 20 for quick and effective screening of cognitive impairment in our locality'".

The Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) is primarily used by occupational therapists to assess cognitive and perceptual function after stroke and other brain injury 148. It is more comprehensive than CMMSE and is slightly better than CMMSE and Functional Independence Measure (FIM) in predicting functional status change after stroke rehabilitation 149 150. Since it is more time consuming, it is best used after screening by CMMSE.

Riverhead Behavioral Memory Test (RBMT) can be used to evaluate cognitive abilities such as memory in functional activities in order to adequately plan a rehabilitation program whose ultimate goal is to improve everyday functional capacities 151. The RBMT correlates well with occupational therapists' ratings of patients' memory abilities. It also correlates significantly with everyday memory performance as demonstrated by head-injured patients. The Cantonese version (RBMT-CV('1 15J was also well validated for wide local application with high inter-rater reliability, parallel form reliability, internal consistency, predictive validity. The studyl52 also suggested that a cut-off point of 15 or less of the total standardized profile score appeared to effectively discriminate between patients with brain damage and memory dysfunction from those without memory dysfunction.

The Neurobehavioural Cognitive Status Examination (COGNISTAT) is a second-generation mental status device that outperforms traditional examinations (e.g. mini-mental state) and is sensitive to cognitive disorder in neurosurgical populations 154 155. NCSE is highly sensitive in identifying cognitive impairment but cannot be the gold standard for cognitive assessment because of the poor

. fi . . h 1 I . I I . 156 157 TI CI' . f

speer icity wit neuropsyc 10 ogica eva uation . re 11l1eSe version 0

Cognistat for patients with stroke was validated with local norms in stroke patients'j",

The Rivcrmead Perceptual Assessment Battery (RPAB) is a sensitive test for perceptual impairment because it covers a wide variety of perceptual tasks ranging from size recognition, colour and object matching, figure ground discrimination. sequencing, unilateral neglect and three-dimensional copying. The test is

30

time-consuming. It may require an hour to complete, which may be too tiring for an elderly. A simplified version has been found to be just as good as the full version in predicting outcome. I:<J

Grade B, Level III 30

Cantonese version of MMSE will be used as the screening tools for cognitive impairment. Therapists should conduct specific validated assessments if CMMSE result revealed certain cognitive problems.

6.3.1.2. Perceptual assessment in rehabilitation phase

Perceptual impairment such as unilateral neglect has been shown to be one of the major disruptive factors impeding functional recovery and rehabilitation success 113 120. The Behavioral Inattention Test (BIT) is a standardized test for unilateral neglect. Its construct and predictive validity have been supported by previous studies 141. The line crossing test from the BIT has been chosen to screen for visual neglect due to its good sensitivity and easy administration 160. There is a significant correlation between unilateral neglect and functional ability III. The Chinese Behavioural Inattention Test (CBIT - Hong Kong Version)'?'. was validated with good intra-class correlation, test-retest reliability, internal consistency, item-total correlation, sensitivity and specificity with new cut off scores for the Chinese article reading and copying Chinese address. The Chinese translation of the behavioral subtests items: article reading, and address & sentence copying, was transferred from the Chinese proto typed version of Tongji Hospital, Wuhan (2001). The local modifications also included: changing the picture of scanning, telephone number, restaurant manual, and coin sorting relevant to the Hong Kong culture

The Arnadottir OT-ADL Neurobehavioral evaluation (A-ONE) is an assessment tool that links functional performance in daily activities to neurobehavioral deficit 16~. The content validation was provided by a literature review and expert opinion. The interrater reliability was examined by 20 case studies indicating that further refinement of the instrument was desirable.

The A-ONE and the Behavioral Inattention Test have been recommended as the most suitable tools for measuring perceptual and body image dysfunction 16, Grade C, Level IV . -

31

The Assessment of Motor and Process Skills (AMPS) is a standardized test that provides the occupational therapist with a method for detailed analysis of a person's executive ability 164. It is designed as a multi-layered tool which allows the occupational therapist to assess simultaneously both global task performance and the quality or efficiency of a person's motor and process skills, as they are manifested in the context of performing meaningful, chosen and appropriately challenging daily

1· . k 154

rvmg tas s .

The reliability and validity of AMPS have been proven by several studies, and a later study is also validated across three different cultures showing the applicability of AMPS in different cultures 1(,5

Grade C. Level H'

Assessment of Motor and Process Skills (AMPS) is recommended

for assessing clients' excessive function in carrying out BADL & IADL tasks.

6.3.2. Intervention approaches for Cognitive and Perceptual Problems

There are two approaches that occupational therapy used in cognitive rehabilitation: remedial and functional. Remedial approach involves the retraining or restoring of impaired core areas of cognitive skills. Functional or compensatory approach aims at teaching clients to use their assets to achieve successful performance despite the

[ d I . .. d fici 166 167 168 P' h ld b 'd d

presence 0 un er ymg cogrutive e icits . atrcnts s ou e provi e

with opportunities for choice and selection, planning and self-correction?'" Recovery from visuo-spatial neglect is associated with improvement in function 16K. Visuo-spatial deficits are an important independent factor governing functional outcome 169. The treatment goal in cognitive rehabilitation is to enhance the client's awareness of his/her deficits, and their impact on functional performance 170

A methodical review of the scientific literature 3 levels of recommendation on cognitive rehabilitation for persons with traumatic brain injury (TBI) and stroke' ~ I. The 3 levels of recommendations are: (1) practice standards which are based on well-designed Class I randomized control trials with good evidence to support specific treatment in cognitive rehabilitation; (2) practice guidelines based on Class II studies with fair evidence for effectiveness of treatment; (3) practice options which are based on Class II or Class III studies which support a recommendation to specific treatment but with unclear clinical certainty. Treatment interventions that

32

are recommended as "practice standards" include visuospatial rehabilitation for visual neglect17~17.1I7~, cognitive-linguistic therapies, interventions on functional communication deficits including pragmatic conversational skills 17S 176, and compensatory memory strategy training, "Practice guidelines" include attention trainingI77178[79180, scanning training, visuospatial interventions to increase visual fields 181182, reading comprehension and language formation training, problem solving strategy training 183184185 apply in every day situations and functional activities. For "practice options" recommend the optional use of memory notebooks and other aids 18() , verbal self-instruction, self-questioning, and self-monitoring to promote self_regulationl87188189 which are based on limited evidence and need further research. Computer-based interventions studies report in no significant

diff b d .. 190191 H ' ,

1 terence etween computer an non-computer trammg . . owever, It IS

recommended to carry out in multi-modal intervention and active therapist involvement to foster insight into cognitive strengths and weaknesses, to develop compensatory strategies, and to facilitate the transfer of skills into real-life situations,

Evidence also supports the use of occupational tasks and homemaking activities rather than paper -and-pencil tasks in cognitive perceptual training 192,

Use of consistent strategies to accomplish functional activities can improve cognitive-perceptual function after stroke.

Grade B, Level /lb171

6.3.3.

Treatment of Unilateral Neglect

Unilateral neglect has a direct implication in the success of rehabilitation after

k 193194 All I I' I dencv. i '11' f

stro e ,t 10Ug 1 t iere IS a natura recovery ten ency, It IS sti Important or

occupational therapist to treat the problem promptly in order to improve the related functional problems. There is some evidence that cognitive rehabilitation for spatial neglect improves performance in some impaiITnent tests but its effect on disability is

195 unclear

Stroke patients with visual neglect are found to perform better when there are cues. The training effect will better if the cueing involves movement into neglected

196 197. T lik hi 1<)81<)<) nk ' . .. 71)02Ul

space reatments I e eye-pate 111g· . tru rotation acuvmes: to the

neglected side show some efficacy in improved attention to affected side. However, the studies are commonly lack of sample size and little investigation of functional outcome'" ,

33

Spatiomotor cueing seems to be effective in the treatment of unilateral neglect Grade B, Level lIb 140 196 197

Evidence: Table 6.3

6.4. Psychological adjustment to the disease

6.4.1.Screening for depression and anxiety

Disturbance, both of mood itself and of the control of mood, is common after stroke. Diagnosis of the presence or absence of an abnormal mood state is difficult, particularly in the presence of speech disturbance. Among all kinds of emotional disturbance, depression is the most common 203. Generalized Anxiety Disorder constitutes about 28% in the acute stage 204. There is a high prevalence of

.. . 20S 206 207 20S . .

depression 111 stroke patient . . Symptoms suggestive of depression

include crying, feeling miserable or hopeless, lack of motivation, reduced appetite, reduced social activities, etc. Many patients are unable to cope with the major changes that result from a stroke 51 205 and in particular, the loss of functional

. d d . I lv related d . 209 2 1 0 21 I

111 epen ence IS c ose y re ate to epression. .

The Geriatric Depression Scale (GDS) should be used during hospitalization, as it is reliable in predicting post-discharge depression in stroke elderly.

"p Grade A, Levellb - -

6.4.2. Psychological support

There is much evidence on the prevalence of depressive symptoms after stroke, but it is difficult to use the available evidence to guide specific treatment. The primary difficulty is in deciding whether a specific intervention is needed to improve the mood state and the outcome is difficult to document in terms of quality of life

measures

213

Grade B, Level II 2

Patients should be given information, advice and the opportunity to talk about the impact of illness upon their lives

Evidence: Table 6.4

34

7. Pre-discharge planning

Discharge planning refers to any process that formally involves the team or service in transferring responsibility from one group of people or team to another. The process should involve the multi-disciplinary team, patient and carer 1.

Occupational therapist plays a significant role in preparing patients to be discharged by providing home visit to ensure safe discharge, prescription of assistive devices, carers education and home programmes.

7.1. Prescription of Assistive Devices

7.1.1. Consideration on prescriptions of assistive devices

Prescription of assistive devices is one of the means of rehabilitative approach. There is evidence that the prescription of aids with the immediate instruction significantly increases the level of satisfaction in the use of bathing aids by 90-100% 214. Assistive device when wisely selected and designed can provide independence and often increases safety and speed in daily activity 215. Functional decline is slower with the prescription of assistive devices and environmental modification and the cost of domiciliary care staff and institutional care are also lower in the .. I 216

intervention group as a resu t .

Common assistive devices prescribed for stroke patients include: feeding aids. bathing aids, toileting aids, hand rails, wheelchair and kitchen aids. If patients have communication problems, occupational therapists will also provide communication boards or augmentative devices for communication. For minor adaptation like velcro, fastener front is the best option for clothing adaptation 217

The best approach to select a wheelchair is to set priorities based on the patient's mobility and seating needs with consideration of daily routine, home environment, and accessibility. This would help identify the features that are most important and those on which the patient is willing to compromise 218.

Prescription of assistive devices and providing environmental modification promote patient's functional performance and are cost effective.

'16 Grade A, Levellb -

Organized care with provision of assistive devices in the Stroke Unit facilitates the

continual use of more aids and equipment ::!19. However, patients' needs and utilization of aids vary widely over time 220. Pattern of use is normally established in 4 weeks ::!21. A study on stroke users shows that 21 % are consistent users; 11 % delayed users; 21 % temporary users and 47% non_users220. Follow up domiciliary visits are suggested to review the home environment 221. To facilitate smooth discharge planning, the provision of aids loaning service can be considered.

Grade C, level IV 220 22 t

As patients' needs and use of assistive devices vary over time due to change in health and functional status, therapist should consider the use of aids loaning service.

7.1.2. Education on the use of prescribed assistive devices

Significant resources are needed for assessing and teaching about aids at

.".,

pre-discharge phase after stroke ---. Six areas of training have to be covered:

operation of devices; utility of device; social contexts; personal meaning of using devices; leaming to use devices; and the transitory nature of assistive devices.223.

Training should be provided to patients and caregivers in the use of prescribed assistive devices. Wheelchair training should include the proper handling techniques and the maintenance process to ensure safety for both the patients and carers 4. Practical sessions on wheelchair handling in using public transportation such as low platform bus. MTR. KCR can enhance better community reintegration.

.,.,'

Grade B level III z :»

Education in the use of aids is needed. Follow up action is required to promote utilization after discharge.

Evidence: Table 7.1

7.2. Community occupational therapy visit !Environmental modifications

"Community occupational therapy visit", as defined in the Clinical Guideline and Performance Standards for Community Occupational Therapy, is 'a visit to the home or client-related environment of a hospital in-patient, out-patient or community based client which involves an occupational therapist!s in accompanying the client!

36

patient to assess hisl her ability to function within the environment, or to assess the potential for the client to be as independent as possible with the support of care-givers. The visit may include assessment of the environment relating to the

224 provision of equipment and lor environmental adaptation'

7.2.1. Pre-discharge home visit

An early supported discharge service (similar to the existing Allied Health Community Project service) following acute stroke rehabilitation with individualized rehabilitation in the community decreased the length of stay and improve IADL score n5 . There are no significant differences in clinical outcomes apart from increased satisfaction with hospital care but the length of stay in the

226 community therapy group was significantly reduced

Patients' length of stay in the hospital for rehabilitation can be much reduced with pre-discharge community occupational therapy service.

Grade A, level Ib 226

7.2.2. Post-discharge follow-up

A brief occupational therapy programme carried out at patients' home immediately after discharge can improve the functional outcome and satisfaction of stroke patients 227. The provision of a follow-up community occupational therapy service benefits stroke patients by addressing their problems after discharge, ensuring that they receive all necessary aids and helping them to maintain themselves at home 228. Evidence shows early supported discharge with follow up home rehabilitation services for moderately disabled stroke patients in the first three post stroke months is more beneficial than routine rehabilitation. Further studies are needed to confirm the effectiveness of these services in at 6 and 12 months after stroke 229. Trials also support the use of community occupational therapy for stroke patients after discharge with improvements in functional outcomes in the short-term 230

Grade A, level Ib228

Community occupational therapy service addresses stroke patients' problems after discharge, ensures that the clients receive the necessary aids and assists tbem to maintain independence at home.

37

Grade A, levellb

Pre-discharge education and Post-discharge follow up together improve the functional outcome and satisfaction of stroke patients and are more beneficial to them than to prolong their stay in hospital for routine rehabilitation.

229230

Evidence: Table 7.2

7.3. Fall prevention

Stroke patients with unsteady gait are the high-risk group of clients to have potential hazard on fall 231 232. Taking multiple medications can increase the risk of falling. Risk-taking behavior, 233 environmental factors and external hazards also contribute to falls 234. The goal of Occupational Therapy for clients having had fall is to improve safety, prevent fall 233, minimize risk factors and achieve a 'person-environment fit' that enable the person to function as completely as possible 235 and reduce the psychological stress and fear so as to improve the quality of life. Through thorough assessment of (1) the fall history, (2) foundation skills in the sensory, motor, perceptual, cognitive and psychological domains, (3) functional tasks including ADL, IADL and risk-taking behaviors, (4) and the environment, the risk factors for fall can be identified and different treatment interventions including foundation skills training, functional tasks training, environmental adaptation and education programmes can be conducted accordingly.

7.3.1. Community occupational therapy visit can prevent falls

Home visits by occupational therapists can prevent falls among older people. Such visits may result in home modifications and changes in behavior that enable older people to live more safely 236 237. Occupational therapy may also bring about improvements in the following tests: controls on the extended activities of daily living scale, Barthel Index, the carer strain index and the London handicap scale 238. Patients treated by domiciliary team have higher household and leisure activity

I . . . 'W'40

scores t lan those recelvmg routme care -- - .

Major home modification recommended by Occupational Therapist to prevent fall include: Remove mats/rugs (48%), Change footwear (24%), Use non-slip bath mat (21 %), Change behavior (15%), Use light at night (13%), Add railing (12%), Move

I . I ( 2"7

e ectnca cords 12%) - .

38

Grade A, levellb 238 239 240

Community occupational therapy visits prevent falls among older people, facilitate higher daily activity performance as well as household and leisure engagements.

7.3.2. Hip protectors

The use of hip protectors is effective in preventing hip fracture for clients with

hi h isk f c. II 241 242 243 Th h' ddi d c. I . c.

rg ns 0 ra s . e ip pa mg ecreases remora Impact rorce

which subsequently reduces the hip fracture rate 244, It also improves the clients' 245

confidence as monitored by the Fall Efficacy scale

Hip Protectors can reduce the risk of hip fracture resulting from falls.

Grade A, Level I 241

Evidence: Table 7.3

7.4. Carers education

The disability caused by stroke can lead to high level of strain on caregiver and risk of burnout 246. Findings suggest that caregiver-related problems can have a collective effect on rehabilitation outcome. Patients are at risk for less than optimal home care have caregivers who are (a) more likely to be depressed, (b) less likely to be married to the patient, (c) below average in knowledge about stroke care, and (d) reporting more family dysfunction 247,

Stroke services must be alert to the likely stress on caregivers and provide appropriate level of support to different types of caregivers.

246 247 Grade B, level III

7.4.1. !\lode of training

Carers education is one of the core services of occupational therapy in stroke rehabilitation. The quality of care is correlated with how well the carers are educated. trained and prepared to care for their stroke survivor upon discharge 248. Information leaflets may lead to improved knowledge about stroke several months after they have been distributed 249. The slide/audio programme appears to offer a short, easily used and effective educational experience for diverse communities 250

39

There is some evidence that information combined with educational sessions Improves knowledge and is more effective than providing information only. Information provision alone has no effect on mood. perceived health status or

251 quality of life for patients or caregivers

Grade A, level Ia 251

Information combined with educational sessions improves knowledge and mental health of patients arid/or caregivers, and is more effective than providing information only.

7.4.2. Information provision content and strategies

It is recommended that treatment should focus on reducing caregiver depression, minimize family dysfunction and increase the family's knowledge about stroke care 247 25~ 253

The information needs identified relate to recovery, treatment and

prognosis; practical caring tasks; social activities and support 246 ~54; and resources

'1 bl . h . 253254

aVaJ a e III t e community .

The present educational programmes and information provided for stroke patients include: fall prevention, carers handling teclmiques, dressing techniques, upper limb function training, use of wheelchair on public transportation, community resources.

Support programmes should focus on self-efficacy, social support, coping strategy. higher mental well-being and greater vitality 246. Counseling should be provided in relation to "care" problems arising from the disability of stroke patients and the

h . d d d d 252253

C anges 111 epen ency pro LIce .

'53 '54 Grade B, level III - -

A structured education programme for patients and caregivers needs to be developed with reference to information about their ongoing needs throughout the care-giving journey.

Evidence: Table 7.4

40

7.5. Home Programme

Written and illustrated home exercise programme can encourage clients to continue the training oflimb control 255 256 257. It is an effective tool in helping the clients to organize their movements and use actual objects to reach functional goals 128.

Evidence: Table 7.5

7.6. Community Re-integration

7.6.1. Occupational Adaptation

A reduction in social and leisure activities has been found to be an important sequel to stroke, Occupational therapists intervene to promote adaptation in stroke survivors whose occupational performance has been impaired by their disability. It is important for the occupational therapists to screen for occupational adaptation problems and intervene as necessary. It is well documented that leisure participation

'"158 ')5<) '"160 "')61 ••

decreases after stroke - - - -. Stroke cases with leisure rehab perform

significantly better in mobility and in psychological well being than those without 262

Qualitative studies have identified the need for meaningful activity and creative participation in life as crucial elements related to successful coping mechanisms for people with chronic illness and physical disability 263 264.

To enable occupational performance, therapists need to be client-centered, understand the meaning of occupation for the individual and facilitate engagement

. ions th h 11' h' h bili 265 2(,6 267 E id h

III occupations t at are c a engmg to IS or er a 1 ity , VI ence sows

that the use of intervention guided by the occupational adaptation frame of reference is associated with improved functional independence and discharge to more

268 accessible environment for stroke patients

Occupational therapy demonstrates the effectiveness to improve stroke patients' participation in activities. It is recommended that the therapists use structured instruction in specific and client-identified activities, as well as appropriate adaptations to enable performance and practice within a familiar context and give feedback to improve client performance.

'58 '6"') Grade A, Level fa -- --

41

7.6.2. Support program

Occupational therapists take a leading role in enabling clients to reintegrate into the community by encouraging them to participate in more social activities. Occupational therapists can also provide information on the availability of community resources. Occupational therapists can actively refer clients to some subvented organizations e.g. Community Rehabilitation Network or self-help groups on stroke in the local community, so that patients can develop a support network. There is no significant evidence on organizing social support group can improve the social support measures or psychosocial outcomes, but significant changes in support within sample in relation to gender, living situation, marital status and

2()')

employment status .

Evidence: Table 7.6

42

8. Service Evaluation

8.1. Audit of guideline

The development of the clinical guidelines on stroke is based on a thorough and careful review of the relevant research evidence and clinical experiences. Conducting clinical audit can evaluate their applicability and getting feedback from clinician for the continuous improvement for the service.

The auditing criteria selected are based on:

• strength of research evidence,

• systemic review of each element of care identified as important in determining "70

outcome - ,

• the elements for clinical risks, and

• importance of the limitation of the resources available.

The criteria are then categorized as 'must do' and 'should do' for prioritization and

f h 1· h . I' 271

urt er eva uation on t err comp lance .

The clinical audit of the guidelines will be conducted in three aspects (structure, process and outcome of care) and two levels (general and specific condition) by phases.

The structure aspect

It refers to the resources available which may include the staff skill mix and the provision of equipment.

The process aspect

It refers to the actions and decisions taken by the therapists. The action may include communication, assessment, education investigations, prescribing, any therapeutic interventions, evaluation and documentation.

The outcome of care

It refer to the typically measures of the physical or behavioral response to an intervention, reported health status and level of knowledge and satisfaction 271.

For the general compliance auditing level, the aim of audit IS to evaluate the compliance of important guidelines. Therefore, the audit criteria will focus on the generally agreed procedures or interventions i.e. the 'must do' level.

43

For specific condition auditing level, some specific clinical conditions or management are selected for intensive audit in the process of collecting more information for

. 271

Improvement .

Performance level or standard is set for each criterion by group consensus among the participated hospitals in NTE Cluster. These levels and standards then become the basis for comparisons during the auditing exercise.

8.2. Data Collection

8.2.1.

Sampling

Random sampling is used to minimize the risk of bias 271 Random sample of 5% stroke patients attending each setting in the set time period will be selected for auditing.

8.2.2.

Data abstraction

• General compliance audit

Data are collected retrospectively from the medical records and are "71

extracted onto standard forms - .

The time period for audit is six months to one year.

• Specific condition audit

Concurrent data are collected from the medical records and are extracted onto standard form 271

Patient interview is also used in some specific intervention for assessing the outcome or collecting feedback.

The time period for audit is not more than two months.

8.3. Data interpretation

Data collected are analyzed and compared through criterion-based evaluation and validated by statistical tests.

The results are compared with the set performance level for review.

The factors associated with non-compliance are also evaluated for review and improvement. The results are used as the feedback for further revision of the developed clinical guidelines.

44

9. Table of Evidence

Table 4 t· Table of evidence on common validated assessments

. .
Source Dcsign & SamjlJe 111 terventionfs) Conclusions
Wikander,B., RCT; Ward using structured assessment with Structured assessment led to urinary continence
Ekellund, P. & n = 34 acute stroke patients FIM, or ward using Bobath clinical
Milsom, I. 6 with urinary incontinence. assessment
( 1998) Table 43· Table of evidence on zoal settlnz in rehabilitation

. .
Source Design & Sample Intervention(s) Conclusions
Bar-Eli, M., RCT; Strength training with differing levels Moderate/hard specific goals led to more strength gain
Tenenbaum, G., n = 346; high-school of target and differing practice than easy or unachievable goals or non-specific goals.
Pie, J .S., et a1. II students intensity.
( 1997)
Van Vliet, P., et CCT; Goal directed or non-goal directed Goal directed movement (reaching and grasping) more
al. 12 ( 1995) n = 5 patients after stroke movement (otherwise similar).
Blair, C.E. Jj RCT; Routine care; or mutual goal setting ± Combination of goal setting and behaviour
(1995) n = 79; nursing home behaviour modification. modification reduced dependence in ADL.
Blair, C.E., et a1. residents
(1996)
Glasgow,R.E., RCT; Routine care, or patient-centred goal Goal setting led to prolonged change in dietary
Toobert, D . .1. & n = 206; people with setting (20 minutes) aided by computer behaviour.
Hampson, S.E. 15 diabetes assessment.
1(1996) 45- "16

Table 4.4: Table of evidence on therapy approaches

Source Design & Sample Intervention(sJ Conclusions
Pollock, A.S., et Systematic review of Systematic review for efficacy studies There is insufficient evidence to conclude one approach
al. 18 11 RCT on motor learning, neurophysiological is more effective than any other approach.
(Bobath) and orthopaedic principles.
Basmajian, .LV., RCT; Bobath approach or behavioural Outcome the same; no differences seen
et al. 21 (1987) n = 29 stroke patients approach to aml therapy.
Jongbloed, L., RCT; Compare effectiveness using functional No difference 111 outcome including Bl, meal
Stacey, S. & n = 90; first stroke within approach, or sensorimotor integrative preparation and Sensorimotor Integration Tests.
Brighton, C. 22 12 weeks approach.
(1989)
Richards, c.L., et RCT; Early, intense conventional therapy; Early muscle retrammg and gait retraining (on
a!. 23 (1993) see n = 27 acute stroke patients later less intense conventional therapy; treadmill) facilitated gait recovery; no differences
also Malouin, E, early intense gait and muscle between conventional.
et al. (1992) retraining.
Nelson, D.L., et RCT; This experiment compared the effect of Functional task greatly increased supination of forearm,
a1. 24 (1996) n = 26 post-stroke patients an occupational embedded activity This study advances the experimental analysis of
involving therapeutic occupation III the area of occupational
functional task (dice game) or rote embedded activity.
exercise (identical rotation movement).
Using electronic record to document
degree of rotation of grasp during
activity / exercise.
Dean, C.M. & RCT; Training at reaching (functional), Task-related training improved ability at similar tasks.
Shepherd, R.B. 25 n = 20; stroke 1 + years ago against cognitive training.
(1997) 47

Table 4.5: Table of evidence 011 Intensity of therapy input

.
Source Design & Sample Intervention(s) Conclusions
Kwakkel, G, et MIA; n = 9 trials, 1051 Daily rate of physiotherapy or Higher rate of therapy associated with better outcome;
al. 26 (1997) stroke patients occupational therapy. but many confounding factors.
Kwakkel, G, et RCT; Arm training; leg training vs control Greater intensity of leg training improved functional
al. 27 (1999) n = 101 severely disabled programme of ann and leg recovery and status; greater intensity of ann training
patients with primary immobilized with an inflatable improved dexterity.
middle-cerebral-artery pressure splint for 30 minutes,S days a
stroke week for 20 weeks after stroke.
Smith, D.S., et al. RCT; Three intensities hospital outpatient Dose-response effect seen. Beneficial effect of treatment
28 (1981a) n = l33 patients after therapy: 4 whole days/week; 3 was achieved in first 3 months, progress maintained for
discharge half-days/week; no rehabilitation. the rest of the first year. Table 5 I: Table of evidence on earlv disabilitv assessment and mauazement

. .
Source Design & Sample Measure(s) & Analysis Conclusions
Chiu, H.EK., et N=190, Cantonese Version of Mini-Mental Reliability:
al. 30 (1994) 111, normal elderly State Examination internal consistency = 0.86,
79, demented patients Reliability: test-retest reliability = 0.78,
internal consistency and test-retest inter-rater reliability = 0.99
reliability with Cronbach's alpha, Validity:
inter-rater reliability with intra-class Discriminant validity = 0.94
correlation (ICC) Sensitivity of cut-off scores (19/20) = 97.5%
Validity: Specificity of cut-off scores (19/20) = 97.3%
Discriminant validity with canonical Cut off scores (19/20)
correlation Middle school/higher education <25
Sensitivity and specificity test. Elementary education <21
No schooling <18
Ncuro-Rehabilitat Comparison of 2 groups: RBMT was translated into Cantonese. The RBMT-CV is suitable for the evaluation of patients
ion Working Brain damage n= 86 Psychometric properties were tested. with specific memory deficits. It has high inter-rater 48

Group t az (1993)

Chan, C.C.H. et al158 (2002)

Fong, K. et al 35(2004)

Without Brain damage n = 84

Match 2 group of subjects with age, gender and literacy level.

n= 53 patient with stroke n =34 normal elderly

n= 57 stroke patients from 8 local hospitals with convenience sampling

Both groups of subjects were tested with Chinese translated version of Cognistat.

Sensitivity and specificity test.

Inter-rater and test-retest reliabilities, concurrent validity were tested.

reliability and standardized profile scores of 11 items show high intcmal consistency. A cut -off total standardized profile score of 15 was found to be useful IJ1 discriminating patients with and without memory dysfunction.

The Chinese version of Cognistat has high sensitivity and specificity. The translation into Chinese does not appear to impede its psychometric properties and usefulness, particularly 111 its norm-reference group comparisons.

The final version of the test had 7 levels in grading upper limb function related to daily life task and motor requirements. There was high sensitivity and specificity for the test items in each level. Satisfactory inter-rater agreement on both testing procedure and functional levels. Significant correlations with the upper extremity and hand subscores of the Fugl-Meyer Assessment

(FMA).

Chan, M. et.al.'": (2004)

Ozdemir, E, et al. RCT

31 (2001) N=60, stroke age (43-80)

n = 14 in or out patients with stroke

Translation of Chinese prototypes version 0 fTongji Hospital, Wuhan (2001) was used with local modification of picture scanning 0 food, add one more digit to telephone number dialing and Chinese food manual. Reliability test were done.

Correlation between total score of MMSE, MMSE sub-section scores, motor Functional Independence Measure (FIM) score and functional ambulation as categorized in "Adapted Patient Evaluation and Conference System" functional scale.

49

ICC = 0.99, test-retest reliability = 0.75 to 0.84.

Item analysis shows good intemal consistency, item-total correlation, sensitivity and specificity with new cut off scores for Chinese article reading and copying Chinese address of the CBIT.

Total MMSE score showed a significant correlation with discharge motor FIM improvement;

Baseline orientation score correlated significantly with functional ambulation score improvement.

Granger, C. v., ct 539 stroke patients Logistic regression analysis 41 % of206 patients with discharge BI ~ 60 living in the
a1. 32 (1989) community,
85% of333 patients with discharge BI > 60 living in the
community; whereas 91 % of patients with discharge BI
> 80 living in the community,
Konda, K. & 126 stroke patients admitted 8 factors were analyzed using a Higher Barthel index was found to facilitate discharge to
Adachi, M. 33 to a community hospital multiple logistic regression. home
(1999) within 30 days from the
onset of stroke
Sze, K.H., et a1. J4 Retrospective Study; Logistic regression BI score ~ 15 at admission strongly predicted that the
(2000) 793 Chinese patients with patient's BI at discharge would be ~ 15;
acute stroke.
for those whose BI score at admission was less than 15,
these factors correlated negatively with discharge BI of
~ 15;
Patients with very severe disability (admission BI < 5),
severe neurologic impairment, urinary incontinence, old
age, and impaired cognition at admission are less likely
to recover to mild disability at discharge (discharge BI
score ~ 15 ) Table 6 1· Table of evidence on manasement of UDDer extremitv

. .
Source Design & Sample Intervention(s) Conclusions
Trombly, CA. & Repeated-measure The study examined the effect of Goal-directed reach enabled persons with stroke to
19 counterbalanced design in absence of object display characteristics typical of reach to a target by
Wu, c.v presence or an
(1999) each of two experiments (goal-directed action vs. rote exercise) persons who have not had a stroke better than reaching
n=14 and the effect of functional specificity out in space. These findings support the occupational
of the object on the organization of therapy practice of using objects in a functional context
reaching movements of persons who to improve coordinated movement. 50

have had a stroke.
Borello- RCT; Compare posture of patients sitting on Posture altered by boards, but these improvements
France, D.F., n=41 acute stroke patients wheelchair with scat hoard and back cannot be maintained after removal of hoards.
Burdett, R.G. & board and none for eight weeks.
Gee, Z.L.
47 (1988)
Feys, H.M. et aI, RCT; multicenter Investigate the effect of an additional Adding a specific intervention during the acute phase
70 (1998) Single-blind, treatment of sensorimotor stimulation after stroke improved motor recovery, which was
11=100 on a1111 function in the acute phase after apparent 1 year later. These results emphasize the
stroke. potential beneficial effect of therapeutic interventions for
the arm.
Crocker, M.D., Single case; Investigate whether the restnction of The subject had increased voluntary control of her
MacKayLyons, ABA design study the less-involved hand would result in more-involved arm and hand and used them more
M. & McDonnell, n=1 increased use of the more-involved spontaneously for completion of daily occupations.
E. 71 (1997) hand in a child with spastic cerebral
palsy.
Van der Lee, J .1-1., Observer-blinded This study evaluates the effectiveness The study showed a small but lasting effect of forced use
et al. 72 (1999) randomized clinical trial of forced use therapy. therapy on the dexterity of the affected arm and a
n= 66 temporary clinically relevant effect on the amount of use
of the affected ann during activities of daily living.
Kunkel, A., et al. Case series; Assessment of the effectiveness of CI therapy is an efficacious treatment for chronic stroke
73 (1999) pretreatment to post constraint-induced (Cl) movement patients.
treatment measures therapy and quantitative evaluation of
n=5 the effects of CI therapy.
Kriz, G., Case series; pretreatment to Feedback-based training of grip force Feedback-based training of grip force may be a useful
Hermsdorfer, J., post treatment m~asures control in patients with various brain enrichment of motor therapy.
Marquardt, C. & n=10 lesions was evaluated.
MaL N. 75 (1995) 51

Brouwer, BJ. & Ambury, P. 7(,

(1994)

Winstein, C.l., et al 78 (2004)

Carey, L.M., Matyas, T.A. & 79 Oke, L.E.

(1993)

Yekutiel, M. &

G E 80 uttman, .

(1993)

Dursun, E., DurSUI1, N., Ural, C.E. & Cakci, A. 82 (2000)

Recordings cortically evoked and segmental postsynaptic potentials from 10 patients and 5 control subjects indicated the

RCT N=64

Four AB, single-case quasi-experiments

RCT; n=39

Case-control study; 11=70

The effects of upper extremity weight-bearing on the excitability of corticospinal neurons projecting to the flexor carpi ulnaris (FCU) muscle of patients having had cerebrovascular accidents (strokes) were examined.

Comparison of treatment efficacy of:

1. Standard Care (SC)

2. Functional Task Practice (FT)

3. Strength Training (ST)

Investigated the effect of a somatosensory retraining program on tactile discrimination.

Investigate the effectiveness of received systematic retraining of tile sensory function of the hemiplegic hand.

Examine the relation between glenohumeral joint subluxation and reflex sympathetic dystrophy (RSD) in hemiplegic patients.

52

Upper extremity weight- bearing normalizes corticospinal facilitation ofFCU motor units in stroke patients. A sustained increase in motor cortical excitability through augmented afferent input may be responsible.

Task specificity and stroke severity are important factors for rehabilitation of ann use in acute stroke. 24 hours of upper extremity - specific therapy over 4 to 6 weeks significantly affected functional outcomes. The immediate benefits of a functional task approach were similar to those of a resistance-strength approach, however, the former was more beneficial 111 the long-term,

Improvements were clinically significant, discrimination in the affected hand becoming comparable to the other hand and normal performance. Therapeutic effects were maintained at 3-month to 5-month follow-up tests.

Somatosensory deficit can be alleviated even years after stroke and that rehabilitation for stroke patients should include sensory retraining for those with sensory deficit.

Shoulder subluxation may be a causative factor for RSD. Therefore, prevention and appropriate treatment of glenohumeral joint subluxation should be included in rehabilitation of hemiplegic patients.

Roy, C. W., Sands, Prospective observation of Decide whether shoulder pain in stroke Shoulder pain appears to influence outcome of stroke
M.R. & I-liIL L.D. consecutive admissions is a marker of severity, or an independent of severity.
85 (1995) n=76 independent predictor of poor outcome.
Priebe, M.M. & Literature review; Discuss management of reflex Therapeutic exercise, range of motion, and edema
Holmes, S.A. 86 Ref: 33 sympathetic dystrophy based on control are important components of the comprehensive
(1996) physical medicine strategies. management of reflex sympathetic dystrophy and should
be started early to maximize treatment benefits. Table 6 2· Table of evidence on ADL and IADL

. .
Source Design & Sample Intervention(s) Conclusions
Dodds, T.A. et al Validation ofFIM High internal consistency and adequate discriminative
104 capabilities for rehabilitation patients. It is a good
(1993) indicator for burden of care but the capacity to measure
change over time needs further examination and
comparison with competing scales
Heinemann, A. W. To evaluate the extent to which The admission functional status was consistently related
et al. 105 (1994) rehabilitation outcomes and resource to discharge function and length of stay, though the
use can be predicted by functional status strength of association varied with impairments. Motor
measures was a strong predictor of length of stay than was
cognitive function for all impairments.
Walker, M_E, et a1. single-blind, randomized Assess the efficacy of an occupational Occupational therapy significantly reduced disability
113 (1999) controlled trial therapy intervention for patients with and handicap in patients with stroke who were not
n=185 stroke who were not admitted to admitted to hospital.
hospital. 53

Parker, Y.M., Wade, D.T. & Langton Hewer R. 114 (1986)

Wade, D.T. and Langton Hewer, R. 115 (1987)

Longitudinal study for 6 months

Longitudinal study for 6 months

n=967

Wade, D.T., Multiple

Skilbeck, C.E. & analysis

Langton Hewer, R. n=83 116(1983)

Fong, N.K., Chan, C.C.H. & Au, D.K.S. 117 (2001)

II S Au, K.M.

(2000)

Establish the frequency of paralysis Severity of initial paralysis was an important prognostic and other ann problems after stroke; factor.

the recovery of lost function; and to

compare various tests of the affected

arm.

Actual functional performance of 976 The major prognostic factors were urinary incontinence, acute stroke patients was assessed functional ability, sitting balance and age.

using the Barthel index: the data were

analyzed to determine the frequency of

disability after stroke, the validity of

the Barthel index, and the recovery

seen.

regression Age, the presence of hemianopia or The success of the 1st equation in predicting the final visual inattention, the presence of Barthel score was about 55%.

urinary incontinence, the motor deficit

in the affected arm, and the patient's

sitting balance were measured at the

1 st assessment shortly after stroke, that

related to the Barthel ADL score at 6

months.

Multiple linear regression n=34

Multiple linear regression n=41

Explore the relationships between motor and cognitive performance, and functional performance of stroke patients who are undergoing in-patient rehabilitation.

Investigate the relationships between impairments (motor, cognitive, unilateral neglect and depression) and functional ability of stroke patient. Explore the 111£1111 predictors for

54

Postural and lower extremity control was important prognostic factors. Clinical instruments such as FMA and NCSE are useful for developing prognostic algorithms for predicting patients' functional outcome at discharge.

Balance and judgment were the key predictors for functional independence.

functional outcomes of stroke patient at four weeks.

Chan Y. L. I I Y (2000)

Liu, K.P.y', et al, 129 (2002)

Tangeman, P. T., Banaitis, D.A. & Williams, A.K. 13°(1990)

Matched pair, RCT N=52

RCT N=46

Pre-post test design study n=40

Compare the di fference in functional outcome for clients with stroke after 2 group of treatment: I.Motor relearning group for functional balance training. 2. Conventional training.

Investigate the effects of occupational therapy to remediate psychosocial, cognitive-perceptual, and sensorimotor impairments after stroke.

Twogroup comparison study:

I. mental imagery program

2. conventional rehabilitation

Assess the effectiveness of the occupational and physical therapy program for stroke.

Ma, H. & Trombly, Meta-analysis

C.A. 128 (2002) Ref=29

n=832

55

The Motor relearning group reflected signi ficant difference in improving functional balance, ADL, lADL and community living skills for the subjects,

Homemaking tasks resulted in greater improvement of cognitive ability than paper-and-pencil drills. Coordinated movement improved under these conditions: a) following written and illustrated guides for movement exercises, b) using meaningful goal objects as targets, c) practicing movements with specific goals, dO moving both arms simultaneously but independently, and e) imagining functional use of the affected limb.

Patients in the mental imagery program group showed a better results in task relearning, maintenance of task performance over time and transfer of skills releamt to other untrained tasks.

The patients demonstrated significant improvement in the outcome measures of weight shift, balance, and ADL scores after the one-month rehabilitation program.

Davidoff, G.N., Retrospective study

Karen, 0., Ring, n=139

H. & Solzi, p.IJI

(1991 )

van Heugten, C.M. Pre-post test design

133(1998) n=33

von Koch, L., et al. single-blind, randomized, Evaluate the effect of early supported

136(2000) controlled trial discharge and continued rehabilitation

n=83 at home after stroke.

van Heugten,

C 132

.M., et al.

(2000)

Pre-post test design n=36

Evaluate the efficacy of rehabilitation programs to facilitate recovery after acute stroke.

Investigated which additional cognitive and motor impairments were present in stroke patients with apraxia and which of these factors int1uenced the effects of treatment.

Evaluation of a therapy programme for stroke patients with apraxia.

56

The programme seems to be successful in teaching patients compensatory strategies that enable them to function more independently, despite the lasting presence of apraxia.

Both groups of patients attending or not attending out-patient rehabilitation program made clinically and statistically significant improvements in all functional indices between stroke onset and discharge from inpatient rehabilitation, and follow-up.

The successful outcome of strategy training was not negatively influenced by cognitive comorbidity, The outcome seemed to be more prominent in patients who were more severely impaired at the start of rehabilitation in terms of the degree of motor impairments, the severity of apraxia and the initial ADL dependence.

Moderately disabled stroke patients with mental function within normal limits, early supported discharge and continued rehabilitation at home had no less a beneficial effect on patient outcome than routine rehabilitation, reduced initial hospitalization significantly and had no adverse effects on mortality and number of falls.

Table 6 3' Table of evidence on coznitive and perceptual function

.. ,
Source Design & Sample Intervention(s) Conclusions
Agrell, B.M., Correlation studies Sensitivity and intercorrelations Neglect patients showed a slower recovery after 6 and
Dehlin, 0.1. & n=57 between star cancellation, line 12 months.
Dahlgren, C.J, III crossing, line bisection, draw a clock
(1997) and copy a cross were determined.
H artman- Mai er, n= 40 Right CVA patient Patients were evaluated with BIT, The result supports the construct and predictive validity
A. & Katz, N.141 performance tasks and checklist of ADL of most of the BIT behavioral subtests as functional
(1995) measure of unilateral neglect.
Edmans, .T.A. & n=75 Right hemi Clients were assess on perceptual Patients without perceptual deficits were more often
Lincoln, N.B. n=75 Left hemi difficulties and ADL performance independent than those with perceptual deficits.
142(1990) (Consecutively admitted) There was a significant correlation between perceptual
abilities and independent in all ADL.
Mckinney, M., RCT; Single blind To assess the effect of cognitive No differences between the 2 groups in functional
Treece, K.A., n=228 stroke patients assessment on the functional outcome outcome, perceived cognitive ability, level of
Lincoln, N.B., of stroke patients and QOL for both psychological distress on satisfaction with care
Playford, E.D. & patients and their carers.
Gladman, .T.R.F. The provision of information about cognitive assessment
146 (2002) in stroke rehabilitation may decrease carer strain.
Zwecker, M., Cohort study, n=66, acute in Patients' cognitive status were assessed The LOTCA is slightly better than the MMSE and the
Levenkrohn, S., patients after first stroke with LOTCA, MMSE. and FIM FIM cognitive subscale in predicting functional status
Flesig, Y, Zeilig, cognitive sub-scale. change after stroke rehabilitation, but it is a time
G, OhI)', A. & consuming instrument to use.
Adunsky, A. ISO
(2002) The similar correlation between the 3 tests suggests the
use ofMMSE as initial screening
Construct validity of the 3 tests are evident 57

Osmon, D.e.. Smet, I.e., Winegarden, B. & Gandhavadi, B. 155 (1992)

Mysiw, W.J., Beegan, J.G. & Gatens, P.F. 156

(1989)

Wallace, .1..1., Caroselli, lS., Scheibel, R.S. & High Jr, W.M. 157

(2000)

Cassidy. T.P., Lewis S. & Gray, c.s. 160 (1998)

n=12 (R hemi) n=12 (L hcmi)

n=12 (Ortho , non brain dysfunction, with matched age and education as controls)

Multiple regression n=38, stroke patients admitted for in-patient rehabilitation

Concurrent validity design 11=48 severe traumatic brain Injury

Single observer, prospective study 11=27 acute patients neglcet out of66 CVA

NCSE administered to the selected clients

NCSE, MMSE and Albert's Test were administered to patient before rehabilitation to determine the extent to which they predict rehabilitation outcome.

Rehabilitation outcome measured by admission and discharge BI.

To measure the agreement and association between the results on patients assessed by NCSE and neuropsychological evaluation

Describe the natural recovery of visuospatial neglect in stroke patients with and the distribution of errors made on

cancellation tests using a standardised neuropsychological test battery.

58

Significant univariate occurred between the stroke groups and controls in comprehension, naming, constructions, memory and similarities.

Strong relationship among the scales, little relationship to age was found.

The test was found to be sensitive to cognitive effects of stroke, but non-sensitive to the side of stroke i.e. left vs right.

Group di fference on the NCSE was noted between the brain-damaged and control groups verifying construct validity of the test.

NCSE: More sensitive indicator of impairment especially for orientation and memory.

Attention, calculation and judgement were the best variables in predicting improvement.

NCSE has high sensitivity to identify the presence of cognitive impairment,

However, it has a poor specificity ,with neuropsychological evaluation serving as the "Gold" standard.

Recovery from visuospatial neglect was associated with improvement in function.

On admission, the best test to predict the recovery of visual spatial neglect was line cancellation. (Speakman's rank con-elation r=0.4217, p=0.028).

Niemann, H. et al177 (1990)

Tsang, H. M. & 199 Sze, K. H.

(2003)

Wiart, L. et al III. ( 1997)

Berg, et al IISI (1991 )

RCT N=26

RCT n = 35

RCT n =25

RCT n = 39

Comparison of attention training group (computerized tasks on focused and alternating attention to visual and auditory stimuli and divided-attention tasks and memory training group. 36 hours 9 week treatment was done.

Intervention group received 4 weeks for eye-patched glasses during occupational therapy treatment, while the control group had no eye-patching. Outcomes of conventional subtest of BIT and FIM was administered on admission and four weeks by blind assessors.

Experimental group wears a thoracolumbar vest with metal pointer above head to targets, which reinforce trunk rotation and scanning in sitting and standing. While control group with conventional therapy.

Outcome assessment on line bisection, cancellation and bell cancellation, and FIM collected before treatment, 30 and 60 days.

Comparison of "memory strategy training" group and "pseudo treatment" group. With repeated measure of memory at pre-treatment, post treatment and post treatment for 4 months.

59

Repeated measures showed that the attention training group had significant improvement in the 4 attention measures administered throughout the treatment period.

Stroke patients treated with right half-field eye patching had significantly (p=0.046) BIT gain than stroke patients. However, there is no significant difference (p= 0.467) in FIM gain in both groups.

Showed greater resolution of unilateral neglect and reduced functional impairments for subjects who received a combination of visual scanning and voluntary trunk rotation compared with 11 subjects with traditional rehabilitation for acute stroke.

Objective memory test showed that the "memory strategy training" had significant improvement in memory function, although both groups of subjects reported subjective improvement. The largest effect of "memory strategy training" was found at follow Up 4 months after therapy, suggesting that subjects continued to practice the strategies learned.

von Cramen, D.Y RCT

et al183 (1991) n = 61 TBI cases who were "poor" problem solvers as identified by formal tests.

Lincoln, N.B., Majid, M.J. & Weyman, N.1SO (2002)

Systematic reviews 2 RCT studies n=56

The "problem solving group" received training oftechniqucs to analyze complex problems into manageable steps based on a social problem solving model in problem orientation, definition and formulation, generation of alternatives, decision making, and solution verification. The other group was the "memory strategy" group which might have implicit effects on

problem solving,

Determine the effects of cognitive rehabilitation for attention deficits following stroke.

There is some indication that training improves alertness and sustained attention but no evidence to support or refute the use of cognitive rehabilitation for attention deficits to improve functional independence following stroke.

The "problem solving group" had significant improvement for the problem-solving treatment on 3 of 5 intelligence subtests and on both measures of planning ability. The significantly greater improvement in behavioral ratings showed evidence for generalization of treatment effects to everyday ward activities.

Katz, N., et al I'JJ

(1999)

Neglect is associated with lower performance in all tests.

Bowen,A. Lincoln, N.B. & Dewey, M. 195

(2002)

Repeated measures n=40

patient with and without neglect

Systematic review 15 studies

n=400

Assessments were made at admission, discharge, 6 months and 1 year after discharge. Behavioral inattention Test, FIM for ADL, the Rabideau Kitchen Evaluation for JADL were used.

Determine the effects of cognitive rehabilitation for spatial neglect following stroke as measured on impairment and disability level assessments, and destination on discharge from hospital. To determine whether any effects persist at follow-up assessment.

60

There is some evidence that cognitive rehabilitation for spatial neglect improves performance on some impairment level tests but its effect on disability is unclear.

Table 6 4· Table of evidence on nsvchosocial adjustment to the disease

. . •
Source Design & Sample I nterven tion(s) Conclusions
Monica, «?" Prospective cohort of 80 - ADL- measure by Katz - GAD after stroke-28lYo in acute stage, no significant
( 1996) patients - GAD- diagnosed by DSM IIJ-R decrease over 3 years
- Anxiety- diagnosed by DSMIIl- R
- left hemisphere lesion - GAD + depression
- right hemisphere lesion - Anxiety
Stokes, L. T. & Systematic review Review of journals The frequency of depression varies with time affect
Hassan, N. 205 Computer aided search of stroke but it probably affects between 113 and 112
(2002) published studies on patients at some stage (0-55%).
depression in stroke and
references There is some evidence that treatment of post-stroke
depression (PSD) improves functional outcome.
Sinyor, D., et. a1. Correlation study Examined the phenomenon of Depression is a frequent companion of stroke, that it is
20Cl (1984) n=64 post-stroke depression and evaluated associated with degree of functional impairment, and
its impact on rehabilitation outcome. that it may exert a negative impact on the rehabilitation
process and outcome.
Fuh, 1.L., et a1. ~VI Door-to-door survey Investigate the prevalence and other Depressed mood was common after stroke, and activities
(1997) Multiple regression characteristics related to depressive of daily living were an important factor for depression in
n=2065 disorders of stroke survivors in an stroke survivors in the community.
elderly Chinese population.
Kotila, M., Multivariate linear and Determine in a population-based stroke Depression was common among stroke survivors and
Numminen. H .. logistic regression register: among their caregivers at 3 months, and its rate did not
Waltimo, O. & n=594 (I) the incidence and severity of decrease at l-year follow-up. The lower depression rate
Kastc, M. 208 depression at 3 and 12 months after in districts with active programs compared to those
( 1998) stroke among patients and their chief without supports the idea that outpatient rehabilitation
caregivers; (2) possible differences in and support provided by local divisions of the FHA may 61

frequency of depression between districts with enhanced after-discharge rehabilitation programs provided by the local divisions of the FHA and those without such facilities; and

(3) analysis of factors influencing the occurrence of depression and its severity.

be an effective way of decreasing the rate of depression after stroke.

Herrmann, N., et al. 2\0 (1998)

O'Mahony, P.G, Rodgers, 1-1., Thomson, KG., Dobson, R. &

213 James,O.F.W.

( 1998)

Cohort study n=436

n=104 cases of stroke in random sample of 2000

Assess the prevalence of depressive Depressive symptoms and functional outcome are symptoms, their clinical correlates, and correlated.

the effects of depressive symptoms on

stroke recovery.

SF-36- self completion questionnaire The instrument is not suitable for assessing outcome on it's own due to high ceiling effect.

Postal administration of SF-36 is not appropriate.

Table 7 1· Table of evidence on Prescription of assistive device

. .
Source Design & Sample Intervention(s) Conclusions
Chamberlain, RCT; Immediate provision of aids and At 3-6 months OT home visit significantly increased
M 214 n= 1 00 patients leaving instruction by occupational therapy the use of bathing aids and level satisfaction to
.A., et al.
(1981 ) Hospital needing bath aids (OT) Vs usual service 90-100% 62

Mann, W.e., et al. ReT; Assistive devices, and environmental In the intervention group decline was slowed, and
216( 1999) n=104 home-based frail changes to maintain independence as costs for domiciliary care staff and institutional care
elderly persons (not only required vs. 'usual care services- were lower; total cost lower in intervention group
stroke)
Huck,.I. & ReT; Type and location of fastener studied Velcro fastener center front was best and preferred
Bonhotal, B.H. 217 n=10 stroke patients (factorial block design study) option
(1997)
Smith, M.E., et al. Obs; Stroke unit patients given more aids Organized care (as recommended) associated with
219(l981b) n=311 stroke patients in (852 vs. 325)and used more at one year provision and continued use of more aids and
ReT (295 v s 165); use of aid declined over equipment
year; frequency:
mobility>hygiene>feeling>dressing>rest
Gitlin, L.N., et al. Obs; 31-39% never used, 41-57% always Needs and use varied widely, and over time. Need to
220 (1993) n=13 patients (4 with used assess and train in home with carer
stroke) and 72 devices
issued
Gitlin, L.N., et al. Prospective study, data from 32% devices for mobility, 30% for Pattern of use established in 4 weeks; 20% of stroke
221 (1996) personal interviews dressing, 26% for bathing. Only about patients only used device short term
n=86 patients (28 stroke) 50% used always, 47(% never used
and 642 devices
Gladman, l.R.F., ReT, Median (inter-quartile range): 3 (2-4) OT service focus on ADL, aids and appliances. The
et al. 223(1995) n= 162 stroke patients at treatments after discharge teaching use need to devote significant resources to assessing and
home of equipment/aids teaching about aids at home after stroke
Gitlin, L.N., et al. Qualitative Study: Structured-discovery, qualitative Six areas of concerns were identified: operation of
224 (1998) Interview with approach to examine the personal devices; utility of device; social contexts; personal
questionnaire meanings associated with first-time meaning of using device; learning to use device; and
n= 103 stroke patients at end encounters with device use following (hope) that it is transitory
of rehabil itation; 823 the acute onset of illness.
devices 63

Table 7.2' Table of evidence on communitv occunatlonal theranv service

.
Source Design & Sample lntervention(s) Conclusions
Walker, M.F., et ReT; Assessed at six months follow up by Received OT had significant higher median scores
al. 113 (1999) ISS patients, 94 received different outcome measurement tools that control on the extended activities of daily living
max 5 months OT while scale, Barthel, the carer strain index and the London
others had no intervention handicap scale.
Rodgers, H., et ReT; Compare an early supported discharge An early supported discharge service following acute
al. 226 (1997) 11= 92 acute stroke patients service or conventional care based on stroke with individualized rehabilitation in the
outcome measures on: placement, length community decreased the length of stay and improves
of stay, readmission rates, mortality, IADL score. No significant different in global health
functional ability, handicap, global status or carer stress. A multi-centre trail is needed
health status and carer stress. before such a service is widely adopted.
Rudd, A.G., et ReT; 3 months specialist community No significant differences in clinical outcomes apart
al. 227 (1997) n= 331 medically stable rehabilitation or conventional hospital from increased satisfaction with hospital care in
patients with stroke, with 167 and community care community therapy group. LOS in community therapy
received specialist group was significantly reduced.( 12 vs.1S days,
community rehabilitation for P<O.OOOI).
3 months Early discharge with specialist community
rehabilitation after stroke is feasible.
Gilbertson, L. Single Blind RCT; Six week domilciliary occupational A brief occupational therapy program carried out at
228 (2000) 11=138 stroke patients with a therapy or routine follow up patients' home immediately after discharge can
definite plan for discharge improve the functional outcome and satisfaction of
home from hospital patients with stroke. Major benefits may not be
sustained.
Corr, S., et al.UlJ RCT; Intervention group reviewed regularly The provision of a follow up occupational therapy
(1995) n=110 stroke patients, with by occupational therapist in additional to service benefits stroke patients by addressing
continual OT service after normal follow up service. The control problems they have after discharged. ensuring they
discharge from Stroke unit or group received no special intervention. receive all necessary aids and helping to maintain
none The two groups were compared at them at home.
one-year post stroke. 64

Lo~an, P.A., et ReT; Enhanced social service occupational The trials support the use of domiciliary occupational
al. 31 (1997) n=111 stroke patients with 53 therapy (SSOT) or the usual service therapy for stroke patients after discharge with
randomly allocated to the improvements in functional outcomes in the short
enhanced service, while 58 to term, but the long-term benefit remain unclear.
usual service
Galdman, .T.R.F., RCT; Functional recovery was assessed by the No difference between extended ADL scores at 3 or 6
et a1.24O (1993) 327 patients of acute stroke Extended Activities of Daily Living Scale months or their Nottingham Health Profile score at 6
admission recruited over 16 3 and 6 months after discharge and months. Patient treated by domiciliary team had
months perceived health by Nottingham Health higher household and leisure activity scores than those
Profile receiving routine care. No difference in effectiveness
of domiciliary and hospital based services. Table 7 3- Table of evidence on Fall Prevention

- -
Source Design & Sample Intervention(s) Conclusions
Tinetti. M.E. et A sample of 30 1 elderly - Linear interactive model by modeling During 1 year follow up 35% of the intervention
al 232 (1994) female who had at least one the logarithmically transformed on group fall as compared with 47% of control group
risk factor for fall recruited probabilities as a linear focus of the (p=0.04). The multiple risk with factor intervention
for multifactorial correlates. strategy resulted in a significant reduction in the risk
intervention including ADL of fall.
training and home visit
Sze, K.H., et a1. Historical cohort study; - Study on the incidents of fall with the The fall protocols followed at Shatin Hospital in HK
233 (2001) n = 677 stroke patients fall prevention protocol have reduced the incidence of repeated falls.
Teasell, R., et al. Retrospective cohort study; - Incident reports on patients who Patients who experienced fall had significantly lower
237 (2002) n =238 stroke in-patients experienced a fall BBS, FTM, and CM arm, leg, and foot scores.
Incidence of fall can be predicted by impairment and
functional assessments 65

Gumming, R. G., RCT; - Study on the effectiveness of home Home visits by occupational therapists can prevent
et al. 238 (1999) n = 530 patients discharged visits on reducing risk of falls with falls among older people with history of fal1s.
from hospitals in Sydney 12-111onth follow-up period using a
monthly falls calendar The effect was due to home modifications and
changes in behavior that enable older people to live
more safely.
Cameron, LD., RCT, n=131 elderly female Use of extemal hip protectors and Hip protectors improve the fall self-efficacy. Fear of
et. al. 241 (2000) n = 61 : intervention group encouragement to use the protectors by fall at followed up : hip protector group -43%, control
n = 70: control group. an group- 57%
adherence nurse. Table 7.4: Table of Evidence on Carers education

Source

212 caregivers from four Caregiver Strain index, and two scales regions of the Netherlands of the Short Fom1-36 were used to were interviewed, the measure caregivers' mental well being majority of the caregivers and vitality.

were female spouses.

Evans, R.L., et a1. 247(1991)

A prospective study.

Discriminant function analysis was used.

Women, younger caregivers, caregivers IJ1 poor physical health, and caregivers of patients with severe cognitive, behavioral and emotional changes constitute the main risk factors for bumout.

Support programs should focus on self-efficacy, social support, and the coping strategy confronting as this helps to expenence less strain, higher mental well-being and greater vitality.

No specific moment could be identified at which support programs should be offered.

Design & Sample Intervention(s)

Conclusions

Van den Heuvel, E.T.P., et al. 246 (2001)

Multiple stepwise regression analysis was performed.

135 first occurrence stroke patients and their pnmary support persons were evaluated during the initial hospitalization after stroke and again I-year post stroke.

Patient at risk for less than optimal home care had caregivers who were (1) more likely to be depressed, (2) less likely to be married to the patient, (3) below average 111 knowledge about stroke care, and (4) reporting more family dysfunction.

Findings suggest that caregiver-related problems can have a collective effect 011 rehabilitation outcome and that treatment should reduce caregiver depression,

66

rmrnrrnze family dysfunction, and increase the family's knowledge about stroke care.

Dale, L., ct al. 248( 19(7)

A pilot study.

Convenience sample consisted of 26 stroke caregivers from 4 Indiana facilities with established rehabilitation units and2 Indiana stroke clubs. Subjects were divided into groups according to the amount of time after discharge in the caregiver role.

Survey results were obtained by phone interviews and by self-administration, and interpretation involved visual inspection and frequency distributions.

Both the newer and more experienced caregivers feel prepared. This study can help rehabilitation staff in their efforts to prepare caregivers for assisting stroke survivor at home.

Rod,Mers, 1-1., et al. 2 9( I 999)

RCT;

n= 204 acute stroke patients and their 176 informal carers

Determine the effectiveness of a multidisciplinary Stroke Education Program (SEP) for patients and informal carers

SEP improved patient and informal carer knowledge about stroke and patient satisfaction with some components of stroke services, this was not associated with improvement in perceived health status.

Mant, J., et a!. 250 (1998)

RCT;

n=71 stroke patients and 49 informal carers of these patients

Intervention group received an information pack containing various Stroke Association publications linformation pack one month after stroke. The control group received nothing.

Follow -up interview at place of residence six months after stroke.

Patients and carers in the intervention group tended to know more about stroke but no significant difference when adj listed for age.

Patient behavior in terms of access to community services and benefits; and health status and quality of life improved in intervention group,

There were no differences with regard to any aspects of quality of life in patients in the intervention group, though carers in the intervention group were found to have significantly better mental health (p=O.04).

Forster, A., ct al. 251 (2001)

Systematic review of information provision strategies for patients and

To examine the effectiveness of an information andlor education strategy to improve the outcome of stroke patients

67

Information combined with educational sessions improved knowledge and was more effective than providing information only. Information provision

their carers after stroke and/or their identified caregivers. only had no effect on 11100d, perceived health status or
quality of life for patients or carers.
Mel.can, 1., et A pilot study. The study elicited information about the The main findings were a requirement for more
al. 252( 1991 ) psychological, physical, social and information about stroke and for counseling in
20 patients and their carers service needs, and the feelings of stroke relation to "care" problems arising out of the
were interviewed separately survivors and their informal carers. disability of stroke disease and the changes in
in their own homes. dependency produced.
Miebet, E., et al. The questionnaire was The study used a cross-sectional design. The needs of the relatives of stroke patients are
253(2001 ) completed by 106 relatives A questionnaire was designed for the information, counseling (a combination of
of stroke patients admitted to purpose of data collection. communication and support) and accessibility.
the neurology wards of 19 The findings show a discrepancy between the
Dutch hospitals (response importance of the needs and the degree to which these
rate 64%). needs are met.
Female relatives requested most information, whereas
Descriptive and multivariate highly educated relatives needed less counseling.
analyses. Satisfaction about the care provided is positively
influenced by the period of hospitalization and
negatively influenced by prior experiences of
hospitalization.
Wiles, R., et al. Qualitative study In-depth qualitative interviews to The information needs identified related to: recovery,
254 (1998) N=31 patient and carer explore information needs at three treatment and prognosis; practical caring tasks; social
different points post-stroke: during activities; and resources available in the community.
hospitalization, up to 1 month
post-discharge, and 2-12 months Both patients and carers desired for information about
post-discharge. recovery and prognosis 68

Table 7 5- Table of Evidence on Home Prozram

-- -
Source Design & Sample Intervention(s) Conclusions
Turton, A. & n=22 acute Experimental group: Home therapy by Southern Motor Group's Motor Assessment: UE
Fraser, C. 255 LCVA:13 individualized written and diagrammed Reaching subtest ( increase 2 points): (p=0.08)
(1990) RCVA: 9 program of exercises and booklet of stroke Timed Ten-Hole Peg Test ( decrease of 4 sec):
Mean age :58 information, (p=O.Ol)
Control group: No treatment, assessed at
home
Three to four visits for an average of 9
weeks, patient practiced 2-3 time/day
Baskett, LT., et RCT; Control group received outpatient or day A supervised home-based program is as effective as
I 256 100 patients discharged from hospital therapy; experimental group were outpatient of day hospital
a.
(1999) hospital after a stroke, visited once a week by an OT or PT who
requiring ongoing therapy prescribed activities program which last
for a total of 3 months
Holmqvist, RCT; Rehabilitation program at home Early supported discharge with continuity of home
257 81 patients with impaired emphasized a task and context oriented rehabilitation services for moderately disabled stroke
L.W., et al.
( 1998) motor function or aphasia approach for a minimum of 3 months. patients in 3 months post stroke is beneficial than
after stroke Spouses were offered education and routine rehabilitation. Need further studies to
individual counseling. COnfil111 the effectiveness at 6 and 12 months. Table 7 6- Table of Evidence on Occupational Adaptation

. .
Source Design & Sample Intervention(s) Conclusions
Ma, I-I.I. & Meta-analysis To synthesize the research findings Out of II studies, 7 randomized controlled trials
Trombly, C.A.258 Ref= 15 regarding the effects of occupational found that role participation and instrumental and
(2002) n=892 therapy on the restoration of role, task and basic activity of daily living performance improved
activity performance to persons who have significantly more with training than with the control 69

had a stroke. conditions.
Drummond.A. RCT Evaluate the effectiveness of a leisure The subjects performed significantly better in
& Walker, M.262 Group 1 (leisure group) = 21 rehabilitation program on functional mobility and psychological well-being than the
(1996) Group 2 (OT group)=21 performance and mood. subject in control group
Group 3 (control) = 23
Do Rozario, L. Qualitative study Using analytical induction and content Five categories of successful coping mechanisms
263 (1992) n=40, in depth interviews analysis to explore adjustment of people have been identified: the power of hope, the need for
nN= 1 ° autobiographies with disabilities and chronic disease personal control, the contribution of positive extemal
support, the need for meaningful activity and
creative participation in life and the healing ability of
spiritual experiences.
Clark, F. .tb'l Narrative analysis and Researcher and client used a collaborative Narrative approach of "story telling" about the past
(1993) grounded theory process to explore past occupation and occupations and "story making" to enable new
methodology on one single develop new occupation after stroke. occupations. The stroke survivor was able to rebuild
case a new identity and acknowledgement of her "past
self'.
Gibson, A. W. & Quasi -experimental To examine the use of occupational Use of intervention guided by the occupational
268 Control = 25 adaptation frame of reference in the adaptation frame of reference was associated with
Schkade. 1.K.
(1997) Subject = 25 evaluation and treatment of patients with improved functional independence and dlc to less
CVA restrictive environment.
Friedland, J.F., RCT; n=48 in experimental Social support intervention program No significant differences were found between
et a1. 269 (1992) group and n=40 in control groups either on social support measures or
group from a community psychosocial outcomes. Significant changes in
based sample support within sample in relation to gender, living
situation, and marital status and employment status 70

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