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
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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)
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Table of Contents
Page
1. Background……………………………………………………………………. 1
1.1 Introduction………………………………………………………………… 1
1.2 Objectives of Occupational Therapy in Stroke Rehabilitation…………….. 2
1.3 Objectives of Stroke Protocol……………………………………………… 3
2. Stages of Occupational Therapy Management for Patients with

Stroke…………………………………………………………………………… 4
2.1 Occupational Therapy Service Network for Different Stages of Stroke 4

Rehabilitation in Hospital Authority……………………………………….
2.2 Summary of Goals of Occupational Therapy Intervention in Different 5
Stages of Stroke Rehabilitation…………………………………………….
2.3 Occupational Therapy Service Focus in Different Stages of Stroke
Rehabilitation……………………………………………………………… 7
2.4 Acute Phase………………………………………………………………... 8
2.5 Rehabilitation Phase……………………………………………………….. 11
2.6 Ambulatory Phase…………………………………………………………. 14
2.7 Community Phase………………………………………………………….. 17
3. Occupational Therapy Assessment for Patients with Stroke…....... 19
3.1 Medical Background………………………………………………………. 19

3.2 Social History……………………………………………………………… 19
3.3 Physical Assessment……………………………………………………….. 19
3.4 Sensory Assessment………………………………………………………... 20
3.5 Perceptual Assessment……………………………………………………... 20
3.6 Cognitive Assessment……………………………………………………… 20
3.7 ADL Assessment…………………………………………………………… 21
3.8 IADL Assessment…………………………………………………………... 21
3.9 Psychosocial Assessment…………………………………………………... 21
3.10 Work Assessment……………………………………………………........... 22
3.11 Community Integration and Leisure Pursuit Assessment………………….. 22
3.12 Quality of Life Assessment………………………………………………… 22
3.13 Home Environment Assessment…………………………………………… 22
3.14 Fall Risk Assessment………………………………………………………. 22
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4. Occupational Therapy Treatment Interventions…………………….. 23
4.1 Upper Limb Function Training……………………………………………. 23

4.2 Perceptual Training………………………………………………………... 24
4.3 Unilateral Neglect Training………………………………………………... 24
4.4 Cognitive Training…………………………………………………………. 25
4.5 Proper Positioning ………………………………………………………… 25
4.6 Activities of Daily Living Training………………………………………… 26
4.7 Environmental Modification……………………………………………….. 27
4.8 Care Giver Education………………………………………………………. 27
4.9 Fall Prevention…………………………………………………………....... 28
4.10 Community Living Skills Training…………………………………………. 29
4.11 Work Rehabilitation………………………………………………………... 29
4.12 Leisure Pursuits…………………………………………………………….. 29
4.13 Psychosocial Adjustment………………………………………………....... 30
4.14 Prescription of Assistive Devices and Adaptive Techniques………………. 30
4.15 Prescription of Splintage and Pressure Therapy…………………………… 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……………………….. 37

7.6 Appendix VI Summary of psychometric properties of instruments…………. 39
8. Bibliography……………………………………………………................ 44
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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.
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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.
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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.
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2. Stages of Occupational Therapy Management for Patients with Stroke
2.1 Occupational Therapy Service Network for Different Stages of Stroke Rehabilitation in Hospital Authority
Clusters
Stages NTE NTW KC KW KE HKW HKE
Acute Phase PWH, NDH TMH QEH CMC, KWH UCH QMH PYNEH
AHNH PMH, YCH TKOH RHTSK
Rehabilitation SH POH KH CMC UCH TWH RHTSK
Phase TPH TMH BH OLMH HHH FYKH TWEH
PMH (LKB) MMRC CCH
WTSH GH
YCH
Ambulatory PWH (OPD) TMH (OPD & GDH) KH (OPD) CMC (GDH & OPD) YFS (OPD & GDH ) TWH (DRC & GDH) PYNEH (GDH)
Phase SH (GDH) POH (OPD) YMT (GDH) KWH (GDH & OPD) HHH (DRC & OPD) MMRC(ARC) RHTSK (GDH)
AHNH (DRC & OPD) OLMH (OPD) TKOH (OPD) FYKH (GDH) TWEH (GDH)
NDH (DRC & OPD) PMH (GDH & OPD) DTRC (OPD) SJH (OPD)
WTSH (GDH)
YCH (OPD)
Community All settings (HV) All settings (HV) All settings (HV) All settings (HV) All settings (HV) All settings (HV) All settings (HV)
Phase (COST) for NTE TMH (CGAT ) KH (CMRS & COT) CMC (CGAT) HHH (CGAT) FYKH (CGAT) RHTSK (CGAT)
cluster KH (CGAT) KWH (COT, CGAT & YFS (CGAT) MMRC (ECS)
COST) DTRC (COT)
PMH (COT & CGAT)
Note:
OPD – outpatient service DRC –Day Rehabilitation Center
GDH – Geriatric Day Hospital ARC- Ambulatory Rehabilitation Center
COST – Community Outreach Service Team ECS – Extended Care Service
CMRS – Community Medical Rehabilitation Service CGAT – Community Geriatric Assessment Team
COT – Community Occupational Therapy HV – pre and post discharge home visits
Stroke Rehabilitation Protocol – Occupational Therapy 4

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 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
2.2.3 To improve functional performance
2.2.3.1 Maximize ADL function
2.2.3.2 Maximize IADL function
2.2.3.3 Work/productive activity enhancement
2.2.4 To facilitate safe discharge to community
2.2.4.1 Facilitate safety at home and institution

2.2.4.2 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 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

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):
1. Consolidate foundation skills. 1. Improve safety at home/in community.

2. Optimize ADL and IADL functions.
2. Facilitate community re-integration, adjustment to
3. Improve clients’ safety at home and community.
4. Facilitate community re-integration disability, and engagement in social and leisure
5. Provide vocational assessment and training activities.
6. Encourage social interaction and leisure activity 3. Maintain optimum level of ADL and IADL functions
engagement. 4. Prevent complications and maintain health
7. Empower patients with knowledge of life style
re-design

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 To assist patient and family in adjusting to disability and life changes.
2.4.2 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

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 Foundation skills and functional tasks training
i 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 Patient and Caregivers Education
i. Provide education to patient and family through counseling, to understand on

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.

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 To recommend level of care required at discharge.
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.

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.

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.

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

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.
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.

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.

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.
2.7.1.3 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 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.

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)

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.

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

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

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.)

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.

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.

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.

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.

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.

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,

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.

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

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.)

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.

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, Consensus in Pre-discharge

patient and relatives multidisciplinary assessment on
meeting patient’s function
Arrange Aids Home Fall Prevention:

Essential skills - Assess
post-discharge prescription Program
training e.g.. environmental
follow-up service e.g. hazards
car transfer,
if necessary, e.g. wheelchair, - Prescribe
simple IADL necessary
GDH commode
home
modification
Pre-discharge Caregiver and equipment
Referral to other - Prescribe hip
home visit as education:
service required protectors
indicated- home - Assistive skills - Fall prevention
e.g.. home-helper,
modification, on training education
for caring at home
site patient and - Use of equipment
caregiver training and aids
- Post discharge
rehab process
No
Refer for OPD or GDH to continue OT Post-discharge follow-up by
Follow –up
COT
required

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 A Associated reactions

shoulder & elbow B Hand Onto Lap
3 ¾ 30-60º shoulder flexion C Arm Clearance

¾ 60-100º elbow flexion 3-5lb gross grasp During Shirt Tuck
D Hold a Pouch
4 ¾ >60º shoulder flexion E Stabilize a Jar

¾ >100º elbow flexion some elbow F Wringing a Rag
extension
¾ 3-5lb gross grasp
¾ ½ -3lb lateral pinch
5 ¾ Beginning of mass flexion & extension G Eat with a Spoon

combination patterns in shoulder and elbow H Box and Blocks
¾ >5lb of grasp
¾ >3lb of lateral pinch some release
6 ¾ Isolated control in the shoulder, elbow & I Box on Shelf

wrist against gravity J Drink from glass
¾ >5lb of grasp
¾ >3lb of lateral pinch
¾ poor controlled & coordinated movements
7 ¾ Isolated control of all upper extremity K Key turning

musculature with good coordination and L Using chopsticks
control M Clip cloth peg

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.

7.4 Appendix IV Community Occupational Therapy intervention for Stroke Patients
Post-discharge from In-patient Rehabilitation
Case referred for

Post-discharge follow up
Health status Referral to

screening: appropriate
Appointment by phone -continence, pressure agents and
and information collection sore social
-drug compliance, resources for
-nutrition problem follow up if
indicated
Post-discharge
NO
home visit
YES
Assessment on
Any problem
Self care, caregiver skills,
needed to be
compliance of home Close case
solved
program and use of assistive
devices and home visit
report
Follow up
Problem identified
visit and
under the service
re-evaluation
scope Refer to OPD or
GDH OT service
if indicated for
Arrange next rehabilitation
Plan and implement
follow up visit due to
intervention:
deterioration or
-caregiver education
new problems.
-functional training
-aids prescription
-home modification

7.5 Appendix V Outcome Measurement Reference List
Assessment Area Common Outcome Measure Used
¾ Manual muscle testing (MMT)

Physical Components
¾ Protective sensation assessment
¾ Coordination test: finger nose test,
heel shin test
¾ Functional range of motion
¾ Functional Test for the Hemiplegic

Upper limb function
Upper Extremity (FTHUE-HK) – 7
levels (Appendix II)
¾ Action Research Arm Test (ARAT)
¾ Nine Hole Peg Test
¾ Purdue Pegboard
¾ Geriatric depression scales (GDS)

Psychological Status
¾ Hospital Anxiety and Depression
Scale (HAD)
Cognitive assessment ¾ Chinese Mini-Mental State

Examination (CMMSE)
¾ Abbreviated Mental Test
¾ Chinese version of Cognistate
(CNCSE)
¾ Rivermead Behavioral Memory
Test – Cantonese Version
(RBMT-CV)
¾ Loewenstein Occupational Therapy
Cognitive Assessment (LOTCA)
Perceptual assessment
¾ Rivermead Perceptual Assessment
Battery (RPAB)
¾ Behavioral Inattention Test- Hong
Kong Version (BIT-HKV)
¾ Albert’s Test
¾ Árnadóttir Occupational Therapy
Neurobehavioral Evaluation
(A-ONE)
¾ Loewenstein Occupational Therapy
Cognitive Assessment (LOTCA)

Assessment Area Common Outcome Measure Used
¾ Barthel Index (20/100)

Activities of Daily Living (ADL)
¾ Modified Barthel Index
¾ Functional Independence Measure
(FIM)
¾ Assessment of Motor and Process
Skills (AMPS)
¾ Chinese Lawton Instrumental

Instrumental ADL
Activities of Daily Living Score
¾ SAFER
Home Environment
¾ Westmead Home Assessment

Fall Risk
Community living skills ¾ Community Integration

Questionnaire (CIQ)
Quality Of Life ¾ Stroke Adapted – Sickness Impact

Profile 30 (Chinese version was
recently validated)
¾ SF- 36
¾ SF-12
¾ Modified Rankin Scale (MRS)

Level of disability

7.6 Appendix VI Summary of psychometric properties of instruments
Instrument Construct Reliability Validity Current used

version
Functional Test Stroke upper Fong et al. Fong et al. FTHUE – HK

for the limb – 7 functional (2004) (2004) version, Training
Hemiplegic levels Manual: Stroke
Upper Extremity rehabilitation –
(FTHUE-HK) promoting
recovery of upper
limb function,
OTCOC, Hospital
Authority 2001
Action Research A performance test Lyle, (1981) Lyle, (1981) Action Research
Arm Test for assessment of Arm Test
upperlimb Lyle, (1981)
function
Nine Hole Peg Measures manual Mathiowetz et Hellera Mathiowetz et al
Test dexterity al (1985) (1987) (1985)
Purdue Pegboard Dexterity and fine Tiffin J. (1948) Costa et al. Purdue Pegboard
motor function (1963) Model #32020,
Revised edition
1999 – (for Adult),
Lafayette
Instrument
Company.
Geriatric Depression Chinese version Chinese Chinese version of
depression Scale screening of the 30-item version of the 30-item GDS
(GDS) GDS (Chan, the 30-item (Chan, 1996)
1996) GDS (Chan,
1996)
Chinese version Chinese Chinese version of
of the 15-item version of the 15-item GDS
GDS (Mui, the 15-item (Mui, 1996; Wong
1996; Wong et GDS (Mui, et al., 2002)
al., 2002) 1996; Wong
et al., 2002)
Chinese version Chinese Chinese version of
of the 4-item version of the 4-item GDS
GDS ( Cheng & the 4-item ( Cheng & Chan,
Chan, 2006; GDS 2006; Chau et al.,
Chau et al., ( Cheng & 2006)
2006) Chan, 2006;
Chau et al.,
2006)

version
Hospital Anxiety Measuring anxiety Chinese version Chinese Chinese version of

and Depression and depression of the HADS version of the HADS (Leung
Scale (HADS) states in hospital (Leung et al. the HADS et al. 1993; Lam et
and medical 1993; Lam et al. (Leung et al. al. 1995; Leung et
out-patient clinic 1995; Leung et 1993; Lam al. 1999)
settings al. 1999) et al. 1995;
Leung et al.
1999)
Chinese Patient ‘s global Chiu et al., 1994 Chiu et al., Hong Kong
Mini-Mental State cognitive 1994 Chinese version
Examination performance Chiu et al., 1994
Cognistat 5 major areas Kiernan et al Kiernan et al Cognistat
Neurobehavioral -Language (2002) (2002) Neurobehavioral
Cognition Status -Constructional Northern Northern Cognition Status
Exam (NCSE) ability California California Exam (NCSE)
-Memory Neurobehaviora Neurobehav Kiernan et al
-Calculation skills l Group (1998) ioral Group (2002)
-Reasoning/ (1998) Northern
judgment California
Neurobehavioral
Group (1998)
Rivermead Assess memory ( RBMT ) ( RBMT ) Rivermead
Behavioural skills related to Wilson et al Wilson et al Behavioural
Memory Test everyday (1989) (1989) Memory
situations. Useful Test( RBMT )
to predict Wilson et al (1989)
everyday life task
memory problems.
Loewenstein The purpose of (LOTCA) (LOTCA) Loewenstein

Occupational this tool is to ( Itzkovich et ( Itzkovich Occupational
Therapy measure the basic al., 1990) et al., 1990) Therapy Cognitive
Cognitive cognitive Assessment
Assessment functions that are (LOTCA)
prerequisites for ( Itzkovich et al.,
managing 1990)
everyday living
tasks. (Itzkovich et
al., 1990)

version
The Árnadóttir Measured the (Árnadóttir, (Árnadóttir, The Árnadóttir

Occupational clients’ 1990) 1990) Occupational
therapy neurobehavioral therapy
Neurobehavioral through five daily Neurobehavioral
Evaluation. living tasks. They Evaluation.1990
were dressing,
grooming and
hygiene, transfer
and mobility,
feeding and
communication.
The assessment of AMPS is a test of (AMPS) (AMPS) The assessment of
Motor and disability and (Fisher, 1997a) (Fisher, Motor and Process
Process Skills focusing on 1997a) Skills (AMPS)
clients’ ADL skills (Fisher, 1997a)
that comprised of
motor and process
actions.
Rivermead RPAB was (RPAB) (RPAB) Rivermead
Perceptual designed to assess (Whiting et al., (Whiting et Perceptual
Assessment visual perceptual 1985) al., 1985) Assessment
Battery deficits in clients Battery (RPAB)
after head injury or (Whiting et al.,
stroke. 1985)
The Behavioral BIT was Wilson, Wilson, The Chinese

Inattention Test developed to Cockburn & Cockburn & Behavioral
assess clients for Halligan, 1987a Halligan, Inattention Test
The Chinese the presence of 1987a (Hong Kong
Behavioral unilateral neglect Fong et al., version)
Inattention Test and its impacts on 2007. Fong et al.,
(Hong Kong the client’s ability 2007.
version) to perform
(CBIT-HK) everyday
occupations
Stroke-Adapted Stroke relevant van Straten et al. van Straten Validated Chinese
Sickness Impact quality of life (1997) et al. (1997); version of
Profile 30 van Straten Occupational
(Chinese Version) et al. (2000) Therapy Central
Coordinating
Committee,
Hospital Authority
2006

version
Modified Rankin Status of disability van Swieten et van Swieten Culture free
Scale in patients with al. (1988) et al. (1988);
stroke de Haan et
al., (1995);
Uyttenboog
aart et al.
(2005)
Chinese Patient ‘s global Chiu et al., 1994 Chiu et al., Hong Kong
Mini-Mental State cognitive 1994 Chinese version
Examination performance (Chiu et al., 1994)
Barthel Index 20 Basic activities of Wade (1992); Wade Original version
daily living for Novak et al. (1992); with minor
patients with (1996) Novak et al. adaptation of “use
stroke (1996) of chopsticks” in
feeding item
Modified Barthel Basic activities of Shah et al Shah et al Modified version

Index daily living for (1989) (1989) from BI 20 by
patients with Fricke Shah (1989)
stroke (1993)
Functional Measure disability Ficke (1993) Ficke (1993) Functional
Independence in motor and Independence
Measures cognitive aspect Measures
The Lawton To assess Carla Graf., Carla Graf Lawton IADL
Instrumental independent living 2007 2007 scale
Activities of Daily skill which is
Living (IADL) considered more
Scale complex than the
basic ADL.
Chinese Version To assess Tong and Man, Tong and Chinese Version of
of the Lawton independent living 2002 Man, 2002 the Lawton
Instrumental skills for older Instrumental
Activities of Daily adults in Hong Activities of Daily
Living Scale Kong Living Scale
The Safety Safety and Letts et al., 1998 Oliver et al., SAFER
Assessment of function within the 1993; SAFER-Home
Function and the home environment Letts &
Environment for Marshall,
Rehabilitation 1995;
(SAFER) Letts et al.,
1998

version
Westmead Home Assessment of Clemson et al., Clemson, WeHSA

Safety physical & 1992 1997
Assessment environmental Clemson et al., Cooper et
(WeHSA) home hazards of 1999 al., 2005
people at risk of Cooper et al., Law et al.,
falling 2005 2005
Law et al., 2005
Community Community living Tepper, Beatter Willer et al. Community

Integration skills for brain & DeJong (1993) Integration
Questionnaire (1996) Chan (1999) Questionaire -
(CIQ) Chinese Version
(Chan, 1999)
Stroke-Adapted Stroke relevant van Straten et al. van Straten Validated Chinese
Sickness Impact quality of life (1997) et al. (1997); version of
Profile 30 van Straten Occupational
(Chinese Version) et al. (2000) Therapy Central
Coordinating
Committee,
Hospital Authority
2006
Modified Rankin Status of disability van Swieten et van Swieten Culture free
Scale in patients with al. (1988) et al. (1988);
stroke de Haan et
al., (1995);
Uyttenboog
aart et al.
(2005)

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.
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Ot Guidelines Stroke Rehab Protocol Final

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Stroke Rehabilitation

Stroke Rehabilitation Protocol

Updated by Stroke Working Group,

Occupational Therapy (NTE Cluster) - Stroke Rehabilitation Protocol Working

2. Stages of Occupational Therapy Management for Patients with

2.1 Occupational Therapy Service Network for Different Stages of Stroke 4

3. Occupational Therapy Assessment for Patients with Stroke…....... 19

3.1 Medical Background………………………………………………………. 19

4.1 Upper Limb Function Training……………………………………………. 23

5. Common Treatment Approach and Technique………………............. 32

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

7.2 Appendix II Seven Functional Levels of the Functional Test of Hemiparetic

7.3 Appendix III Assistive Devices Aids For Daily Living……………………... 35

7.4 Appendix IV Community Occupational Therapy Intervention for Stroke

7.5 Appendix V Outcome Measurement Reference List……………………….. 37

Report, 2004). In the Hong Kong Occupational Therapist Profile Survey

2004/5, there were 34.4% of the occupational therapists participating in stroke

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

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,

from the Stroke Rehabilitation Guideline (OTCOC, Jan 2005). We aim at

providing a holistic and continuous Occupational Therapy Service for patients

Early referral to occupational therapy for stroke rehabilitation is important.

1.2.1 To assist stroke patients in achieving maximum level of independence

1.2.2 To prevent secondary complications resulting from stroke.

1.2.3 To educate patients and caregivers regarding ongoing treatment and

1.2.4 To minimize residual disabilities and to improve quality of life of

This protocol was developed through the consensus of frontline therapists

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.

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

Stroke Rehabilitation Protocol – Occupational Therapy 4

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 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

2.2.3 To improve functional performance

2.2.3.1 Maximize ADL function

2.2.3.2 Maximize IADL function

2.2.3.3 Work/productive activity enhancement

2.2.4 To facilitate safe discharge to community

2.2.4.1 Facilitate safety at home and institution

Stroke Rehabilitation Protocol – Occupational Therapy 5

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 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