Ot Guidelines Stroke Rehab Protocol Final

Stroke Rehabilitation Protocol Occupational Therapy

Stroke Rehabilitation Protocol January 2008

Updated by Stroke Working Group, & Endorsed by the Service Development Subcommittee, Coordinating Committee in Occupational Therapy, Hospital Authority

i Stroke Rehabilitation Protocol – Occupational Therapy

Members of the Stroke Working Group Coordinating Committee for Occupational Therapists (OTCOC), HA (2007/8) Coordinator Teresa Leung, Occupational Therapist I (SH, NTE Cluster)

Members Cecilia Sum, Department Manager (Occupational Therapy), (SH, NTE Cluster) Christina Yau, Senior Occupational Therapist (TWH, HKW Cluster) Dora Chan, Senior Occupational Therapist (KH, KC Cluster) Grace Yuen, Occupational Therapist I, (RHTSK, HKE Cluster) Joyce Cheung, Occupational Therapist I, (POH, NTW Cluster) Kathy Chow, Occupational Therapist I, (KH, KC Cluster) Cheung Sau Han, Occupational Therapist I (KH, KC Cluster) Albert Tsai, Occupational Therapist I, (HHH, KE Cluster) Sharron Leung, Occupational Therapist I, (CMC, KW Cluster)

Acknowledgement: The Stroke Working Group (OTCOC) would like to give special acknowledgement to the Stroke Rehabilitation Protocol Working Group of the New Territories East Cluster of the Hospital Authority for providing their protocol (12/2002) as our basis of work to extend it as this protocol at OTCOC level in 2007.

Occupational Therapy (NTE Cluster) - Stroke Rehabilitation Protocol Working Group Co-ordinator Cecilia Sum, Department Manager (Occupational Therapy), Shatin Hospital (SH) Members Brian Au, Occupational Therapist I, Tai Po Hospital (TPH) Amy Chan, Occupational Therapist I, Shatin Hospital (SH) Raymond Ching, Occupational Therapist I, North District Hospital (NDH) Teresa Leung, Occupational Therapist I, Shatin Hospital (SH) Dawn Poon, Occupational Therapist I, Prince of Wales Hospital (PWH) Ewert Tse, Occupational Therapist I, Alice Ho Mui Ling Nethersole Hospital (AHNH) ii Stroke Rehabilitation Protocol – Occupational Therapy

Table of Contents Page

1. Background……………………………………………………………………. 1.1 1.2 1.3

1

Introduction………………………………………………………………… Objectives of Occupational Therapy in Stroke Rehabilitation…………….. Objectives of Stroke Protocol………………………………………………

1 2 3

2. Stages of Occupational Therapy Management for Patients with Stroke……………………………………………………………………………

4

2.1 2.2 2.3 2.4 2.5 2.6 2.7

Occupational Therapy Service Network for Different Stages of Stroke Rehabilitation in Hospital Authority………………………………………. Summary of Goals of Occupational Therapy Intervention in Different Stages of Stroke Rehabilitation……………………………………………. Occupational Therapy Service Focus in Different Stages of Stroke Rehabilitation……………………………………………………………… Acute Phase………………………………………………………………... Rehabilitation Phase……………………………………………………….. Ambulatory Phase…………………………………………………………. Community Phase…………………………………………………………..

3. Occupational Therapy Assessment for Patients with Stroke…....... 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11 3.12 3.13 3.14

Medical Background………………………………………………………. Social History……………………………………………………………… Physical Assessment……………………………………………………….. Sensory Assessment………………………………………………………... Perceptual Assessment……………………………………………………... Cognitive Assessment……………………………………………………… ADL Assessment…………………………………………………………… IADL Assessment…………………………………………………………... Psychosocial Assessment…………………………………………………... Work Assessment……………………………………………………........... Community Integration and Leisure Pursuit Assessment………………….. Quality of Life Assessment………………………………………………… Home Environment Assessment…………………………………………… Fall Risk Assessment……………………………………………………….

4 5

7 8 11 14 17 19 19 19 19 20 20 20 21 21 21 22 22 22 22 22

iii Stroke Rehabilitation Protocol – Occupational Therapy

4. Occupational Therapy Treatment Interventions…………………….. 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 4.12 4.13 4.14 4.15

23

Upper Limb Function Training……………………………………………. Perceptual Training………………………………………………………... Unilateral Neglect Training………………………………………………... Cognitive Training…………………………………………………………. Proper Positioning ………………………………………………………… Activities of Daily Living Training………………………………………… Environmental Modification……………………………………………….. Care Giver Education………………………………………………………. Fall Prevention…………………………………………………………....... Community Living Skills Training…………………………………………. Work Rehabilitation………………………………………………………... Leisure Pursuits…………………………………………………………….. Psychosocial Adjustment………………………………………………....... Prescription of Assistive Devices and Adaptive Techniques………………. Prescription of Splintage and Pressure Therapy……………………………

23 24 24 25 25 26 27 27 28 29 29 29 30 30 30

5. Common Treatment Approach and Technique……………….............

32

6. Documentation……………………………………………………………….

32

7. Appendices.........................................................................................................

33

7.1 Appendix I Possible Options of Intervention in Pre-discharge Planning in Stroke Rehabilitation…………………………………………………………

33

7.2 Appendix II Seven Functional Levels of the Functional Test of Hemiparetic Upper Extremity……………………………………………...........................

34

7.3 Appendix III Assistive Devices Aids For Daily Living……………………...

35

7.4 Appendix IV Community Occupational Therapy Intervention for Stroke Patients Post-discharge from In-patient Rehabilitation……………………….

36

7.5 Appendix V Outcome Measurement Reference List……………………….. 7.6 Appendix VI Summary of psychometric properties of instruments…………. 8. Bibliography……………………………………………………................

37 39 44

iv Stroke Rehabilitation Protocol – Occupational Therapy

1. Background 1.1.

Introduction

Stroke care is a major healthcare issue in Hong Kong. In 2005, it was the third leading cause of death and first leading cause of disability. The age-specific mortality rate was 2,974 per 100,000 population among patients age ≥ 65 and 377 per 100,000 for age 45 to 64 in year 2004 (Hospital Authority Statistical Report, 2004). In the Hong Kong Occupational Therapist Profile Survey 2004/5, there were 34.4% of the occupational therapists participating in stroke rehabilitation.

According to Dukes, J. (1993), guidelines are systematically developed statements based on clinical evidence to assist practitioner’s decision about appropriate health care for specific clinical circumstances, whereas, “clinical protocols” refers to the precise and detailed plans for a medical or biomedical problem and/or plans for a regimen of therapy (Medline database of the National library of Medicine, Bethesda, U.S.A.).

The Stroke Working Group of the Coordinating Committee for Occupational Therapists (OTCOC) revised a common guideline for all occupational therapists in different clusters to enrich our practice with evidence in January, 2005. This clinical protocol for stroke rehabilitation is based on the evidence from the Stroke Rehabilitation Guideline (OTCOC, Jan 2005). We aim at providing a holistic and continuous Occupational Therapy Service for patients with stroke and improving the communication among colleagues in the care process.

1 Stroke Rehabilitation Protocol – Occupational Therapy

1.2. Objectives of Occupational Therapy in Stroke Rehabilitation

Early referral to occupational therapy for stroke rehabilitation is important. Occupational therapy can improve the ability of stroke patients in ADL and IADL after stroke. Functional training for stroke patient is important for better functional outcome. Caregivers’ stress is subsequently reduced. Specific compensatory strategies in coping with functional disability resulting from cognitive and perceptual impairments are effective. Further functional training after an initial phase can also bring about improvements even one year after a stroke and can prevent deterioration. Occupational Therapy significantly reduces disability and handicap of patients with stroke. The following are the main aims of Occupational Therapy in Stroke Rehabilitation.

1.2.1 To assist stroke patients in achieving maximum level of independence at self-care, work and leisure.

1.2.2 To prevent secondary complications resulting from stroke.

1.2.3 To educate patients and caregivers regarding ongoing treatment and ensuring consistent home management/home programme for patients upon discharge.

1.2.4 To minimize residual disabilities and to improve quality of life of stroke patients through appropriate prescription of aids and environmental adaptations.

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

2 Stroke Rehabilitation Protocol – Occupational Therapy

1.3. Objectives of Stroke Protocol

This protocol was developed through the consensus of frontline therapists from different settings of the Hospital Authority, with reference to the best current practice pattern. It should be considered as a guide for day to day clinical practice but not a rule. Variations in practice may occur with the difference in the clinical data presented by the patient, the diagnostic and treatment options available and the decision of the multi-disciplinary health care team. Moreover, the information in this protocol is subject to change as scientific knowledge and technology advance and patterns of care evolve (Von, Widen, Kostulas, Almazan, & de Pedro-Cuesta,2000). The following are the main objectives of this protocol.

1.3.1 To provide management protocol for different stages of rehabilitation.

1.3.2 To employ common outcome measuring tools to measure the overall effectiveness and efficiency of services provision for stroke patients.

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

1.3.4 To improve the quality of care provided to stoke patients through sharing of stroke management concept with other health care colleagues.

3 Stroke Rehabilitation Protocol – Occupational Therapy

2. Stages of Occupational Therapy Management for Patients with Stroke 2.1 Occupational Therapy Service Network for Different Stages of Stroke Rehabilitation in Hospital Authority

Clusters Stages

NTE Acute Phase PWH, NDH AHNH Rehabilitation SH TPH Phase

NTW TMH

KC QEH

POH TMH

KH BH

Ambulatory Phase

PWH (OPD) TMH (OPD & GDH) KH (OPD) POH (OPD) SH (GDH) YMT (GDH) AHNH (DRC & OPD) NDH (DRC & OPD)

Community Phase

All settings (HV) All settings (HV) (COST) for NTE TMH (CGAT ) cluster

All settings (HV) KH (CMRS & COT) KH (CGAT)

KW CMC, KWH PMH, YCH CMC OLMH PMH (LKB) WTSH YCH CMC (GDH & OPD) KWH (GDH & OPD) OLMH (OPD) PMH (GDH & OPD) WTSH (GDH) YCH (OPD) All settings (HV) CMC (CGAT) KWH (COT, CGAT & COST)

PMH (COT & CGAT)

KE UCH TKOH UCH HHH

HKW QMH

YFS (OPD & GDH ) HHH (DRC & OPD) TKOH (OPD)

TWH (DRC & GDH) PYNEH (GDH) MMRC(ARC) RHTSK (GDH) TWEH (GDH) FYKH (GDH) DTRC (OPD) SJH (OPD)

All settings (HV) HHH (CGAT) YFS (CGAT)

All settings (HV) FYKH (CGAT) MMRC (ECS) DTRC (COT)

TWH FYKH MMRC GH

HKE PYNEH RHTSK RHTSK TWEH CCH

All settings (HV) RHTSK (CGAT)

Note: OPD – outpatient service GDH – Geriatric Day Hospital COST – Community Outreach Service Team CMRS – Community Medical Rehabilitation Service COT – Community Occupational Therapy

Stroke Rehabilitation Protocol – 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

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2.2 Summary of Goals of Occupational Therapy Intervention in Different Stages of Stroke Rehabilitation

These goals are references that apply to all stages of stroke rehabilitation depends on the needs, ability and support system of the patient at a particular time, and it is not exhaustive either as special goals may arise in particular patients with that specific background.

2.2.l

To screen and triage patient in the rehabilitation program 2.2.1.1

Screening for rehabilitation potential

2.2.1.2

Provide recommendation for level of care needed upon discharge

2.2.1.3

Recommend on the need for further rehabilitation

2.2.2

2.2.3

To improve patients’ foundation skills 2.2.2.1

Prevent complications

2.2.2.2

Facilitate sensory recovery

2.2.2.2

Improve limbs and trunk control

2.2.2.3

Tone normalization

2.2.2.4

Improve Perceptual and cognitive skills

2.2.2.5

Enhance functional balance

To improve functional performance Maximize ADL function

2.2.3.2

Maximize IADL function

2.2.3.3

Work/productive activity enhancement

2.2.4

2.2.3.1

To facilitate safe discharge to community 2.2.4.1

Facilitate safety at home and institution

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Empower caregiver with education and community resources information

2.2.4.3

Prescribe and train the use of assistive devices

2.2.4.4

Identify environmental hazards and recommend home modifications

2.2.5

2.2.4.2

Improve quality of life and enhance community re-integration 2.2.5.1

Facilitate adjustment to disability

2.2.5.2

Encourage social interaction and activity engagement

2.2.5.3

Improve patient’s community living skills

2.2.5.4

Occupational life style re-design

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2.3 Occupational Therapy Service Focus in Different Stages of Stroke Rehabilitation

In-patient Rehabilitation Acute Phase (OT Goals): 1. Screening for potential and triage for rehabilitation 2. Prevent complications 3. Bedside ADL training 4. Improve foundation skills 5. Assist patients and families in adjustment to disability

Rehabilitation Phase (OT Goals): 1. Prevent complications. 2. Improve foundation skills 3. Maximize ADL and IADL function. 4. Facilitate adjustment to disability 5. Provide caregiver education. 6. Facilitate safe discharge 7. Recommend on the need of further rehabilitation. 8. Provide recommendation on level of care needed upon discharge.

Community Ambulatory Phase (OT Goals):

Community Phase (OT Goals):

Consolidate foundation skills. Optimize ADL and IADL functions. Improve clients’ safety at home and community. Facilitate community re-integration Provide vocational assessment and training Encourage social interaction and leisure activity engagement. 7. Empower patients with knowledge of life style re-design

1. Improve safety at home/in community. 2. Facilitate community re-integration, adjustment to disability, and engagement in social and leisure activities. 3. Maintain optimum level of ADL and IADL functions 4. Prevent complications and maintain health

1. 2. 3. 4. 5. 6.

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2.4 Acute Phase

In acute phase of stroke rehabilitation, occupational therapist will act as assessor and trainer to provide service to stroke patient.

As an assessor, Occupational Therapists will evaluate the individual potential and needs for rehabilitation in order to have a tailor-made rehabilitation plan for each patient. On the other hand, as a trainer, Occupational Therapists will provide different trainings to maximize patient’s potential to improve primary impairments and prevent secondary complications. At the same time, Occupational Therapists will provide functional training to minimize patient’s disability by enabling patient to perform relevant daily life tasks. Ultimately, our patient can receive the most appropriate Occupational Therapy service in acute setting and can be transferred to rehabilitation ward or discharged earlier.

2.4.1

Goals of therapy 2.4.1.1

To evaluate client’s potential and triage for different tracks of rehabilitation.

2.4.1.2

To prevent complication secondary to stroke.

2.4.1.3

To maintain and improve self-care function.

2.4.1.4

To improve foundation skills i.e. sensori-motor, cognitive and perceptual functions in preparation for further functional training.

2.4.1.5

2.4.2

To assist patient and family in adjusting to disability and life changes.

Possible Interventions 2.4.2.1

Prevention of secondary complications

i. Provide pressure relieving devices, e.g. heel protectors, sheepskin and pressure relief cushion etc. ii. Educate on positioning of affected limbs and the use of assistive positioning Stroke Rehabilitation Protocol – Occupational Therapy

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supports (such as wedged cushions, pillows, towels, orthoses, lapboard, or wheelchair inserts, etc), to facilitate normal alignment and prevent shoulder subluxation or deformity. iii. Educate protective techniques for sensori-perceptual deficits, (e.g. hemianopia or unilateral neglect) so as to prevent potential dangers, e.g. abrasion , shoulder dislocation, etc. iv.

Provide pressure stocking to prevent venous thrombosis or dependent oedema when necessary.

2.4.2.2

Screening for rehabilitation potential

Assess cognitive-perceptual function, upper limb function, and ADL function with standardized assessment tools: e.g. Cantonese Mini-mental State Examination (CMMSE), Albert’s Test (AT) / Behavioural Inattention Test (BIT), Functional Test for Hemiplegic Upper Extremity (FTHUE), Barthel Index (BI) / Modified Barthel Index (MBI) and Lawton Instrumental Activities of Daily Living (Lawton IADL) in order to identify patients’ status for early discharge or continue intensive rehabilitation (Please see appendix V). 2.4.2.3 i

Foundation skills and functional tasks training

Provide cognitive and perceptual assessment and training to facilitate the patient’s independence in ADL.

ii

Provide self care training, to improve bedside self-care skills such as feeding, bed mobility, bed-side transfer, grooming, dressing and toileting, etc.

iii

Improve patient’s ability to feed safely by use of proper positioning and the use of assistive device.

iv

Provide Upper limb training to increase voluntary use of the involved upper extremity.

2.4.2.4 i.

Patient and Caregivers Education

Provide education to patient and family through counseling, to understand on

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disease and rehabilitation process, and encourage their active participation in rehabilitation process. ii.

Provide training in caring skills and educate caregivers in the use of adaptive equipment as necessary.

2.4.3

Follow-up service

2.4.3.1

Patients with mild disability will usually be discharged from acute wards. Occupational Therapists will ensure the safe discharge of patients with the provision of simple home adaptation, assistive devices prescription, caregiver education and recommendation of community supporting service.

2.4.3.2

Patients with rehabilitation potential will be transferred to rehabilitation ward/ hospital to continue in-patient rehabilitation.

2.4.3.3

If discharged patients are indicated for further ambulatory care, Occupational Therapists will refer patients to attend OPD/ GDH for a short course of training to further improve specific

aspects of recovery e.g. hand function, cognitive

and perceptual training, IADL and vocational rehabilitation, etc. 2.4.3.4

Referral to community Occupational Therapy service will be given to the patients who need post-discharge follow up visits to ensure safety and community re-integration.

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2.5 Rehabilitation Phase Stroke patients will be transferred from acute wards/hospitals to rehabilitation wards/ hospitals to continue the stroke rehabilitation process. The multi-disciplinary team will regularly review the progress of the cases. Occupational Therapists help in triaging patients to different tracks of rehabilitation and set realistic goals to optimize patient’s function and in turn to prepare for community re-integration.

2.5.1

Goals of therapy 2.5.1.1 To prevent complications. 2.5.1.2 To improve foundation skills in: sensory-motor, limbs and postural control cognitive and perceptual functions. 2.5.1.3

To maximize the ADL function level.

2.5.1.4 To provide IADL retraining for community re-integration. 2.5.1.5

To facilitate adjustment to functional disability.

2.5.1.6

To provide caregiver education and skills training.

2.5.1.7

To facilitate safe discharge.

2.5.1.8

To recommend any needs for further training at discharge from in-patient care.

2.5.1.9

2.5.2

To recommend level of care required at discharge.

Possible Interventions 2.5.2.1

Patients with severe disability

This group of patients is dependent in the majority of ADL. Their sitting balance had little or no return in the rehabilitation period, or the cognitive level indicated poor learning ability to comply with functional training. Patients in the severe disability levels are usually with relatively poor rehabilitation potential.

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The focus of occupational therapy would be on complication prevention, e.g. prevent shoulder pain or pressure sores; basic feeding and grooming tasks training; educate caregiver in handling techniques and prepare necessary aids or environmental adaptation, for empowering caregiver to handle patients at home or institution. 2.5.2.2

Patients with moderate to severe disability

This group of patients needs moderate to maximal assistance in majority of the ADL. Patients have gradual improvement especially in sitting and standing balance during functional tasks. Patients’ cognitive level is able to comply with intensive retraining of foundation skills and ADL training, and has a better rehab potential.

The focus would be on maximizing the foundation skills, neurological and functional recovery. These patients will undergo a more intensive course of rehabilitation in rehabilitation hospitals. The foundation skills training aimed at improving the limb function, sitting and standing balance during functional tasks, cognitive and perceptual function. There is intensive self-care training progressively from basic ADL (grooming, bed mobility, bed-chair transfer, dressing upper garment) to more complex ADL tasks (lower garment dressing, toileting, bathing and related transfers). For patients who will be discharged home, IADL training will be given for those with needs. 2.5.2.3

Patient with mild disability

Patients’ ADL functions are mainly at minimal assistance to supervision level. A short course of rehabilitation is provided usually in area of fine motor dexterity, transfer safety, fall prevention, IADL (e.g. cooking and other simple household tasks) and community living skills. Assessment on work potential will be performed if applicable. Stroke Rehabilitation Protocol – Occupational Therapy

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2.5.2.4

Pre-discharge Program

With consensus from the rehabilitation team, Occupational Therapists will provide service to enhance safety of patient in the community after discharge with appropriate settlement of caregiver education, resolving of environmental hazards, prescription of aids, training on community integration skills and fall prevention program. Patient will also be referred for continuation of Occupational Therapy treatment if further rehabilitation is required. Before discharge back to the community, Occupational Therapists will educate caregivers in caring skills and the use of assistive devices. They may perform on-site assessment and recommendations on appropriate modifications on physical environment (e.g. demolishing wall/ bathtub, installation of grab rail/ ramp, furniture re-arrangement, etc.) to improve access, minimize risk of fall and facilitate functional independence/ caring.(Please refer to Appendix I for the possible intervention options in Pre-discharge planning.) 2.5.3

Follow-up service

2.5.3.1

Continuation of rehabilitation in ambulatory service:

Occupational Therapists may recommend patient to continue rehabilitation after discharge from in-patient care. For patients require further training in specific problems in a single discipline, they will continue training in out patient department (OPD) for stroke rehabilitation. For patients require multi-disciplinary intensive rehabilitation, they will usually attend a full day rehabilitation program with multi-disciplinary team in day rehabilitation center or geriatric day hospital. 2.5.3.2

Community service:

In post-discharge community service, Occupational Therapists will pay home visit to patient for enhancement of caregiver skills, prescribing home program, ensuring proper use of assistive devices, and indicating community resource etc.

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2.6 Ambulatory Phase

Upon discharge from hospital settings, patients in need of further training/ intervention will be referred for ambulatory care, i.e. day hospitals/rehabilitation centres and Occupational Therapy Out-Patient Department (OPD). The role of Occupational Therapy in this phase of rehabilitation is to act as a bridge and fill up the gap between a hospital setting and a community living environment. The ultimate goal is to optimize functional independence of an individual and enhance community re-integration.

A day hospital / rehabilitation centre rehabilitation emphasizes on multi-disciplinary approach and the setting provides a one-stop service for patients. The patients can receive intensive and comprehensive training without going from place to place and the skills learnt in in-patients phase are reinforced and strategies for adaptation to community living are emphasized. Whereas, a single discipline intervention will be provided in an OPD setting and a problem-solving approach is adopted.

The duration and types of intervention are varied according to the specific needs of individual patients. When conditions progress and needs change, patients will be discharged from day hospitals / rehabilitation centres or referred to OPD for single-disciplinary intervention. Home programs will also be prescribed to supplement hospital-based training for refinement of foundation skills and functional performance.

2.6.1

Goals of Therapy 2.6.1.1

To consolidate foundation skills

2.6.1.2

To optimize ADL performance

2.6.1.3

To enhance appropriate IADL skills as required by patient’s life role

2.6.1.4

To improve safety at home / in community

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2.6.1.5

To facilitate community re-integration

2.6.1.6

To provide vocational assessment and training

2.6.1.7

To encourage social interaction and leisure activity engagement

2.6.1.8

To empower patients with knowledge of life style re-design towards a more meaningful life.

2.6.2

Possible Interventions

When stroke patients enter the ambulatory phase, Occupational Therapists review patients’ medical history (e.g. diagnosis, CT Brain, past and present medical history, premorbid functional level, social support, etc.) through medical record and / or patient / caregivers interview. In-depth assessments will be offered as indicated after screening. Interventions provided in previous phases will be reviewed and followed up. Appropriate interventions will be offered as listed in the following. In view of variation in resource constraints in different settings, assessments may focus on essential areas and interventions will be prioritized. 2.6.2.1

Functional training will focus on independence and safety in ADL, IADL

and community living skills required for community re-integration. 2.6.2.2

Patients’ support systems will be enhanced and carers will be empowered to

adapt and overcome challenges in the process of community re-integration. 2.6.2.3

Remedial training will be continued to consolidate or elicit further

improvement in foundation skills. The importance of home program emerges and the therapeutic environment will gradually shift from hospital-based settings to patients’ home or community. 2.6.2.4

Education for more balanced way of living for primary prevention and

maintenance of fitness and health. 2.6.2.5

Work assessment and rehabilitation as indicated by patients’ life role

requirement. Stroke Rehabilitation Protocol – Occupational Therapy

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2.6.3

Follow up Service

Patients will be discharged from the ambulatory phase with the fore-mentioned goals achieved. For patients who have risk of new life maladjustment, deterioration, community disintegration and / or home accidents will be referred for appropriate ambulatory or community services.

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2.7 Community Phase In the stroke rehabilitation program, the phase of community care is considered to be the stage in which the client has been discharged from hospital as well as other sort of formal rehabilitation system. In this phase, client lives in the community (alone or with family) or lives in institutions such as grouped home, aged hostel, private or subvented aged home. Outreach service will be provided.

Community Occupational Therapy tackles patients with wide range of disability level with diverse conditions, whereas Community Geriatric Assessment Service usually tackles patients who are frail and of high risk, also focus on collaboration with health care workers in institutions for provision of care.

2.7.1

Goals of Therapy

2.7.1.1

To improve safety at home/ in community.

2.7.1.2

To facilitate community re-integration through supporting patients/ carers for community living, facilitating adjustment to disease/ disabilities and encouraging social interaction and avocational activities. To maintain optimum level of ADL independence after discharge.

2.7.1.4

To enhance appropriate IADL skills as required by patient’s life roles

2.7.1.5

To prevent complications and maintain health.

2.7.2

2.7.1.3

Possible interventions

In this phase, patients and caregivers may have risks of maladjustment to new life, disintegration with community, deterioration in physical / mental conditions or functions, community disintegration and/ or home accidents. Therefore, the major emphasis of therapy is to maintain the optimum level of function.

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2.7.2.1

On-site assessment and recommendations on appropriate modifications on

physical environment (e.g. demolishing wall/ bathtub, installation of grab rail/ ramp, furniture re-arrangement, etc.) to improve access, minimize risk of fall and facilitate functional independence/ caring. 2.7.2.2

On-site assessment and training for patients and care givers to overcome

problems encountered in daily living. ADL training, IADL training, community living skills training and application of assistive devices fall in this category. 2.7.2.3

Consolidation of support systems (e.g. community resources, self help

groups, etc.) and empowerment of both patients and caregivers will facilitate psychological adjustment and community re-integration. 2.7.2.4

Occupational life-style re-design for a balanced, healthy, active living

contributes to health maintenance and disease prevention.

(Please refer to Appendix IV for the work flow of community occupational therapy intervention for stroke patients post discharge from in-patient rehabilitation)

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3. Occupational Therapy Assessment for Patients with Stroke 3.1 Medical Background 3.1.1

History of present illness: date of onset, course of incident, CT-brain and other medical investigations, neurosurgery record, other complications as a result of this stroke incident.

3.1.2

Past medical history: date of previous stroke and resulting functional limitations, other medical history including physical and psychological aspects, any medical or rehabilitation follow up programs.

3.2 Social History 3.2.1

Premorbid functional level of patient: ADL, ambulatory status, life role.

3.2.2

Social support: family (caregiver) and finance.

3.2.3

Home environment: for simulated environmental training of ADL and early identification of environmental barriers indicating for home visits or modification.

3.3 Physical Assessment 3.3.1

Vital signs: conscious level, blood pressure, pulse, other discomfort complains at rest and during different activities should be carefully monitored.

3.3.2

Risk of complications: edema, contracture / joint stiffness, swelling of limbs

3.3.3

Strength

3.3.4

Coordination

3.3.5

Functional range of motion

3.3.6

Upper and lower limbs function

3.3.7

Functional balance: relate the static and dynamic sitting and standing balance in daily living tasks.

3.3.8

Muscle tone

3.3.9

Presence of abnormal reflex and reactions: clonus, associated reactions etc.

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3.4 Sensory Assessment 3.4.1

Pain, temperature and touch

3.4.2

Proprioception and kinesthesia

3.4.3

Stereognosis

3.4.4

Visual field

3.4.5

Vestibular function

3.4.6

Hypersensitivity and numbness

3.5 Perceptual Assessment 3.5.1

Unilateral neglect.

3.5.2

Apraxia

3.5.3

Visual spatial perception e.g. position in space, figure-ground, depth perception

3.5.4

Somatoagnosia

3.5.5

Topographic orientation

3.5.6

Perceptual problems in ADL tasks

3.6 Cognitive Assessment 3.6.1

Attention

3.6.2

Orientation

3.6.3

Memory

3.6.4

Judgment and decision making

3.6.5

Sequencing

3.6.6

Problem-solving

3.6.7

Abstract thinking

3.6.8

Executive function

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3.7 ADL Assessment 3.7.1

Feeding

3.7.2

Grooming

3.7.3

Dressing

3.7.4

Bed mobility

3.7.5

Transfers

3.7.6

Toileting

3.7.7

Bathing

3.7.8

Functional ambulation

3.8 IADL Assessment 3.8.1

Cooking

3.8.2

Medication Management

3.8.3

House keeping

3.8.4

Use of telephone

3.8.5

Finance management

3.8.6

Taking transport

3.8.7

Shopping

3.8.8

Laundry

3.9 Psychosocial Assessment 3.9.1

Mood

3.9.2

Insight to own disability

3.9.3

Adjustment to disability

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21

3.10 Work Assessment 3.10.1

Comprehensive work assessment and work rehabilitation is required for stroke patients who have potential to resume previous work role or change work role.

3.11 Community re-integration and Leisure Pursuit Assessment 3.11.1

Leisure exploration

3.11.2

Social engagement

3.11.3

Productivity

3.11.4

Family participation

3.12 Quality Of Life Assessment Patients with stroke will be assessed on the quality of life after stabilization of medical condition to see his/her coping and integration in the community, and how well his/her lifestyle can be re-designed to enhance the quality of life.

3.13 Home Environment Assessment Assess architectural barrier that limit accessibility and identify potential hazards in the environment. 3.14 Fall Risk Assessment Assess the risk factors that affect the “person-environment fit” including the fall history, risk-taking behavior, the home and outdoor access environment in relations with the patient’s cognitive and physical functional level. Moreover, overall assessment on the possible intrinsic and extrinsic factors leading to fall would be performed.

(Please refer to Appendix V for Outcome Measurement reference list.)

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4. Occupational Therapy Treatment Interventions 4.1 Upper and Lower Limbs Function Training 4.1.1

Prevent complications and development of inappropriate compensatory motor pattern in daily living tasks.

4.1.2

Normalize muscle tone and inhibit abnormal reflexes which interfere normal motor pattern relearning.

4.1.3

Restore functional range, strength, manipulation skills and maximize functional use of the affected upper limb according to the 7 functional levels of the FTHUE – HK.

The training protocol on promoting recovery of upper limb function developed by the Stroke Focus Group of OTCOC (2000) are recommended as Occupational Therapy practice in Hospital Authority settings. (Please refer to Appendix II for the summary of the definition and treatment at the 7 levels of function.)

4.1.4

Sensory re-training: relearning of sensing objects of different textures was provided either through visual assistance and relearning from the unaffected side sensory input. If recovery is not possible, compensatory techniques will be employed so as to avoid domestic accidents, such as direct touching sharp or hot objects in daily living.

4.1.5

Assistive devices will be given to patients to maximize independence in daily life tasks and encourage normal movement patterns.

4.1.6

Enhance postural and lower limb motor relearning in functional activities.

4.1.7

Prevention of shoulder subluxation especially for patients at level 1 to 2, including:

4.1.7.1

Positioning techniques in different resting positions.

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23

4.1.7.2 Proper facilitation techniques to prevent shoulder subluxation in transfers, ADL activities. 4.1.7.3

Furniture and cushion support system to support forearm and shoulder in proper alignment.

4.1.7.4

Prescription of shoulder slings when a furniture or cushion support is not available.

4.1.8

Facilitative training to normalize muscle length, tone, maintains normal passive range and maximizes active range of shoulder.

4.1.9

Proper handling techniques will be taught to caregivers to protect shoulder, trunk and limb alignment while assisting patients in daily functional tasks.

4.2 Perceptual Training 4.2.1

Remediate and relearn the perceptual function, and apply functionally in daily living.

4.2.2

Minimize the risk or disability in daily living due to the perceptual problems e.g.figure ground discrimination problem, visual spatial disturbance.

4.2.3

Environmental adaptation or simplification of task procedures so as to avoid potential danger that caused by perceptual problems.

4.3 Unilateral Neglect Training 4.3.1

Improve the patient’s tracking and scanning abilities across midline and towards the affected side.

4.3.2

Reduce the risk caused by unawareness of the unilateral neglect problem.

4.3.3

Teach patient to use adaptive skills when performing routine tasks by capitalizing on intact perceptual/cognitive skills.

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4.4 Cognitive Training 4.4.1

Remediate and relearn the cognitive skills and integrate them in daily activities.

4.4.2

Minimize the risk or disability in daily living that caused by cognitive problems.

4.4.3

Conduct therapeutic groups such as problem solving group, memory group, social skills training group, ad hoc party preparation group and craft group. The groups are well structured and aim to facilitate patient’s learning on specific techniques and the application to daily life.

4.4.4

Functional training is specially designed by therapist to provide opportunity for client to experience attention, detection of problem, reasoning, problem solving, decision-making and application of the skills to complete the task. These include personal ADL and instrumental ADL, for example, bathing, to plan a meal and to travel from one place to another.

4.4.5

Virtual Reality and computer based remedial activities may be applied to allow patients to pre-learn some real life situation with a programmed real life situation in computer, which the patient can re-learn the steps and problem solving skills step by step. Suitable training topics include road crossing, value adding of “Octopus” and take cash from cash machine, etc.

4.5 Proper Positioning 4.5.1

Facilitate proper resting position so as to prevent abnormal tone, deformity, stiffness or contracture of joints due to mal-alignment

4.5.2

Use of facilitation techniques and provide assistive devices to protect shoulder from subluxation and pain.

4.5.3

Advice on the proper position of limbs for patients in supine, side lying, reclined in bed, sitting in geriatric chairs.

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25

4.6

Activities of Daily Living Training 4.6.1

Maximize the functional independence of patient in Activities of Daily Living.

4.6.2

Generalize the use of normal motor pattern to perform functional tasks.

4.6.3

Functional training follows the clinical reasoning steps of the Motor Relearning Theory: 4.6.3.1

Activity analysis of the performance components in the selected functional task.

4.6.3.2

Training of missing components as identified in step i through remedial activities, neurodevelopment theory facilitation and normal movement patterns & skills.

4.6.3.3

Practice of the task: apply the skills learned in step ii to actual practice on functional task.

4.6.4

Transfer of training: to generalize the skills in functional tasks in step iii in other similar functional tasks (lateral transfers) or more advance tasks (vertical transfer).

(The ADL Training Manual written by the Stroke Working Group of OTCOC, May 2005 will be adopted as the guideline of retraining ADL skills for patients with stroke with the application of Motor Relearning Theory and the Neurodevelopmental Approach)

4.6.5

Adaptive approach will be applied if indicated, therapist will provide adapted steps or techniques (one hand techniques) according to the maximum return level of the affected limb or balance function, and the residual cognitive or perceptual dysfunctions.

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26

4.7 Environmental Modification 4.7.1

Ensure safe discharge of patient back home and reduce re-hospitalization.

4.7.2

Continue proper caring and handling of patients after discharge.

4.7.3

Pre-discharge home visit includes the following intervention: 4.7.3.1

Assess hazards of home access and home environment.

4.7.3.2

Provide recommendation and take application procedure for home modification e.g. bath tub removal, hand rail installation or furniture re-arrangement.

4.7.3.3

Identify risk factors e.g. slippery floor mat, unstable furniture, or soft and low seat for patients and recommended patient / care giver to take necessary action.

4.7.3.4

Provide on site caregiver training and practice.

4.7.3.5

Provide home program for better continuation of therapy after discharge.

4.7.3.6

Recommend and provide suitable assistive devices e.g. commode, wheelchair which can reduce caregiver’s stress and increase patient’s independence.

4.7.4

Education of fall prevention and home safety knowledge to patients and caregivers.

4.7.5

Post-discharge home visit will be provided for cases who have risks of potential home safety problem, poor compliance of home program, problem in use of assistive device or who are living alone. The post discharge home visit aims to minimize social and environmental risks and enhance functional independence and better re-integration into community.

4.8 Care Giver Education 4.8.1

Increase the patient’s and the caregiver’s knowledge of the stroke rehabilitation process.

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27

4.8.2

Equip the caregiver with the safe and proper handling skills when assisting patient in daily living tasks.

4.8.3

Educate the importance of and techniques recommended for involving the hemiplegic side in ADL.

4.8.4

Handling skills on the affected side: appropriate positioning to promote function and to prevent secondary problems, such as contractures and subluxation.

4.8.5

Educate the importance of skin care to minimize sore formation.

4.8.6

Use of proper body mechanics by the caregiver when assisting the patient, to minimize injury.

4.8.7

Proper use of adaptive equipment to increase independence and decrease stress.

4.8.8

Equip caregivers with relevant information of community resources to facilitate social and community support in the caring process.

4.8.9

Managing challenging behaviour because of cognitive impairment or mood problem.

4.9 Fall Prevention 4.9.1

Enhance a “person-environment fit” condition of a safe discharged life for patients with stroke.

4.9.2

Reduce the chance of re-hospitalization.

4.9.3

Safety education should be started at the very beginning of the rehabilitation program since self care training started which educate patient to turn / pivot safely in proper direction, and correct impulsive behavior.

4.9.4

Home environment should be modified or re-arranged to enhance safety e.g. removal of bath tub, installation of hand rails, rearrangement of furniture for wider passage etc.

4.9.5

Identify and remove hazards for risk of fall, e.g. remove mats, proper footwear,

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28

lighting at night time etc. 4.9.6

Prescribe hip protectors to reduce risk of fracture.

4.10 Community Living Skills Training 4.10.1

Grocery shopping training

4.10.2

House keeping

4.10.3

Use of telephone and other communication device

4.10.4

Personal finance management

4.10.5

Training Skills in taking public transport e.g. Taxi, minibus, train etc

4.10.6

Driving rehabilitation-referring to the Rehabaid Centre to perform a detail driving assessment for the patients if patient is appropriate for driving,

4.10.7

Banking and using Octopus

4.11 Work Rehabilitation 4.11.1

Maximize patients’ physical and cognitive function to resume work role, either by resume pre-morbid work or matching new job.

4.11.2

Work adaptation: one handed typing technique, equipment and work environment modification.

4.11.3

Refer patients to vocational retraining and resettlement service if required.

4.12 Leisure Pursuits 4.12.1

Explore interests and assess adaptations needed to allow the patient to continue to participate.

4.12.2

Evaluate the patient’s leisure interests, and integrate the patient’s physical, cognitive, perceptual and behavioral abilities/deficits to develop his or her skills for leisure pursuit.

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4.13 Psychosocial Adjustment 4.13.1

Enhance the patient’s and family’s psychological adjustment to disease.

4.13.2

Provide psychological support throughout the rehabilitation process and after patients are discharge from the HA service.

4.13.3

Provide support and encouragement for the patient and the family to verbalize ongoing reaction to hospitalization, lifestyle changes, changes in body image, and disease progression through individual counseling or facilitative groups like Self-Management Group.

4.13.4

Refer to support groups such as Community Rehabilitation Network (CRN). These groups can enrich stroke knowledge and community reintegration of patient after discharge from formal rehabilitation service provided by the Hospital Authority.

4.14 Prescription of Assistive Devices and Adaptive techniques Training 4.14.1

Patients are always encouraged the maximum use of returned or residual motor ability to participate in functional tasks. However, if the patients’ recovery is stagnant or very slow, for safety and maximization of functional level, OT will firstly recommend adaptive techniques (e.g. one hand techniques) to patients before considering the use of assisitve devices.

4.14.2

Provide user friendly assistive device for patient to maximize independence level in daily live.

4.14.3

Avoid forceful effort in strength and manipulation required tasks, which may induce associated reaction and increase tone of the affected limb in long run.

4.14.4

Reduce the stress of the caregivers. (Please refer to Appendix III for Assistive Devices for Daily Living)

4.15 Prescription of Splintage and Pressure Therapy 4.15.1

Anti-spasticity hand and wrist splint: to prevent hypertonicity and contracture

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30

and wrist and hand. 4.15.2

Resting paddle: to prevent mal-alignment and hand and wrist at flaccid stage.

4.15.3

Short opponent static or dynamic splint: to prevent adduction pattern of thumb in relearning opposition pattern of the thumb or in pinching.

4.15.4

Shoulder sling : full shoulder forearm support, shoulder and humeral support to prevent shoulder subluxation and pain in upright posture when furniture or cushion support are not available.

4.15.5

Anti-footdrop sling: to facilitate dorsi-flexion of ankle in walking.

4.15.6

Thumb opponents splint: it can be of static or dynamic design with help to prevent persistent abducted thumb pattern in grasping and pinching.

4.15.7

Pressure Therapy: application should be monitored with blood pressure and pulse condition of the patient in different postures.

4.15.7.1

Hand and arm tubigrip to control oedema and prevent development of shoulder hand syndrome.

4.15.7.2 Pressure stocking for hypotension condition of patients or for deep vein thrombosis after stroke. 4.15.7.3 Therapist may make use of commercially available shaped supportive tubigrip or tailor made pants with socks or stocking up to knee level.

(The details of splint designs can be referred to the Splint Manual (HKOTA) 1996 written up by the Splint Manual Focus Group.)

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5. Common Treatment Approach and Techniques

¾ Neurodevelomental Therapy ¾ Neuro-Integrative Functional Rehabilitation And Habilitation ¾ Motor Relearning ¾ Functional Approach ¾ Biomechanical ¾ Rehabilitative ¾ Adaptive

6. Documentation

Clear and concise documentation are important for team communication of the patient’s problems, treatment, progress, and further rehabilitation plan. The documentation should follow the basic guidelines in clinical records and also covers the relevant points to reflect the patient’s condition in respect to the types of documentation. Good records are also for protecting the right of patient to have detail retrospective enquiry of their clinical management especially for legal cases.

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7. Appendices 7.1 Appendix I Possible options of intervention in Pre-discharge Planning of Stroke Rehabilitation

Stroke Rehabilitation Pre-discharge Planning

Discussion with carer, patient and relatives

Arrange post-discharge follow-up service if necessary, e.g. GDH

Consensus in multidisciplinary meeting

Aids prescription e.g. wheelchair, commode

Referral to other service required e.g.. home-helper, for caring at home

Home Program

Pre-discharge home visit as indicated- home modification, on site patient and caregiver training

Refer for OPD or GDH to continue OT

Stroke Rehabilitation Protocol – Occupational Therapy

Pre-discharge assessment on patient’s function

Essential skills training e.g.. car transfer, simple IADL

Caregiver education: - Assistive skills training - Use of equipment and aids - Post discharge rehab process

Post-discharge follow-up by COT

Fall Prevention: - Assess environmental hazards - Prescribe necessary home modification and equipment - Prescribe hip protectors - Fall prevention education

No Follow –up required

33

7.2 Appendix II Seven Functional Levels of the Functional Test of Hemiparetic Upper Extremity (FTHUE) – HK.

Level

Minimum Motion

Task

1

¾

No voluntary motion of the shoulder, elbow Nil or hand

2

¾

Some beginning voluntary motion of the shoulder & elbow

A Associated reactions B Hand Onto Lap

3

¾

30-60º shoulder flexion 60-100º elbow flexion 3-5lb gross grasp

C

>60º shoulder flexion >100º elbow flexion some elbow extension 3-5lb gross grasp ½ -3lb lateral pinch

E F

¾

4

¾ ¾ ¾ ¾

5

¾ ¾ ¾

6

¾ ¾ ¾ ¾

7

¾

Arm Clearance During Shirt Tuck D Hold a Pouch

Stabilize a Jar Wringing a Rag

G Eat with a Spoon Beginning of mass flexion & extension combination patterns in shoulder and elbow H Box and Blocks >5lb of grasp >3lb of lateral pinch some release

Isolated control in the shoulder, elbow & wrist against gravity >5lb of grasp >3lb of lateral pinch poor controlled & coordinated movements

I J

Isolated control of all upper extremity musculature with good coordination and control

K Key turning L Using chopsticks M Clip cloth peg

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Box on Shelf Drink from glass

34

7.3 Appendix I1I Assistive Devices for Daily Living ‹

Feeding aids: Easy scooping bowl or plate, adapted chopsticks require less manipulation effort, non-slippery mat to stabilize utensils etc.

‹

Grooming aids: Toothpaste squeezer, one hand nail cutter etc.

‹

Dressing: Elastic shoelaces, specific steps in dressing upper and lower garment without inducing pull of shoulder/humerus and increase tone of affected limbs.

‹

Bed-side transfers: Adapt bed and chair to same height for easy transfers, and use of firm foaming in bed and seats to facilitate sit to stand transfer, etc.

‹

Toileting and toilet transfers: Commode chair, buttock washing devices, toilet seat, hand rails etc.

‹

Bathing and bathing transfers: Commode shower chair, bath board, hand rail, foot brush, and long handle brush or looped towel to wash back of body,etc.

‹

Functional mobility: Transit wheelchair for outdoor ambulation propelled by caregiver, standard wheelchair or one arm drive wheelchair will increase the functional mobility independence for patient with a stroke.

‹

Kitchen tasks: Jar opener or fixator, nailed chopping board, suction bottle brush to wash glass etc.

‹

Home making: Long handle self-wringing sponge mops, free standing dustpans, light upright vacuum cleaners, left-handed scissors, and automatic needle threaders.

‹

Community living: Lightweight pushcart in grocery shopping, energy conservation techniques, use of Octopus, pre-arrange sections of money to purchases etc.

‹

Writing: Occupational Therapist will provide progressive training to patient for writing, adaptive tripod pen-holder will facilitate better writing effect for patients.

‹

Communication: Communication board can be used to facilitate expression of needs and daily communication with others.

‹

Pressure Sores prevention: Heel protectors to prevent heel sores, ripple bed to prevent bed sores etc.

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7.4 Appendix IV

Community Occupational Therapy intervention for Stroke Patients

Post-discharge from In-patient Rehabilitation

Case referred for Post-discharge follow up

Appointment by phone and information collection

Health status screening: -continence, pressure sore -drug compliance, -nutrition problem

Post-discharge home visit

Assessment on Self care, caregiver skills, compliance of home program and use of assistive devices and home visit report

Referral to appropriate agents and social resources for follow up if indicated

NO

YES

Problem identified under the service scope

Plan and implement intervention: -caregiver education -functional training -aids prescription -home modification

Stroke Rehabilitation Protocol – Occupational Therapy

Any problem needed to be solved

Follow up visit and re-evaluation

Arrange next follow up visit

Close case

Refer to OPD or GDH OT service if indicated for rehabilitation due to deterioration or new problems.

36

7.5 Appendix V Outcome Measurement Reference List Assessment Area

Physical Components

Common Outcome Measure Used

¾ ¾ ¾ ¾

Upper limb function

¾ ¾ ¾ ¾

Manual muscle testing (MMT) Protective sensation assessment Coordination test: finger nose test, heel shin test Functional range of motion

Functional Test for the Hemiplegic Upper Extremity (FTHUE-HK) – 7 levels (Appendix II) Action Research Arm Test (ARAT) Nine Hole Peg Test Purdue Pegboard

Psychological Status

¾ ¾

Geriatric depression scales (GDS) Hospital Anxiety and Depression Scale (HAD)

Cognitive assessment

¾

Chinese Mini-Mental State Examination (CMMSE) Abbreviated Mental Test Chinese version of Cognistate (CNCSE) Rivermead Behavioral Memory Test – Cantonese Version (RBMT-CV) Loewenstein Occupational Therapy Cognitive Assessment (LOTCA)

¾ ¾ ¾ ¾

Perceptual assessment ¾ ¾ ¾ ¾ ¾

Stroke Rehabilitation Protocol – Occupational Therapy

Rivermead Perceptual Assessment Battery (RPAB) Behavioral Inattention Test- Hong Kong Version (BIT-HKV) Albert’s Test Árnadóttir Occupational Therapy Neurobehavioral Evaluation (A-ONE) Loewenstein Occupational Therapy Cognitive Assessment (LOTCA)

37

Assessment Area

Activities of Daily Living (ADL)

Common Outcome Measure Used ¾ ¾ ¾ ¾

Barthel Index (20/100) Modified Barthel Index Functional Independence Measure (FIM) Assessment of Motor and Process Skills (AMPS)

¾

Chinese Lawton Instrumental Activities of Daily Living Score

¾

SAFER

¾

Westmead Home Assessment

Community living skills

¾

Community Integration Questionnaire (CIQ)

Quality Of Life

¾

Stroke Adapted – Sickness Impact Profile 30 (Chinese version was recently validated) SF- 36 SF-12

Instrumental ADL

Home Environment

Fall Risk

¾ ¾ Level of disability

Stroke Rehabilitation Protocol – Occupational Therapy

¾

Modified Rankin Scale (MRS)

38

7.6 Appendix VI Summary of psychometric properties of instruments Instrument

Construct

Reliability

Validity

Functional Test for the Hemiplegic Upper Extremity (FTHUE-HK)

Stroke upper Fong et al. limb – 7 functional (2004) levels

Fong et al. (2004)

Action Research Arm Test

A performance test for assessment of upperlimb function Measures manual dexterity Dexterity and fine motor function

Lyle, (1981)

Lyle, (1981)

Mathiowetz et al (1985) Tiffin J. (1948)

Hellera (1987) Costa et al. (1963)

Depression screening

Chinese version of the 30-item GDS (Chan, 1996)

Chinese version of the 30-item GDS (Chan, 1996) Chinese version of the 15-item GDS (Mui, 1996; Wong et al., 2002) Chinese version of the 4-item GDS ( Cheng & Chan, 2006; Chau et al., 2006)

Nine Hole Peg Test Purdue Pegboard

Geriatric depression Scale (GDS)

Chinese version of the 15-item GDS (Mui, 1996; Wong et al., 2002) Chinese version of the 4-item GDS ( Cheng & Chan, 2006; Chau et al., 2006)

Stroke Rehabilitation Protocol – Occupational Therapy

Current used version FTHUE – HK version, Training Manual: Stroke rehabilitation – promoting recovery of upper limb function, OTCOC, Hospital Authority 2001 Action Research Arm Test Lyle, (1981) Mathiowetz et al (1985) Purdue Pegboard Model #32020, Revised edition 1999 – (for Adult), Lafayette Instrument Company. Chinese version of the 30-item GDS (Chan, 1996)

Chinese version of the 15-item GDS (Mui, 1996; Wong et al., 2002)

Chinese version of the 4-item GDS ( Cheng & Chan, 2006; Chau et al., 2006)

39

Instrument

Construct

Reliability

Validity

Current used version

Hospital Anxiety and Depression Scale (HADS)

Measuring anxiety and depression states in hospital and medical out-patient clinic settings

Chinese version of the HADS (Leung et al. 1993; Lam et al. 1995; Leung et al. 1999)

Chinese version of the HADS (Leung et al. 1993; Lam et al. 1995; Leung et al. 1999)

Chinese version of the HADS (Leung et al. 1993; Lam et al. 1995; Leung et al. 1999)

Chinese Mini-Mental State Examination Cognistat Neurobehavioral Cognition Status Exam (NCSE)

Patient ‘s global cognitive performance 5 major areas -Language -Constructional ability -Memory -Calculation skills -Reasoning/ judgment

Chiu et al., 1994 Chiu et al., 1994

Rivermead Behavioural Memory Test

Assess memory ( RBMT ) skills related to Wilson et al everyday (1989) situations. Useful to predict everyday life task memory problems.

Loewenstein Occupational Therapy Cognitive Assessment

The purpose of (LOTCA) this tool is to ( Itzkovich et measure the basic al., 1990) cognitive functions that are prerequisites for managing everyday living tasks. (Itzkovich et al., 1990)

Kiernan et al (2002) Northern California Neurobehaviora l Group (1998)

Stroke Rehabilitation Protocol – Occupational Therapy

Hong Kong Chinese version Chiu et al., 1994 Kiernan et al Cognistat (2002) Neurobehavioral Northern Cognition Status California Exam (NCSE) Neurobehav Kiernan et al ioral Group (2002) (1998) Northern California Neurobehavioral Group (1998) ( RBMT ) Rivermead Wilson et al Behavioural (1989) Memory Test( RBMT ) Wilson et al (1989)

(LOTCA) ( Itzkovich et al., 1990)

Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) ( Itzkovich et al., 1990)

40

Instrument

Construct

The Árnadóttir Occupational therapy Neurobehavioral Evaluation.

Reliability

Validity

Current used version

Measured the clients’ neurobehavioral through five daily living tasks. They were dressing, grooming and hygiene, transfer and mobility, feeding and communication. The assessment of AMPS is a test of Motor and disability and Process Skills focusing on clients’ ADL skills that comprised of motor and process actions. Rivermead RPAB was Perceptual designed to assess Assessment visual perceptual Battery deficits in clients after head injury or stroke.

(Árnadóttir, 1990)

(Árnadóttir, 1990)

The Árnadóttir Occupational therapy Neurobehavioral Evaluation.1990

(AMPS) (Fisher, 1997a)

(AMPS) (Fisher, 1997a)

The assessment of Motor and Process Skills (AMPS) (Fisher, 1997a)

(RPAB) (Whiting et al., 1985)

(RPAB) (Whiting et al., 1985)

Rivermead Perceptual Assessment Battery (RPAB) (Whiting et al., 1985)

The Behavioral Inattention Test

Wilson, Cockburn & Halligan, 1987a

Wilson, Cockburn & Halligan, 1987a

The Chinese Behavioral Inattention Test (Hong Kong version)

The Chinese Behavioral Inattention Test (Hong Kong version) (CBIT-HK) Stroke-Adapted Sickness Impact Profile 30 (Chinese Version)

BIT was developed to assess clients for the presence of unilateral neglect and its impacts on the client’s ability to perform everyday occupations Stroke relevant quality of life

Fong et al., 2007.

Fong et al., 2007.

van Straten et al. van Straten (1997) et al. (1997); van Straten et al. (2000)

Stroke Rehabilitation Protocol – Occupational Therapy

Validated Chinese version of Occupational Therapy Central Coordinating Committee, Hospital Authority 2006

41

Instrument

Construct

Modified Rankin Scale

Status of disability in patients with stroke

Chinese Mini-Mental State Examination Barthel Index 20

Patient ‘s global cognitive performance Basic activities of daily living for patients with stroke

Modified Barthel Index

Basic activities of daily living for patients with stroke Measure disability Functional in motor and Independence cognitive aspect Measures To assess The Lawton independent living Instrumental Activities of Daily skill which is considered more Living (IADL) complex than the Scale basic ADL.

Reliability

Validity

Current used version

van Swieten Culture free et al. (1988); de Haan et al., (1995); Uyttenboog aart et al. (2005) Chiu et al., 1994 Chiu et al., Hong Kong 1994 Chinese version (Chiu et al., 1994) Original version Wade Wade (1992); with minor (1992); Novak et al. Novak et al. adaptation of “use (1996) of chopsticks” in (1996) feeding item van Swieten et al. (1988)

Shah et al (1989)

Ficke (1993)

Shah et al (1989) Fricke (1993) Ficke (1993)

Carla Graf., 2007

Carla Graf 2007

Tong and Man, 2002

Tong and Man, 2002

Modified version from BI 20 by Shah (1989) Functional Independence Measures Lawton IADL scale

Chinese Version of the Lawton Instrumental Activities of Daily Living Scale

Chinese Version of the Lawton Instrumental Activities of Daily Living Scale

To assess independent living skills for older adults in Hong Kong

The Safety Assessment of Function and the Environment for Rehabilitation (SAFER)

Safety and Letts et al., 1998 Oliver et al., SAFER SAFER-Home function within the 1993; home environment Letts & Marshall, 1995; Letts et al., 1998

Stroke Rehabilitation Protocol – Occupational Therapy

42

Instrument

Construct

Reliability

Westmead Home Safety Assessment (WeHSA)

Assessment of physical & environmental home hazards of people at risk of falling

Clemson et al., 1992 Clemson et al., 1999 Cooper et al., 2005 Law et al., 2005

Community Integration Questionnaire (CIQ)

Community living skills for brain

Tepper, Beatter & DeJong (1996)

Stroke-Adapted Sickness Impact Profile 30 (Chinese Version)

Stroke relevant quality of life

Modified Rankin Scale

Status of disability in patients with stroke

Validity

Clemson, 1997 Cooper et al., 2005 Law et al., 2005

Current used version WeHSA

Willer et al. Community Integration (1993) Chan (1999) Questionaire Chinese Version (Chan, 1999) van Straten et al. van Straten Validated Chinese (1997) et al. (1997); version of van Straten Occupational et al. (2000) Therapy Central Coordinating Committee, Hospital Authority 2006 van Swieten et van Swieten Culture free al. (1988) et al. (1988); de Haan et al., (1995); Uyttenboog aart et al. (2005)

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8. Bibliography 1

Adamovich, B.L.B. (1991). Cognition, language, attention, and information processing following closed head injury. In Kreutzer, J.S. & Wehman, P.H. (Eds.). Cognitive rehabilitation for persons with traumatic brain injury: A functional approach. (pp. 75-86). Balitmore: Paul H. Brookes.

2

Agrell, B.M., Dehlin, O.I. & Dahlgren, C.J. (1997). Neglect in elderly stroke patients: a comparison of five tests. Psychiatry Clinical Neuroscience, 51(5), 295-300.

3

Anderson, A.K. (1971). Sensory impairments in hemiplegia. Archives of Physical Medicine & Rehabilitation, 52, 293-297.

4

Arnadottir, G. (1990). The brain and behaviour: Assessing cortical dysfunction through activities of daily living. St. Louis: Mosby

5

Askenasy, J.J. & Rahmani, L. (1987). Neuropsycho-social rehabilitation of head injury. American Journal Physical Medicine & Rehabilitation, 66, 315-327.

6

Au, K.M.B. (2000). Prediction of functional outcome in stroke patient. Hong Kong: Hong Kong Polytechnic University, 167pp.

7

Axellon P, Minkel J, Chesney D, (1994). A guide to wheelchair selection.

8

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