| Rehabilitation Guidelines | Stroke | | Physiotherapy |

Rehabilitation Guideline for the

Management of Persons with
Stroke

| Physiotherapy Guideline |

Humanity & Inclusion

2018
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Advancing Medical Care and Rehabilitation Education Project
A project funded by the USAID and Implemented by Humanity & Inclusion* in collaboration with
the Ministry of Health in Vietnam

* Since January 2018, Humanity & Inclusion is

Handicap International’s new operating name

Rehabilitation Guideline for the Management of

Persons with Stroke

| Physiotherapy Guideline |

This guideline is made possible by the generous support of the American people through the
United States Agency for International Development (USAID)

The contents are the responsibility of Humanity & Inclusion and do not necessarily reflect the
views of USAID or the United States Government

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Foreword
In the framework of the "Advancing Medical Care and Rehabilitation Education" project in
Vietnam, and with the guidance and support of the Ministry of Health, Humanity & Inclusion
(previously known as Handicap International) and its partners contribute to the strengthening of
medical and rehabilitation care for persons with disabilities due to brain lesion (i.e. stroke,
traumatic brain injury, cerebral palsy and spina bifida and hydrocephalus).

In order to provide rehabilitation specialists (rehabilitation doctors, nurses, therapists…) with the
tools they need to properly support persons with disabilities, the project, with the financial
support of the United States Agency for International Development (USAID), has developed up-
to-date and comprehensive "Rehabilitation Guidelines".

With the assistance of international experts and Vietnamese specialists, these guidelines have
been developed based on the latest available scientific evidences or, where evidences are still
lacking, internationally-recognized best-practices. The constant involvement and support received
from Vietnamese medical and rehabilitation professionals in the development process ensured
contextualization and ownership of these guidelines as they brought in not only their technical
expertise but also their knowledge and experiences on the Vietnamese context and the local
needs and resources.

Two types of documents have been developed. Besides the General Rehabilitation Guidelines,
which provide wide-ranging recommendations on care provision and quality principles, more
“Technical” Guidelines have also been produced for each of the targeted conditions. These
technical guidelines are specific to one "type" of care (physiotherapy, occupational therapy,
speech and language therapy; and for some conditions medical and nursing care as well). They
provide rehabilitation professionals with more specific, detailed technical guidance, allowing
them to better understand their specific role in the general rehabilitation approach and the
provision of multi-disciplinary, person-centred and evidence-based care.

The result of this process is a comprehensive set of guidelines that we hope will be widely
spread and support all rehabilitation actors in providing better and higher quality care to the
people in need.

The present English version of the Rehabilitation Guidelines has been developed with valued
support from the Vietnamese Ministry of Health. It is our hope that the Vietnamese version of
the respective guidelines will be officially endorsed by the Ministry as national guidelines for
rehabilitation care of persons with brain lesions.

On Behalf of Humanity & Inclusion,

Didier Demey
Country Director

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Acknowledgments
Humanity & Inclusion would like to thank the Ministry of Health, and in particular the department
of Administration of Medical Services (AMS) for their support and encouragement during the
development of the Rehabilitation Guidelines for persons with brain lesions.

We also would like to extend our gratitude to the United States Agency for International
Development (USAID) for their guidance and financial support, without which the present
document could not have been produced.

Furthermore, Humanity & Inclusion would like to thank David Lowen for his support in
developing these guidelines. His commitment towards strengthening medical and rehabilitation
care in Vietnam is greatly appreciated.

Finally, we would like to acknowledge and thank all the national experts and medical and
rehabilitation professionals who, through their participation to the guidelines development and
review workshops have greatly contributed to the development of these guidelines. In particular,
we would like to recognize the members of the Guidelines Development Committee:

Prof. Trần Trọng Hải, Prof. Cao Minh Châu, Prof. Hà Hoàng Kiệm, Associated Prof. Lương Tuấn
Khanh, Associated Prof. Phạm Văn Minh, Associated Prof. Nguyễn Trọng Lưu, Dr. Đinh Quang
Thanh, Dr. Nguyễn Đăng Khoa, Dr. Nguyễn Thị Kim Liên, Dr. Hà Chân Nhân, Lê Thanh Vân (MSc),
Dr. Phạm Thị Cẩm Hưng, Dr. Ngân Thị Hồng Anh and Dr. Nguyễn Thanh Huyền.

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FOREWORD ................................................................................................................................................................ 4

ACKNOWLEDGMENTS................................................................................................................................................. 5

LIST OF ABBREVIATIONS ............................................................................................................................................. 7

1. INTRODUCTION ...................................................................................................................................................... 8

1.1. THE NEED FOR GUIDELINES ............................................................................................................................................ 8

1.2. WHO ARE THE GUIDELINES FOR ...................................................................................................................................... 9
1.3. AIM OF THE GUIDELINE .................................................................................................................................................. 9
1.4. STATEMENT OF INTENT .................................................................................................................................................. 9
1.5. LEVELS OF EVIDENCE ................................................................................................................................................... 10
1.6. STROKE EPIDEMIOLOGY ............................................................................................................................................... 10
1.7. PRIMARY AND SECONDARY PREVENTION OF STROKE.......................................................................................................... 11
1.8. RECOVERY AFTER A STROKE .......................................................................................................................................... 12
1.9. WHAT IS PHYSIOTHERAPY............................................................................................................................................. 12

2. PRINCIPLES OF REHABILITATION ............................................................................................................................14

2.1. INTRODUCTION .......................................................................................................................................................... 14

2.2. REHABILITATION CYCLE ................................................................................................................................................ 14
2.3. ICF .......................................................................................................................................................................... 15
2.4. PERSON CENTRED AND FAMILY CENTRED CARE ................................................................................................................ 15
2.5. MULTIDISCIPLINARY APPROACH..................................................................................................................................... 16
2.6. INTENSITY AND DURATION OF PHYSIOTHERAPY REHABILITATION .......................................................................................... 17
2.7. REPORTING ............................................................................................................................................................... 18

3. THE REHABILITATION CYCLE ..................................................................................................................................19

3.1. PHYSIOTHERAPY ASSESSMENT ....................................................................................................................................... 19

3.2. GOAL SETTING AND THERAPY PLANNING ......................................................................................................................... 20
3.3. PHYSIOTHERAPY INTERVENTION AND PREVENTION STRATEGIES............................................................................................ 21

4. MANAGING COMPLICATIONS ................................................................................................................................30

4.1. SPASTICITY ................................................................................................................................................................ 30

4.2. CONTRACTURES.......................................................................................................................................................... 31
4.3. SHOULDER SUBLUXATION ............................................................................................................................................. 31
4.4. PAIN ........................................................................................................................................................................ 32
4.5. SWELLING OF THE EXTREMITIES ..................................................................................................................................... 33
4.6 LOSS OF CARDIORESPIRATORY FITNESS............................................................................................................................. 34
4.7. POST STROKE FATIGUE ................................................................................................................................................ 34
4.8. VISION PROBLEMS ...................................................................................................................................................... 35
4.9. SEXUALITY ................................................................................................................................................................. 35
4.10. EMOTIONAL FUNCTIONING ......................................................................................................................................... 36
4.11. PERCEPTION PROBLEMS ............................................................................................................................................. 36
4.12. COMMUNICATION PROBLEMS ..................................................................................................................................... 37

5. DISCHARGE AND FOLLOW-UP ................................................................................................................................38

REFERENCES ..............................................................................................................................................................40

ANNEXES ...................................................................................................................................................................42

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List of Abbreviations
ADL Activities of Daily Living
AFO Ankle foot orthosis
BBS Berg Balance Scale
BI Barthel Index
CIMT Constraint Induced Movement Therapy
CPSP Central post-stroke pain
DVT Deep vein thrombosis
FAC Functional ambulation categories
FAT Frenchay arm test
FES Functional Electrical Stimulation
FIM Functional Independence Measure
GAS Goal Attainment Scale
LL Lower limb
MAS Modified Ashworth Scale
MDT Multi-disciplinary Team
MI Motricity index
MMT Manual muscle testing
NICE National institute for health and care excellence
OT Occupational Therapist / Occupational Therapy
PE Pulmonary embolism
PT Physiotherapist /Physiotherapy
ROM Range of motion
SIGN Scottish Intercollegiate Guidelines Network
SLT Speech and Language Therapist / Speech and language therapy
SMART Specific, Measurable, Achievable, Realistic, Time-based
TCT Trunk control test
10MWT Ten meter walk test
TIA Transient ischemic attack
UL Upper limb
WCPT World Confederation of Physical Therapy
WHO World Health Organisation

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1. Introduction

1.1. The Need for Guidelines

One of the objectives of the Ministry of Health (MoH) is to “Improve and develop the network of
rehabilitation establishments, improve the quality of rehabilitation services; strengthen disability
prevention, early detection and intervention, and improve the life quality of persons with
disabilities so for persons with disabilities to be fully integrated and participate equally in the
society, and to effectively contribute to development of the community where they live in.”
(MoH, 2014)

With this in mind, guidance to realise the desired improvement of rehabilitation services is
needed. Guidelines for rehabilitation care for main injuries and health conditions do currently
exist in Vietnam and have been validated by the Ministry of Health in 2014. These are made up
of two main resource documents:
"General Guidelines for Rehabilitation Care” describing the needs and procedures to be
followed in regard to diagnosis, rehabilitation care and monitoring, and
"Specialized Rehabilitation Procedures", a guide that provides technical description of
available rehabilitation techniques as well as their fields of application, indications, contra-
indications and expected outcomes.

Such MoH guidelines exist also for ‘Stroke’.1 These guidelines form a rather strong basis for the
development of state of the art general and specific guidelines, based on new research findings
and compatible with international evidence-based rehabilitation guidelines, although adapted to
the Vietnamese context.

A broad group of national and international experts has contributed to the production of updated
General and Specific guidelines for stroke.

The present Physiotherapy Guidelines for Stroke provide recommendations and guidance on
type of physiotherapy care to be provided as well as "cross-cutting" recommendations in regard
of requirements for a system organization, multidisciplinary and comprehensive care, person-
centred care, care pathway and referrals, family support and involvement, discharge and follow-
up, community reintegration and social participation. The guideline acts as an adjunct to the
General Guidelines on Stroke Rehabilitation in Vietnam which have been developed recently.

1
A synonym of ‘stroke’ is Cerebrovascular accident (CVA). This Guideline uses the term stroke.

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1.2. Who Are the Guidelines For
The present guideline is primarily a practical resource tool for Physiotherapists who are involved
in stroke rehabilitation.

They are also useful to any other professional with an interest in stroke rehabilitation including
doctors, neurologists, rehabilitation doctors, nurses, occupational therapists, speech and
language therapists, dieticians, orthotists, pharmacists, psychologists, specialists in public health,
social, community workers and stroke survivors and their family and carers.

1.3. Aim of the Guideline

The guidelines are meant to be a resource guide for the rehabilitation management of those
people in Vietnam who are affected by stroke. The guidelines are not prescriptive. They contain
various ideas for management but, depending on the local situation, not all of the activities will
have to be implemented. In some cases activities should be adjusted to local circumstances.

They are also intended to not only be a practical resource but an educational tool to assist all
health staff and the public as to what is necessary for facilitating effective outcomes in stroke
recovery. They may also act as an awareness tool for all staff as to roles and functions of those
people who are concerned with stroke rehabilitation. They can be simplified in order to adapt to
low level trained staff and for the stroke survivor and family themselves.

Finally, the guidelines can help to bridge the gaps between acute and rehabilitation services
especially in terms of guiding referral and communication systems between the two sectors.
They can also highlight the gaps and needs in the workforce for specific staff (e.g. fully qualified
occupational therapists (OT) and speech and language therapists (SLT) as well as give target
recommendations for the coming 5-10 years in how to improve the primary prevention and
quality of rehabilitation, including secondary prevention, of stroke in Vietnam.

1.4. Statement of Intent

The guidelines are not intended to serve as a standard of medical care. Standards of care are
determined on the basis of all clinical data available for an individual case and are subject to
change as scientific knowledge and technology advance and patterns of care evolve. Adherence
to the guidelines will not ensure a successful outcome in every case, the ultimate judgment
regarding a particular clinical procedure or treatment plan must be made in light of the clinical
data presented by the patient and diagnostic and treatment options available. However, it is

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advised that significant departures from these guidelines should be fully documented in the
patient’s case notes at the time the relevant decision is taken.

1.5. Levels of Evidence

The following recommendations were highlighted by the guideline development group as key
clinical recommendations that should be prioritised for implementation in Vietnam. The grade
attributed to a recommendation relates to the strength of the supporting evidence on which the
recommendation is based. It does not reflect the clinical importance of the recommendation. The
grading system is similar to the method used in the Australian Clinical Guidelines for Stroke
Management (2010).

GRADE
A Body of evidence can be trusted to guide practice
B Body of evidence can be trusted to guide practice in most situations
Body of evidence provides some support for recommendations but care should be
C
taken in its application
D Body of evidence is weak and recommendation must be applied with caution
Good Practice Point - Recommended best practice based on clinical experience and
GPP
expert opinion

1.6. Stroke Epidemiology

Stroke is a vascular condition and is defined by the World Health Organization (WHO) as a clinical
syndrome consisting of 'rapidly developing clinical signs of focal (or global) disturbance of
cerebral function lasting 24 hours or longer or leading to death, with no apparent cause other
than of vascular origin’. According to the WHO (2015) stroke is the major cause of death in
Vietnam (21.7%) with an annual mortality rate of 150.000 (HealthGrove, 2013).

Stroke is the most frequent cause of severe adult disability in the World. Globally, only 15-30%
of all stroke survivors become functionally independent and approximately 40-50% are partially
independent (European Stroke Initiative Committee, 2003).

Recovery from stroke is dependent on medical intervention, spontaneous recovery, rehabilitation

and social services. Because every patient’s recovery process is different, case by case and
complex rehabilitation services is needed for all patients.
Some stroke patients have some spontaneous recovery, but most stroke survivors need
rehabilitation to restore functional ability.

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Stroke can present with the sudden onset of any neurological disturbance, including limb
weakness or numbness, speech disturbance, visual loss or disturbance of balance. Over the last
20 years, a growing body of evidence has overturned the traditional perception that stroke is
simply a consequence of ageing that inevitably results in death or severe disability (National
Institute for health and Care Excellence [NICE], 2008).

1.7. Primary and Secondary Prevention of Stroke

Evidence is accumulating for more effective primary and secondary prevention strategies, better
recognition of people at highest risk, and interventions that are effective soon after the onset of
symptoms. Understanding of the care processes that contribute to a better outcome has
improved, and there is now good evidence to support interventions and care processes in stroke
rehabilitation. (NICE, 2010)

A person with a stroke has an accumulated risk of subsequent stroke of 43% over 10 years with
an annual rate of 4%. The rate of stroke after a transient ischemic attack (TIA) is significantly
higher (up to 10% after 3 months) therefore secondary prevention of stroke and TIA is essential
(National Stroke Foundation Australia, 2010).

The symptoms of a TIA, which are synonymous with that of early onset of stroke, usually resolve
within minutes or within 24 hours at most, and anyone with continuing neurological signs when
first assessed should be assumed to have had a stroke.

If a TIA has occurred, it is necessary to still be assessed by a doctor to clarify the diagnosis. The
validated tool ABCD² (Warlow et al, 2001) can be used at this stage to be a prognostic indicator
as to the potential occurrence of a stroke. Lifestyle change advice (e.g. need to exercise, stop
smoking, etc) can then be given to the client by the treating physician to reduce risks of a
subsequent stroke.

‘Patients should receive information about the risk of recurrent stroke, the signs and symptoms
of onset and the action they should take if stroke is suspected. Tools such as FAST (Face, Arm,
Speech, and Time) can be effective as an early identification of stroke. (SIGN, 2010)

Secondary prevention is essential to reduce the burden of stroke. Lifestyle modifications can be
the best way to reduce both primary and secondary occurrence of stroke. These would include;
cessation of smoking, care with diet (reducing sodium intake, increasing intake of fruit and
vegetables, promoting fish oils, low fat), reducing alcohol intake, reducing obesity, encouraging
physical activity, adherence to pharmacotherapy. (National Stroke Foundation, 2010)

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1.8. Recovery after a Stroke
Recovery after a stroke is not linear, but follows a curve, with most of the recovery taking place
during the first days to months. The recovery process includes four phases, which merge into
each other and are not sharply demarcated:
The (hyper)acute phase (0-24 hours)
The early rehabilitation phase (24 hrs – 3 months)
The late rehabilitation phase (3 – 6 months)
Rehabilitation in the chronic phase ( > 6 months)
(KNGF, 2014)

1.9. What is Physiotherapy

1.9.1. Definition
“Physiotherapy is services provided by physiotherapists to individuals and populations to
develop, maintain and restore maximum movement and functional ability throughout the
lifespan. The service is provided in circumstances where movement and function are threatened
by ageing, injury, pain, diseases, disorders, conditions or environmental factors and with the
understanding that functional movement is central to what it means to be healthy”
(WCPT, 2017)

1.9.2. The Role of the Physiotherapist

Physiotherapy is a healthcare profession that works with people to identify and maximize their
ability to move and function, and functional movement is a key part of what it means to be
healthy (Chartered Society of Physiotherapy, 2010). The therapist focuses on ‘enhancing
maximum potential of movement aiming at preventing, curing, and rehabilitating a patient or
victim so that his/her health and ability can be improved.

In stroke rehabilitation Physiotherapy involves the skilled use of physical interventions in order to
restore functional movement, reduce impairment and activity limitations, and maximise quality of
life after a stroke. They also assist in the treatment of respiratory and musculo-skeletal problems
(eg shoulder pain), and the prevention and treatment of post stroke complications..
Physiotherapists (PT) are generally involved in the care and rehabilitation of patients in all phases
(acute and chronic) of stroke in a variety of settings including emergency wards, ICU, stroke
units, general and neuro-medical wards, rehabilitation units, hospital out-patients, private clinics
and in the client’s own homes.

Physiotherapy management of stroke should continue until the person is able to maintain or
progress function either independently or with assistance from others eg rehabilitation
assistants, family members/ carers or fitness instructors.

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The PT plans and implements treatment for individual patients, based on the assessment of
their unique problems establishing and meeting relevant short and long term goals, which
have been discussed, where appropriate, with patients, carers and other team members.
The PT works closely and intimately with stroke survivors and has the ability to empathise and
communicate with patients in the most challenging of circumstances.
The PT should aim to achieve an evidence based approach to stroke management through
regular and updated training and should be involved in appropriate investigation, audit and
research activity.

In situations where there are no PTs available, it is recommended that the basic role of the PT is
taken on jointly by the rest of the multidisciplinary team after they have received training, e.g.
transfer training, mobility, muscle strengthening, functional exercises etc.

The role of the Physiotherapist

Assessment Intervention
Identifying current movement capabilities Providing planned, staged rehabilitation
and movement potential in particular to meet agreed goals
assessing : Liaising and involving family/carers in
Respiratory function rehabilitation
Muscle tone Education of family/carers
Muscle strength Clinical audit and research
Body alignment and range of joint Translating up-to-date research into
motion clinical practice
Functional movement status Ensuring regular communication with
Sensation other health professional in the
Visuospatial awareness provinces / community to assist with
Undesirable compensatory activity referral systems
Balance
Mobility e.g. transfers, walking,
stairs

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2. Principles of Rehabilitation

2.1. Introduction
WHO describes rehabilitation as “a set of measures that assist individuals who experience, or
are likely to experience, disability [resulting from impairment, regardless of when it occurred
(congenital, early or late)] to achieve and maintain optimal functioning in interaction with their
environments”. “Rehabilitation measures target body functions and structures, activities and
participation, environmental factors, and personal factors.” (WHO, 2011)

Key aspects of rehabilitation care include:

Multidisciplinary screening and assessment
Identification of functional difficulties and their measurement
Treatment planning through goal setting
Delivery of interventions which may either effect change or support the person in
managing persisting change
Evaluation of effectiveness of the intervention
Reporting

2.2. Rehabilitation Cycle

The conventional approach to rehabilitation is a cyclical process:

2.2.1. Assessment
The patient is assessed and needs are identified
and quantified; (Re-)
Intervention
Assessment

2.2.2. Goal setting

On the basis of the assessment the goals for
rehabilitation of the patient are defined. These
can be short term, medium term and long term
goals; Goal Setting
A plan to reach these goals is formulated

2.2.3. Intervention
Giving relevant treatment in order to achieve the goals;

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2.2.4. Re-Assessment
Progress is assessed as to whether the intervention has been effective in order to
achieve the agreed goals. If not, then goals and consequent intervention can be revisited.

2.3. ICF
Rehabilitation can be summarised
in the ICF (International
Classification of Functioning,
Disability and Health) model
developed by WHO (2001). The
ICF conceptualises a person's
level of functioning as a dynamic
interaction between her or his
health condition, environmental
factors, and personal factors. It is
a biopsychosocial model, based
WHO (2001). ICF Model
on an integration of the social and
medical models of disability. All
components of disability are important and any one may
interact with another. Environmental factors must be taken into consideration as they affect
everything and may need to be changed.

2.4. Person Centred and Family Centred Care

Evidence supports the shift towards shared decision making, in which patients are encouraged to
express their views and participate in making clinical decisions (Hurn et al, 2006). The key to
successful therapist-patient partnerships is to recognise that patients are also experts.
Physiotherapists should be well informed about diagnostic techniques, prognosis, treatment
options, and preventive strategies. But only patients know about their experience of illness and
their social circumstances, habits, behaviour, attitudes to risk, values, and preferences. Both
types of knowledge are needed to manage stroke successfully, and the two parties must be
prepared to share information and make joint decisions, drawing on a sound base of evidence.

Person-centred care supports people to develop the knowledge, skills and confidence they need
to more effectively manage and make informed decisions about their own health and health care.
It is coordinated and tailored to the needs of the individual. And, crucially, it ensures that people
are always treated with dignity, compassion and respect.

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Families and carers should have the opportunity to be involved in decisions about treatment and
care. Families and carers should also be given the information, skills and support they need to
take adequately care of the stroke survivor in the hospital environment and at home.

In summary, the important patient and family centred care principles are:
Respect for patient’s values, preferences and expressed needs
Coordination and integration of care
Information, communication and education
Physical comfort
Emotional support and alleviation of fear and anxiety
Involvement of family and/or carers
Continuity and transition
Access to care.

Family-centred practice adopts a similar philosophy to person-centred practice and goes further
to recognise that families and carers are pivotal decision makers when working with stroke
survivors. Family-centred practice is made up of a set of values, attitudes, and approaches to
services for stroke survivors and their families. The family works with service providers to make
informed decisions about the services and supports the stroke survivor and family receive. In a
family-centred approach, the strengths and needs of all family members and carers are
considered. The family defines the priorities of the intervention and services. It is based on the
premises that families know the stroke survivor best, that optimal recovery outcomes occur
within a supportive family and community environment and that each family is unique. Service
provides support and respect each family’s capacity and resources. Family capacity includes the
knowledge and skills the family requires to support the stroke survivor’s needs and well-being.
Capacity is the amount of physical, emotional and spiritual energy necessary to support the
stroke survivor, and it directly influences the sense of competency a family member experiences
when caring for a stroke survivor.

2.5. Multidisciplinary Approach

It has been demonstrated that having patients with a stroke treated by a specialised
interdisciplinary stroke team, who are working together at one common site (stroke unit), has a
favourable effect on survival rates, length of stay, and ADL-independence, compared to regular
care at a non-specialised ward. (KNGF, 2014) [A]
This includes:
Consultant Physicians
Nurses
Physiotherapists
Occupational Therapists
Speech and Language Therapists
Clinical Psychologists

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 Social workers
Orthotist

Speech and
Nurse Language
therapist
Rehab Occupation
doctor al therapist

Consultant
Psychologist
physicians

Physio
Orthotist
therapist

Person with
Social
stroke + Dietician
worker
family/carer

The team should work cohesively with transparency to provide patient-centred and goal- directed
rehabilitation for each person and their family. This approach means that where indicated, joint
assessment and intervention should be provided to enhance rehabilitation outcomes[A]. Members
of the core multidisciplinary stroke team should screen the stroke survivor for a range of
impairments and disabilities, in order to inform and direct further assessment and treatment.

The Multidisciplinary team (MDT) should utilize standardized assessment tools [A] such as the
Functional Independence Measure (FIM)2 or the Barthel Index (BI)3 to ensure goal directed care is
provided and is measurable.

2.6. Intensity and Duration of Physiotherapy

Rehabilitation
The rehabilitation process should begin as soon as possible following a stroke. (KNGF, 2014;
NICE, 2013; SIGN, 2008)[A]. Clinicians should be guided by medical staff regarding when it is first
safe to begin assessment, this could be as early as within hours of the stroke. This can also
occur in all departments including ICU, Stroke Unit as well as ward and provincial hospitals. Refer
to the Rehabilitation Risk Assessment tool (see Annex 1).

2
https://www.strokengine.ca/pdf/FIMappendixD.pdf
3
http://www.strokecenter.org/wp-content/uploads/2011/08/barthel.pdf

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Stroke survivors should be given as much opportunity for rehabilitation as possible within the
first 6 months following stroke (KNGF, 2014. NICE, 2013. SIGN, 2008)[A]. For people that have
the ability to participate and where functional goals can be achieved, at least 45 minutes of PT
per day for at least 5 days per week should be offered[A]. In addition to this other therapies
(including occupational therapy, speech and language therapy (SALT) can also provide the same
intensity of input. For people who continue to make functional gains and have the ability to
participate, increased amounts of rehabilitation should be considered.

Task–specific circuit class training and video self-modelling should be used to increase the
amount of time engaged in rehabilitation practice[A].

In addition the stroke survivor, their family/carer and nursing staff and other MDT members
should be trained and educated to continue to practice skills they learn in therapy sessions
throughout the remainder of the day. This can be in areas such as handling, transferring,
activities of daily living and general movement techniques which will reinforce what has been
provided in therapy sessions.

Further, for people unable to complete the minimum, PT and other therapies should still be
provided at least 5 days per week for the amount of time that can be tolerated by the stroke
survivor each day. (KNGF, 2014; NICE, 2013).

2.7. Reporting
“The physical therapist clearly documents all aspects of the patient/client management including
the results of the initial examination/assessment and evaluation, diagnosis, prognosis/plan of
care, intervention/treatment, response to interventions/treatment, changes in patient/client
status relative to the interventions/treatment, re-examination and discharge/discontinuation of
intervention, and other patient/client management activities.” (WCPT, 2017)

The PT should record all relevant assessments and interventions completed with each individual
in a shared file utilized by the entire MDT. This enables efficient MDT work and reduces
repetition of assessment and intervention across disciplines. A common file is an efficient means
to communicate information to the MDT throughout the therapy process[A].

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3. The Rehabilitation Cycle

3.1. Physiotherapy Assessment

A comprehensive assessment of a stroke survivor should take into account:
Any previous functional abilities
Impairment of body structures and functions[including impairment of psychological
functioning (cognitive, emotional and communication) and subjective factors such as pain]
Activity limitations and participation restrictions
Environmental factors (social, physical and cultural) and personal factors.

Reliable and validated measurement tools are applied whenever possible.

In all areas of assessment covered within the guideline, it is assumed that once assessment
outcomes are available, education is immediately provided to the stroke survivor and their
family/carer in order to decrease any new risk associated with new impairments.

3.1.1. Initial PT Assessment

A rehabilitation risk assessment must be given prior to starting physiotherapy interventions. (see
Rehabilitation Risk Assessment summary - Annex 1).

A general screening should be completed during the initial meeting with the survivor and the
family. Many of these are quite universal to the MDT hence some can be gleaned from the
medical files to prevent overlap and repetition. They should include:
Stroke survivor/family/carers expectations
Medical history/information
Social situation including usual occupation, hobbies/interests and who is living at home
Family history of the condition
Pre-morbid level of function
Current level of function
The initial interview will guide further assessment
Plans for the next session; Goals may be stated however often this stage is too early to
make therapy goals

3.1.2. Specific Assessment

Note that some of these areas can also be assessed by other MDT members in particular OTs.
Where those members are not present then, as a Physiotherapist, principle areas are essential
but other areas may be assessed briefly.

The level of functioning may vary with the recovery stages the patient is going through.

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Principle areas to assess as a Physiotherapist are to identify current movement capabilities and
movement potential of the stroke survivor in particular assessing:
Respiratory Function
Muscle Tone (Modified Ashworth Scale (MAS)4
Muscle Strength [Motricity Index UL and LL 5 or using Manual Muscle Testing (MMT) 6
Body Alignment (including any subluxation)
Passive and Active Range of Joint Motion (including upper limb, lower limb, trunk, neck)
and limitation (eg pain)
Functional Movement Status (Trunk Control Test, Barthel Index7 )
Compensatory Movements
Sensation (deep and light touch, temperature, proprioception, agnosia, stereognosis)
Visuospatial Awareness
Balance – static + dynamic (sitting, standing, step standing) (Trunk Control Test; Berg
Balance Scale 8)
Mobility eg transfers, walking, steps, stairs, 10MWT 9
Home Environment (see section on Discharge from Acute Setting)
Need for and use of assistive devices

3.2. Goal Setting and Therapy Planning

Following the assessment process which informs clinical reasoning, goal setting with the stroke
survivor and their family is imperative. All stroke survivors and their families should be involved in
the goal setting process and their wishes and expectations should routinely be acknowledged.
Ensure that goals for their rehabilitation are SMART goals:

S Specific
M Measurable focus on activity and participation
A Achievable (and challenging)
R Realistic and relevant
T Time–Based (include both short-term and long-term aims with timings)

The use of standardized tools e.g. Goal attainment scale (GAS) (see Annex 2.) is recommended
to enable patient centred, specific goal setting which are underpinned by both performance and
satisfaction.

4
https://www.med-iq.com/files/noncme/material/pdfs/DOC%201--Modified%20Ashworth%20Scale.pdf
5
https://jcphysiotherapy.files.wordpress.com/2015/02/motricity-index-mi.pdf
6
http://www.scottsevinsky.com/pt/mmt.html
7
http://www.strokecenter.org/wp-content/uploads/2011/08/barthel.pdf
8
http://www.strokecenter.org/wp-content/uploads/2011/08/berg.pdf
9
https://www.sralab.org/rehabilitation-measures/10-meter-walk-test

P a g e | 20
Treatment planning will be completed by the PT who considers the person’s goals, strengths,
challenges, the personal resources and the amount of time available for rehabilitation activities.
The PT should also consider resources in the home/community setting to enable ongoing
rehabilitation post discharge from the inpatient setting.

Once all of the MDT have assessed the Stroke survivor, goals for rehabilitation by the team can
then be agreed upon. (Annex 2).

Timing
Initial goal setting and treatment planning should be completed within the first week of
admission to rehabilitation. However, if the person is only able to complete a short period of
rehabilitation, then goal setting should begin as early as is possible.

3.3. Physiotherapy Intervention and Prevention Strategies

These can be aimed for both in the hospital setting such as the Rehabilitation Unit or medical
ward, and when back in the community.
Reliable and validated measurement tools are applied to monitor and evaluate the effectiveness
of interventions.

Rehabilitation of the stroke survivor starts as early as possible depending on the medical stability
of the stroke survivor[A]. It has been demonstrated that increasing the intensity of therapy (in
terms of more hours of exercise) for patients with a stroke, compared to less intensive
exercising, results in more rapid recovery of selective movements, comfortable walking speed,
maximum walking speed, walking distance, muscle tone, sitting and standing balance,
performance of basic activities of daily living, and severity of depression and anxiety. (KNGF,
2014) [A].

Treatment should continue until the person is able to maintain or progress function either
independently or with the assistance from family members and carers.

Physiotherapy treatment includes the following depending on the recovery stage:

Prevention of respiratory complications
Encourage Therapeutic positioning
Early mobilization
Maintenance of ROM
Managing hemiparesis/hemiplegia
Managing Sensory Loss
Facilitating Upper Limb Function
Muscle Strengthening
Improving gait, balance and mobility
Encouraging independence and Activities of Daily Living

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 Manage and Prevent Typical Complications of Stroke

3.3.1. Prevent Respiratory Complications

Regular turning
Therapeutic positioning (discourage lying strictly flat supine which compromises air entry
and safe swallowing
Encourage regular Deep Breathing Exercises
Encourage regular effective cough and clearing of sputum and excessive saliva
Encourage mobility (if medical stable)

3.3.2. Ensure Therapeutic Positioning

(I) Positioning
The aim of therapeutic positioning of the stroke survivor is to promote optimal recovery from
stroke by:
Modulating muscle tone
Providing appropriate sensory information and increasing spatial awareness
Preventing complications such as pressure sores, contractures, pain and respiratory
problems
Assisting swallow and safer eating / drinking
Positional changes should occur every 2 hours especially if the stroke survivor is not so
physically active. This will prevent risks of pressure sores.

The main positions recommended and alternated between are:

Lying
o On the unaffected side
o On the affected side
o In a half supine/half sitting up position (using firm pillows behind head/supporting
shoulders)
Sitting
o Up high in bed
o Up high in a chair

In the sitting position to facilitate optimal recovery:

The trunk should be straight and in the midline
The upper limb of the affected shoulder should be protracted with the arm brought
forward, the wrist in slight extension and the fingers extended (preferably flat on a
surface e.g. a firm pillow).
The hip and knee at right angles with the feet flat on a firm surface (eg floor, firm
platform)

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In the acute phase following stroke (the first 72 hours) there is evidence to support reducing the
risk of cerebral hypoxia by sitting the patient in an upright position, if medically fit to do so. This
position gave the highest oxygen saturation compared to other positions[C].

In the very early stages of stroke survival it is important to monitor for fatigue and changes in
blood pressure.

Specific equipment required are a firm mattress (a soft mattress makes facilitating active
movement difficult), pillows and foam rolls to help maintain the required therapeutic positions,
bedside chair.
Examples of positional chart are available. 10

(II) Pressure Care

Education regarding pressure relieving strategies includes:
Increasing mobility as much as possible
Re-positioning in bed/chair every two hours
Encourage weight shifting
Correct positioning
Correct handling including avoiding shearing when moving the stroke survivor
Regular monitoring of high risk skin areas

For those peoples at moderate to high risk of developing a pressure injury, provision of a
specialized pressure relieving mattress is recommended.

For those people sitting in a chair or in a wheelchair provision of a specialized pressure relieving
cushion is recommended.

Pressure care and equipment such as cushions etc should be provided or educated to the stroke
survivor prior to discharge home. Education of the family on pressure care is vital to prevent
pressure risk complications.

3.3.3. Early Mobilization

Once medically stable, the stroke survivor should be mobilized as early as possible after stroke[B].
There are several reasons for early mobilization:
In the acute phase there is a high risk of post-stroke complications which are associated with
immobility such as; muscle weakness, respiratory problems (e.g. respiratory infection,
pneumonia), pressure sores, loss of range of movement, contractures, lack of fitness (cardiac
deconditioning), thrombotic complications (e.g. PE, DVT) and osteoporosis.

10
https://www.chss.org.uk/documents/2013/08/f16_stroke_positioning_chart.pdf

P a g e | 23
The psychological effects of early mobilization help reduce depression and can reduce costs of
care.

Depending on the medical stability of the stroke survivor (see Annex 1: Rehabilitation Risk
Assessment) mobilization can mean anything from:
Bed rolling
Bridging
Sitting up in bed
Lying to sitting over edge of bed
Sitting out of bed
Standing and walking

3.3.4. Maintain Range of Motion (ROM)

Maintaining passive and active range of movement can be initially shown to the family/carer and
is something they can assist with. There is no evidence as to how long this should be done for[B].

Care must be taken with good handling (not causing pain or discomfort for the stroke survivor)
and to not move limbs out of their range. Education by the physiotherapist is important to avoid
these.

3.3.5. Managing Hemiparesis/Hemiplegia

Initially there is a period of low tone.

(I) Aims
To encourage normalisation of muscle tone and strength in the hemiplegic side
To help to use the hemiplegic side and not neglect it
To prevent any contractures
To prevent trauma to that side

(II) How?
Reduce dangers of complications of weakness by encouraging careful handling and
positioning.
Encourage active exercises with a functional purpose such as reaching for a cup, brushing
hair. This can also be active assisted using either the other arm or assisted by the
therapist/carer. Use of splints can also assist function and help to maintain range of
movement[C]
Use weight bearing through the supported hemiplegic arm/leg
Functional electrical stimulation may be used by trained staff
Task specific repetitive training[B]
Constraint induced movement therapy (CIMT) [A]

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Note: High muscle tone (spasticity) can develop - see management of Spasticity (High Tone)
under Managing Complications

3.3.6. Managing Sensory Loss

(I) Aims
To protect the affected side from injury, to assist with neglect and to help gain return of
sensation

(II) How?
Teach how to monitor the hemiplegic side to protect against trauma (heat, damage from hitting
objects, damage from poor positioning, heavy handling).

Use massage/ stroking techniques on the affected side using different types of material.
Sensory specific exposure retraining can be provided as often as tolerated by the person e.g.
exposing the area with various kinds of materials, temperatures and pressures C.

3.3.7. Facilitating Upper Limb Function

(I) Aims
To encourage return of movement
To encourage independence and motivation

(II) How?
Teach exercises to use the affected arm using functional activities as much as possible,
preferably in a sitting or standing position e.g. bringing a cup to the mouth, moving
objects from one place to another.
Constraint induced movement therapy (CIMT) for appropriate people :
o It has been demonstrated that original CIMT improves the dexterity, perceived use
of arm and hand, quality of arm and hand movements, and quality of life of
patients with a stroke. (KNGF, 2014)[A]
o Be aware of potential adverse events (such as falls, low mood and fatigue).
o Healthcare professional should be trained in CIMT before offering it on an
individualized basis
People with difficulty using their upper limb(s) should be given the opportunity to
undertake as much practice of upper limb activity as possible, especially functional and
purposeful tasks
o Task specific repetitive training[B]
Electrostimulation may be used by trained staff only
o It has been demonstrated that neuromuscular electrostimulation (NMS) of the
paretic wrist and finger extensors of patients with a stroke is not more effective in
terms of selective movements, muscle strength, active range of motion for wrist
and finger extension, and dexterity than other interventions. (KNGF, 2014)[A]

P a g e | 25
 o It has been demonstrated that NMS of the paretic wrist and finger flexors and
extensors of patients with a stroke improves selective movements and muscle
strength. (KNGF, 2014)[A]
o It has been demonstrated that NMS of the paretic shoulder muscles of patients
with a stroke reduces glenohumeral subluxation. (KNGF, 2014)[A]
o It has been demonstrated that EMG-triggered neuromuscular electrostimulation of
the paretic wrist and finger extensors of patients with a stroke improves selective
movements, active range of motion, and dexterity. (KNGF, 2014)[A]
o It remains unclear whether EMG-triggered neuromuscular electrostimulation of
the paretic wrist and finger flexors and extensors of patients with a stroke is more
effective in terms of selective movements and dexterity than other interventions.
(KNGF, 2014)[A]
It remains unclear whether mirror therapy for the paretic arm and hand of patients with a
stroke is more effective in terms of selective movements, resistance to passive
movements, pain, and dexterity than other interventions. (KNGF, 2014)[A]
It is plausible that the use of a mechanical arm trainer by patients with a stroke is not
more effective in terms of selective movements, muscle strength, resistance to passive
movements, and performance of basic activities of daily living than other interventions.
(KNGF, 2014)[B]
It has been demonstrated that virtual reality training of the paretic arm and hand as an
add-on to regular exercise therapy for patients with a stroke improves the performance of
basic activities of daily living. (KNGF, 2014)[A]
It has been demonstrated that unilateral robot-assisted training of the paretic shoulder
and elbow of patients with a stroke improves the selective movements and muscle
strength of the paretic arm and reduces atypical pain in the paretic arm. (KNGF, 2014)[A]

(III) Wrist and hand splints

Do not routinely offer wrist and hand splints to people with upper limb weakness after
stroke[B].
Consider wrist and hand splints in people at risk after stroke[GPP] e.g. those with immobile
hands due to weakness, people with high tone, to:
o Maintain joint range, soft tissue length and alignment
o Increase soft tissue length and passive range of movement
o Facilitate function (e.g. a hand splint to assist grip or function)
o Aid care or hygiene (e.g. by enabling access to the palm)
o Increase comfort (e.g. using a sheepskin palm protector to keep fingernails away
from the palm of the hand).
Where wrist and hand splints are used in people after stroke, they should be assessed
and fitted by appropriately trained healthcare professionals and a review plan should be
established.
Teach the person with stroke and their family or carer how to put the splint on and take it
off, care for the splint and monitor for signs of redness and skin breakdown. Provide a
point of contact for the person if concerned.

P a g e | 26
3.3.8. Muscle Strengthening
(I) Aims
To encourage return of movement
To encourage independence

(II) How?
Consider strength training for people with muscle weakness after stroke. (KNGF, 2014; NICE,
2013)[A].

This could include:

Progressive strength building through increasing repetitions of body weight activities (for
example, sit-to-stand repetitions)
Weights (for example, progressive resistance exercise)
Resistance exercise on machines such as stationary cycles.

It has been demonstrated that training the muscle strength of the paretic leg or both legs of
stroke patients increases their muscle strength and resistance to passive movement, and
improves the patient’s gait in terms of cadence, symmetry, and stride length. (KNGF, 2014)[A].

3.3.9. Improving Gait, Balance and Mobility

(I) Aims
To encourage independence
For psychological support and motivation
To build endurance

(II) How?
It has been demonstrated that exercising balance during various activities results in
improved sitting and standing balance and improved performance of basic activities of
daily living by stroke patients. (KNGF, 2014) A]
Teach walking techniques. If appropriate using an assistive device eg walking stick, AFO
(Ankle Foot Orthosis)
Teach steps and stairs / varying surfaces.
Walking training should be given to people after stroke to facilitate independence and
help build endurance and speed. Assistance of a family member/carer is essential to
continue on gait practice.
It has been demonstrated that body-weight supported treadmill training improves the
comfortable walking speed and walking distance of patients with a stroke. (KNGF, 2014)[A]
It has been demonstrated that robot-assisted gait training for stroke patients who are
unable to walk independently improves their comfortable walking speed, maximum
walking speed, walking distance, heart rate, sitting and standing balance, walking ability

P a g e | 27
and performance of basic activities of daily living, compared to conventional therapy
(including overground walking). (KNGF, 2014)[A]
It has been demonstrated that overground gait training by stroke patients who are able to
walk without physical support is more effective in increasing walking distance and
reducing anxiety than walking on a treadmill. (KNGF, 2014)[A]
It is plausible that manual passive mobilisation of the ankle has a transient favourable
effect on the active and passive dorsiflexion of the ankle of patients with a stroke. (KNGF,
2014)[B]
It is plausible that manual passive mobilisation of the ankle of patients with a stroke has
an adverse effect on the speed with which they stand up and sit down. (KNGF, 2014)[B]
It is plausible that manual passive mobilisation of the ankle is not more effective for
patients with a stroke in terms of symmetry while standing and walking than other
interventions. (KNGF, 2014)[B]
Consider ankle–foot orthoses for people who have difficulty with swing-phase foot
clearance after stroke (for example, tripping and falling) and/or stance-phase control (for
example, knee and ankle collapse or knee hyper-extensions) that affects walking.
Continued muscle strength, encouraging normal movement and discouraging
compensatory movement is also needed as an adjunct to gait training.
Functional electrical stimulation to decrease drop foot can also be used to supplement the
above.[B]
Individual stroke survivors may gain confidence from using a walking aid. If walking aids
improve gait, balance, quality of life and independence, or reduce falls, after stroke, they
could provide a cost-effective intervention. However, walking aids may have adverse
effects on gait pattern and the achievement of independent walking (without an aid). At
present there is insufficient evidence to assess the size of these potential impacts.[C]
The use of walking aids and orthotics are dependent on the needs of the stroke survivor
as assessed by the therapist. Close collaboration with an Orthotist should be considered
when assessing for any assistive devices.
It is plausible that the use of a standing frame is just as effective for patients with a
stroke in terms of maintaining passive range of motion in ankle dorsiflexion and getting
up from a chair as wearing a night splint. (KNGF, 2014)[B]
It remains unclear whether virtual reality mobility training is more effective than other
interventions for patients with a stroke in terms of comfortable and maximum walking
speed, spatiotemporal gait parameters and walking ability. (KNGF, 2014)[A]
It has been demonstrated that circuit class training for walking and other mobility-related
functions and activities improves walking distance/speed, sitting and standing balance
and walking ability, and reduces inactivity in patients with a stroke. (KNGF, 2014)[A]
If walking is not possible then provision of a suitable wheelchair should be arranged for to
facilitate mobility and independence. See OT Stroke Guidelines for further information.

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3.3.10. Encouraging Independence and Activities of Daily Living
ADL training is a frequently used intervention by Occupational Therapists though, in the Vietnam
setting, this can be an activity by the Physiotherapist or trained community worker. ADL training
needs to be encouraged by all the MDT. Measures may include:
Stroke survivors with difficulty completing ADLs should be provided with task specific
practice and trained use of appropriate assistive devices to enhance participation and
independence in personal, domestic and community based ADLs.
The stroke survivor, the family and/or carer and the MDT should be advised regarding
techniques and equipment to maximize outcomes related to ADL performance,
sensorimotor, perceptual, cognitive and physical capacities.
Evidence suggests that people who have difficulty with community transport and mobility
should have up to 7 sessions of community based ADL practice1
Community ADL practice can include: practice of crossing roads, visits to local shops,
completing shopping tasks and practice of money management, accessing public
transport.
Discussions regarding return to driving which can include information about modifications
available for motor bikes and cars in Vietnam which may be relevant for the person.

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4. Managing Complications
Typical complications of stroke include:
Spasticity
Contracture
Shoulder Subluxation
Pain
Swelling of Extremities
Loss of Cardio-Respiratory Fitness
Post Stroke Fatigue
Vision Problems
Cognition Problems including Behavioural/Emotional/Sexual/ Depression
Perception Problems
Communication Difficulties

4.1. Spasticity
Spasticity is one of the underlying causes of poor mobility, soft tissue contracture, pain (e.g. in
the shoulder) and muscle over activity. Spasticity post-stroke is basically a damaged brain not a
local muscular problem. It is caused by miscommunication from the brain due to a block of
messages between muscles and the brain.

Spasticity management is a 24 hour management involving the whole of the MDT.

The aim is to normalize muscle tone and encourage active functional movement. This can be
achieved using specific skills in handling, moving and positioning the patient.

What to do?
Therapy is effective in recovering function and mobility though there are a number of
‘approaches’ to spasticity management with conflicting reports as to which is the preferred.

Interventions to reduce spasticity should be considered when the level of spasticity interferes
with activity or the ability to provide care to the stroke survivor. This can include Clostridium
botulinum toxin type-A which may be considered for use to relieve spasticity following stroke
where it is causing pain or is severely interfering with physical function and the ability to maintain
hand hygiene[B]. Botulinum addresses the symptom of spasticity temporarily, not the cause.
Botulinum toxin type-A treatment has to be supported by active physiotherapy intervention.

Prevention of spasticity, using the neuroplasticity of the brain, is essential and strategies to help
prevention should be used as early as possible. Examples of such strategies are:
Encouraging normal movement and function
Reducing pain and discomfort

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 Reducing fear
Care when handling and moving the stroke survivor.

Note: Routine resting splints (especially for the upper limb) should not be applied for long
periods of time as often these may be ill fitting and uncomfortable causing pain which can then
lead to further spasticity[A].

4.2. Contractures
Contracture is a shortening of soft tissues that results in reduced joint range of motion (ROM)
due to impairments (e.g. weakness or spasticity) and poor sustained positioning. Particularly
common is loss of shoulder external rotation, elbow extension, forearm supination, wrist and
finger extension and thumb abduction, ankle dorsiflexion and hip internal rotation, all depending
on the prevailing synergistic pattern.

People with severe weakness are particularly at risk of developing contractures as any joint or
muscle not moved or lengthened regularly is at risk of soft tissue complications which eventually
will limit movement and may cause pain.

What to do?
Although it is considered that soft tissues must be lengthened to prevent contracture, the
most appropriate intervention to prevent or manage contracture is currently unclear with
expert opinion divided.
To ensure that range of motion is maintained, muscles at risk of shortening should be
monitored.
Conventional therapy (e.g. stretching, encouraging mobility, muscle strengthening) should
be provided for stroke survivors at risk of or who have developed contracture.
For stroke survivors at risk of or who have developed contractures and are undergoing
comprehensive rehabilitation, the routine use of splints or prolonged positioning of
muscles in a lengthened position is NOT recommended[A].
Overhead pulley exercise should NOT be used routinely to maintain range of motion of
the shoulder[B].
Serial casting can be used to reduce severe, persistent contracture when conventional
therapy has failed[GPP].

4.3. Shoulder Subluxation

Shoulder subluxation is often associated with shoulder pain and poor upper limb function.
Cause can be due to low tone or high muscle tone

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 Cause can be due to poor handling of the stroke survivor by health workers or
family/carers.

What to do?
Prevention of subluxation is paramount.
Stroke survivors with very low muscle tone and little or no active shoulder muscle
activity should be considered for subluxation prevention strategies.
Interventions aimed at reducing trauma to the shoulder, such as educating all staff,
carers and stroke survivors, should prevent the occurrence of shoulder subluxation and
pain resulting from weakness. Such education may include strategies to care for the
shoulder during manual handling and transfers and advice regarding supported
positioning. When the person is sitting or lying in bed, then upper limb support via tray
tables, pillows etc rather than a sling is preferred. A sling can be used for walking only
though other strategies such as keeping hand in pocket can also be equally as effective
and prevents encouraging the flexor contracture pattern that can develop.
For people with severe weakness who are at risk of developing a subluxed shoulder,
management should include one or more of the following interventions:
o Education and training for the patient, family/carer and clinical staff on how to
correctly handle and position the affected upper limb
o Electrical stimulation (to the supraspinatus and deltoid muscles)
o Firm support devices, e.g. a sling
For people who have developed a subluxed shoulder, management may include firm
support devices and handling techniques to prevent further subluxation.

Note: Patients with greater active shoulder motion have a lower incidence of subluxation.

4.4. Pain

4.4.1. Shoulder Pain

Stroke patients are particularly prone to pain. This is commonly in the hemiplegic shoulder, most
likely caused by multifactorial factors (e.g. low muscle tone, spasticity, immobility and poor
handling).

Shoulder pain contributes to an increase in spasticity, lack of upper limb recovery, sleeplessness,
depression and poor quality of life, as well as extended stay in hospital.

Age-related co-pathologies resulting from joint changes (e.g. osteoarthritis) can cause added
discomfort, particularly during handling and positioning procedures.

What to do?

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 Therapy is aimed at treating the pain and facilitating mobility. Management using
electrotherapy is not conclusive though strapping, cryotherapy and neurological therapy
techniques have reported to decrease the severity of shoulder pain[D].
Prevention of the pain is considered most important.
Investigate the cause and treat accordingly e.g. Electrotherapy, Cryotherapy and
Neurological handling techniques
Good positioning advice and care of the arm (in case of neglect)
Therapy to treat the pain and facilitate upper limb mobility
Education of staff, stroke survivor and family/carers on preventing trauma
Overhead pulleys as a treatment are not recommended[C].

4.4.2. Central Post Stroke Pain

Central post-stroke pain (CPSP) occurs in approximately 2–8% of stroke survivors and is a
superficial and unpleasant burning, lancinating, or pricking sensation, often made worse by
touch, water or movement.

What to do?
While the evidence for interventions for CPSP is inconclusive, a trial of different treatments
should be considered especially where CPSP interferes with functional tasks. These can include
transcutaneal electrical nerve stimulation (TENS), acupuncture, massage or psychological
interventions (e.g. desensitisation or cognitive behavioural therapy) have also been suggested
and can be considered prior to or concurrently with pain relief medication but evidence for these
is also limited[A].

Any stroke survivor whose CPSP is not controlled within a few weeks should be referred to a
specialist pain management team.

4.5. Swelling of the Extremities

People who are upright (standing or sitting) with their arm or leg hanging and immobile as a
result of weakness are at risk of developing swelling of the hand and foot.

What to do?
There is limited evidence existing for interventions to prevent and treat swelling.
Prevention is paramount. This is done by encouraging mobility, limb support and care of
limb (especially when there is neglect)
Dynamic pressure garments, electrical stimulation, continuous passive motion and
elevation of the limb when resting can also be tried C.
Education of the stroke survivor and their carer/family should be provided regarding:
Positioning
Active assisted and passive movement

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 Encouraging elevation of extremities to reduce swelling
In case of suspected DVT: follow treatment prescribed by the doctor.

4.6 Loss of Cardiorespiratory Fitness

Severe cardiovascular de-conditioning occurs as a result of the immobility imposed early after
stroke.

What to do?
Rehabilitation should include interventions aimed at increasing cardiorespiratory fitness
once patients have sufficient strength in the large lower limb muscle groups[A].
Patients should be encouraged to undertake regular, ongoing fitness training[B].
Assess people who are able to walk and are medically stable after their stroke for
cardiorespiratory and resistance training appropriate to their individual goals.
Cardiorespiratory and resistance training for people with stroke should be started by a
Physiotherapist with the aim that the person continues the programme independently
based on the physiotherapist's instructions.
For people with stroke who are continuing an exercise programme independently,
Physiotherapists should supply any necessary information about interventions and
adaptations so that where the person is using an exercise provider, the provider can
ensure their programme is safe and tailored to their needs and goals. This information
may take the form of written instructions, telephone conversations or a joint visit with the
provider and the person with stroke, depending on the needs and abilities of the exercise
provider and the person with stroke.
Tell people who are participating in fitness activities after stroke about common potential
problems, such as shoulder pain, and advise them to seek medical advice from their GP
or therapist if these occur.
The patient should undergo adequate medical testing (BP, etc.) before embarking on a
cardiorespiratory fitness program

4.7. Post Stroke Fatigue

Fatigue is defined here as abnormal (or pathological) fatigue which is characterised by weariness
unrelated to previous exertion levels and is usually not improved by rest.

The aetiology of fatigue after stroke is uncertain but it is a common long-term problem after
stroke.

Fatigue is significantly associated with limitation in conducting ADLs but commonly this
association is mostly related to depression.

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What to do?
There is insufficient evidence to recommend interventions for management of Post-
Stroke Fatigue. Health professionals should recognise patients with excess levels of
fatigue and provide information and practical strategies such as negotiating therapy times
and times for rest on a case-by-case basis.
Enforced rest periods should not be used[GPP].
Screen such clients for depression.
Stroke survivors and their families/carers should be provided with information and
education about fatigue including potential management strategies such as exercise,
establishing good sleep patterns, and avoidance of sedating drugs and excessive alcohol.

Note: The following chapters (4.8 – 4.12) contain important information on specific parts of a
comprehensive rehabilitation approach. Usually an OT or other specialized health worker will take
care of those parts of the treatment.

4.8. Vision Problems

For people with visual deficits, repetitive practice of remedial and compensatory activities should
be provided such as:
Scanning and tracking to improve oculomotor control
Practice reading skills, road safety, object identification and recognition, meaningful ADL
practice
Compensatory: scanning, prompts to turn face to the effected side, incorporate trunk
rotation
The PT should encourage family to provide verbal reminders to improve efficacy

4.9. Sexuality
The stroke survivor and their partner (where applicable) should be offered the opportunity to
discuss concerns regarding sexual issues. These may include: physical concerns regarding
capacity for engagement, positioning, environmental concerns, methods for self-stimulation and
the availability of assistive devices for use with or without a partner (available locally and
internationally). Sexual activity at middle or older age does not appear to be a risk factor for a
stroke or a recurrent stroke.

Where indicated (and appropriate) this conversation can be held with other members of the
MDT. For example, medical advice regarding available medications can be given by the doctor in
conjunction with advice from the therapist regarding safe positioning and activity endurance.

P a g e | 35
Other sexuality related concerns may require attention through discussion with health staff
including re-integration into society and basic exploration of managing and seeking relationships.

Ideally this would be supported by a Psychologist and where indicated, a Social Worker. The
topic of sexuality can often be sensitive and therefore appropriate precautions and preparations
should be taken into account e.g. gender of the stroke survivor and the therapist, age related
considerations, sexual orientation of the stroke survivor. Therapists and other health staff must
ensure that conversations are to remain confidential and the up most respect for the persons’
goals are maintained at all times.

4.10. Emotional Functioning

Assessment of emotional functioning in the context of cognitive impairment is indicated
Referral to the MDT psychologist, social worker and peer counselling service (where
available) for assessment is recommended[B]
Support and education for stroke survivors and their families regarding adjustment to
disability, recognizing that psychological needs may change over time and in different
settings is recommended
An MDT approach to support emotional functioning is recommended e.g. medical input to
assess the need for medication prescription and OT input to enable management of ADLs
in the context of changes in mood
Ongoing 6 monthly review of emotional functioning (where possible) by the appropriate
member of the MDT is recommended[A].

4.11. Perception Problems

These include neglect / inattention and agnosia and astereognosis.

4.11.1. Neglect/ Inattention

Simple cues to draw attention to the affected side
Manipulation of the affected side
Visual scanning training in addition to sensory stimulation of the affected side through
activity supported by structured feedback
Visual anchoring used as a cue
Scatter items across visual fields to encourage attention to affected side
Activities requiring both sides of body in the context of functional activities
Prism adaption may be prescribed by medical staff and be utilized as a tool for therapy
Eye patching may be prescribed by medical staff and utilized to enhance interventions
Mental imagery to enhance attention to and use of the neglected side

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4.11.2. Agnosia and Astereognosis
Brief compensatory interventions such as increasing the persons’ awareness of the deficit
can be useful
Compensatory strategies can be followed by training to recognize stimuli with the
remaining intact senses/perceptual abilities

4.12. Communication Problems

Aphasia is common, especially in stroke affecting the left hemisphere.
Dysarthria can greatly affect communication and quality of life. It is a motor speech
impairment of varying severity affecting the clarity of speech, voice quality / volume and
overall intelligibility. It is reported in 20-30% of stroke survivors.

What to do?
All stroke survivors should be screened for communication deficits using a screening tool
that is valid and reliable.
Aphasic and dysarthria patients should be referred for Speech Therapy.
If communication problems are present then the aim of rehabilitation is to help empower
the stroke survivor and provide communication strategies and links with the community
such as:
o Sharing information about how the person communicates so that people can
better understand and respond.
o Teaching words, phrases and gestures that are needed in order to be included in
community life
o Promoting skills in using assistive devices, such as hearing aids, communication
boards, assistive seating.
o Encouraging the person, family/carers and community members to use multiple
ways of communicating, such as gesture, facial expression, speaking, reading,
writing, drawing, using communication assistive devices.
The therapist should explain and discuss the nature of the impairment with the stroke
survivor’s family/carers and discuss and teach strategies or techniques which may
enhance communication.
Group therapy and conversation groups can be used for people with aphasia.
The mood of the stroke survivor should be monitored.

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5. Discharge and Follow-Up
Stroke is not only an acute condition, but is also causing lasting impairments, activity limitations
and participation restrictions. To best manage its wide-ranging physical, cognitive, and emotional
implications, stroke patients require an integrated continuum of rehabilitative care that is begun
in an acute hospital setting and actively follows and supports patients as they progress through
post acute and chronic rehabilitative phases.

Patients and their carers need to be prepared for the moment the patient leaves the hospital
returning to the home situation. Improvements in hospital discharge planning and procedures
can dramatically improve the outcome for patients as they move to the next level of care.
Patients, family caregivers, physiotherapists and other healthcare providers all play roles in this
transition process and maintaining a patient’s health after discharge.

In general, the basics of a physiotherapeutic discharge plan are:

Evaluation of the patient by physiotherapy personnel
Discussion with the patient and/or his representative
Planning for homecoming or transfer to another care facility
Determining whether extra caregiver training or other support is needed
Referrals to appropriate support organizations in the community
Arranging for follow-up appointments or tests

It also should include information on whether the patient’s condition is likely to improve; what
activities he or she might need help with; provision of information and instruction on how to help
and assist; information on what extra equipment might be needed, such as a wheelchair or other
assistive devices and how to use them adequately.

Effective discharge planning and proper instruction of the stroke survivor and the carer can
decrease the chances that a stroke survivor is readmitted to the hospital, and can also help in
promoting participation.

The caregiver’s role in the discharge process

The physiotherapist will not be familiar with all aspects of a stroke survivor’s situation. While a
caregiver may not be a medical expert, if (s)he has been a caregiver for a long time, (s)he
certainly knows a lot about the patient and about his/her own abilities to provide care and a safe
home setting.

The physiotherapist should discuss with the caregiver about the ability to provide care. Some of
the care might be quite complicated. It is essential that carers get any training they need in
special care techniques, such as prevention of pressure sores, therapeutic positioning,
transferring someone from bed to chair or assisting with activities like walking. Educational
materials must be provided in an easily to understand language.

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If the patient is being discharged to a rehab facility, effective transition planning should ensure
continuity of care and clarify the current state of the patient’s health and capabilities.

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References
American Heart Association/American Stroke Association. (2016). Guidelines for Adult Stroke
Rehabilitation and Recovery: A Guideline for Healthcare Professionals. Retrieved from:
http://pmr.med.umich.edu/sites/default/files/aha-asa_stroke_ rehab_ clinical
_practice_guidelines_2016.pdf

Clin J. (1988) The World Health Organization MONICA Project (Monitoring trends and
determinants in cardiovascular disease). Epidemiol 41, 105-114.

Hacke et al. (2002). European Stroke Initiative http://www.congrex-

switzerland.com/fileadmin/files/2013/eso-stroke/pdf/EUSI2003_Cerebrovasc_Dis.pdf

Hurn J, Kneebone I, Cropley M. Goal setting as an outcome measure: A systematic review.

Clinical Rehabilitation 2006;20(9):756-72

KNGF (2014) Guideline Stroke. Retrievevd from: http://neurorehab.nl/wp-

content/uploads/2012/03/stroke_practice_guidelines_2014.pdf

MoH (2014) Decision to approve the National Action Plan on Rehabilitation Development Period
2014 – 2020 (Hanoi. 6 October 2014) (VN: 4039_QD-BYT_Ke hoach quoc gia PHCN)

National Institute for health and Care Excellence (NICE). (2013).Stroke rehabilitation: Long term
rehabilitation after stroke. Retrieved from: https://www.nice.org.uk/guidance/cg16
2/evidence/full-guideline-190076509

National Stroke Foundation Australia. (2010). Clinical Guidelines for Stroke Management.
Retrieved from: http://www.pedro.org.au/wp-content/uploads/CPG_stroke.pdf

NICE (2013) Stroke rehabilitation in adults. Retrieved from:

https://www.nice.org.uk/guidance/cg162

Scottish Intercollegiate Guidelines Network (SIGN). (2008) Management of patients with stroke
or TIA: assessment, investigation, immediate management and secondary prevention.
http://www.sign.ac.uk/guidelines/fulltext/108/index.html

Warlow CP, Dennis MS, van Gijn J, Hankey GJ, Sandercock PAG, Bamford JM, Wadlaw JM
(2001) Stroke: A Practical guide to management. ISBN: 978-1-4051-2766-0

WCPT. (2017) Policy statement: Description of physical therapy. (http://www.wcpt.org/policy/ps-

descriptionPT. Access date 31-03-2017))

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WHO/World Bank. (2011) World Report on Disability.
http://www.who.int/disabilities/world_report/2011/report.pdf

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Annexes

1. Rehabilitation Risk Assessment

2. Goal attainment scale (GAS)

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Disclaimer
Healthcare professionals are expected to take the present clinical guidelines fully into account
when exercising their clinical judgment. However, the guidance does not override the
responsibility of healthcare professionals to make decisions appropriate to the circumstances of
each patient, in consultation with the patient and/or their guardian or carer.

Copyright
Humanity & Inclusion

This publication may be used or reproduced for non-commercial uses only, on condition that the
source is cited.

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