21482158 Physiotherapy Practice Guidelines for Stroke Rehabilitation

Physiotherapy Practice Guidelines for Stroke Rehabilitation PTCOC May 2000 ii Preface Physiotherapy has been advocated in the management of stroke patients as an integral and important essence. (AHCPR 1995, RCP 1998 and SIGN 1998). As a responsible and proactive profession, we are constantly striving to upgrade the quality standard of our care; to broaden the scope of our service and to optimise the efficiency of our treatment. Within these framework, it is essential to develop an acceptable set of standards in this area of specialism. This document is developed from the standards recommended by AHCPR, RCP, SIGN and the physiotherapy service standard in Neurology 1998. It is intended that this Physiotherapy Practice Guidelines booklet will be used throughout the HA hospitals and organizations to assure quality of care in the management of stroke patients. We hope that through the awareness and process of quality management the profession can be excelled towards the summit of excellence. This document will be reviewed in one year. Members of the PPG working group: George Au (co-ordinator) Raymond Lo Elsy Chan Robin Tsim Harold Ng Cedric Chow Hazel Ip Mabel Yu CMC POH RH OLMH CMC CMC CMC CMC iii TABLE OF CONTENTS I. Goals of Guidelines Page 1 1 1 1 2 2 4 5 9 23 25 27 30 31 40 II. Epidemiology of Stroke A. Definition B. Incidence C. Classification III. Physiotherapy Management in Stroke Rehabilitation A. Goals of Physiotherapy B. Assessment C. Interventions D. Outcome E. Discharge F. Community G. Service Evaluation III. IV. References Appendices 1 I. Goals of Guidelines The goals of developing the physiotherapy practice guidelines for stroke are to provide evidence-based supports to physiotherapy practice in stroke management within the H.A. It is an exercise of literature search evaluation on related practice and aims to cover common physiotherapy assessment and treatment interventions used and studied in the field. There are several evidence-based clinical practice guidelines available providing management stroke condition (AHCPR, 1995; National Clinical Guideline for Stroke, RCP 1998; SIGN, 1998). Although these documents are not physiotherapy specific, they form the cornerstone of the overall management model. II. Epidemiology of Stroke A. Definition Stroke, also known as cerebro-vascular accident (CVA), is an acute disturbance of focal or global cerebral function with signs and syndromes lasting more than 24 hours or leading to death presumably of vascular origin (World Health Organization, 1989). B. Incidence In United States, the incidence of stroke is approximately 550,000 new cases annually, leaving 300,000 with disability (Stineman, 1997). An estimate of 30 billion of US dollars was spent on the direct medical cost (17 billion) and indirect cost (13 billion) due to productivity loss in 1993. In United Kingdom, the incidence rate is 1.7 to 2.0 per 1,000 population per year (Riddoch, 1995). It is reported that the incidence rate in China is 219 per 100,000 population per year from a 1982 survey (Kay, 1993). In Hong Kong, the exact incidence of stroke is unknown as no community-based study was ever done. However, Hong Kong Hospital Authority has reported that there is about 20,000 of stroke patients admitted into the public hospitals for the stroke condition annually and about 3000 of them were dead in their annual statistical report (HKHA, 1997). Stroke is now the fourth leading cause of death in Hong Kong and has been identified as one of the ten priority health areas by Hospital Authority (Ho, 2000). 2 C. Classification Stroke can be classified into haemorrhagic or ischemic in origin. The common causes of brain haemorrhage include uncontrolled hypertension, ruptured aneurysm, arteriovenous malformation, cavernous angioma, drug abuse with cocaine, anticoagulant therapy and brain tumor. Ischaemic stroke is related to thrombotic, embolic or haemodynamic factors. Two hospital-based studies have been conducted in Hong Kong and published in the Stroke journal (Huang, Chan, Yu, Woo, and Chin, 1992) and in the Neurology journal (Kay, Woo, Kreel, Wong, Teoh, and Nicholls, 1992). In these two studies, 86% and 96% of the entire stroke patients admitted respectively received CT scanning of brain. Both studies clearly established that cerebral haemorrhage constituted about 30% of all stroke occurring in Hong Kong Chinese. This proportion is significantly different from those found in Caucasian populations constituting approximately 10% of all strokes. According to the Bamford study in 1991, ischaemic stroke can be further classified clinically into total anterior circulation infarcts (TACI), partial anterior circulation infarcts (PACI), posterior circulation infarcts (POCI) and lacunar infarcts (LACI) (Appendix 2). III. Physiotherapy management in stroke rehabilitation Physiotherapy plays an important role in the process of stroke rehabilitation. As a part of the interdisciplinary team, physiotherapists work in concert with the managing doctor and other rehabilitation specialists to provide stroke patients with a comprehensive rehabilitation program. The physiotherapy stroke rehabilitation program involves a dynamic process of assessment, goal-setting, treatment and evaluation; its coverage spans from the acute stage, through the rehabilitation stage, to the community stage. The whole rehabilitation program is predicated on two general components. The first includes preventive measure targeted at maintaining physical integrity and minimizing complications that will prevent or prolong functional return. These measures should begin immediately poststroke and continue as long as necessary. The second component is restorative treatment aimed at promoting functional recovery. This phase should begin as soon as the patient is medically and neurologically stable and has the cognitive and physical ability to participate actively in a rehabilitation program. In brief, the aims of physiotherapy interventions are to promote motor recovery, optimize sensory functions, enhance functional independence, and prevent secondary complications. 3 Recommendations: Assessments Clinicians should use assessments or measures appropriate to the needs (i.e., to help make a clinical decision). (Level of evidence = IV, Recommendation = Grade C) Where possible and available, clinicians should use assessments or measures that have been studied in terms of validity and reliability. (Level of evidence = IV, Recommendation = Grade C) Routine assessments should be minimised, and each considered critically. (Level of evidence = IV, Recommendation = Grade C) Patients should be reassessed at appropriate intervals. (Level of evidence = IV, Recommendation = Grade C) Teamwork All members of the healthcare team should work together with the patient and family, using an agreed therapeutic approach (Stroke Unit Trialists' Collaboration, 1998). (Level of evidence = III, Recommendation = Grade B) All staff should be trained to place patients in positions to reduce the risk of complications such as contractures, respiratory complications and pressure sores. (Carr and Kenney, 192; Lincoln et al., 1996). (Level of evidence = III, Recommendation = Grade B) Goal setting Goals should be meaningful, challenging but achievable (Bar-Eli et al., 1994, 1997; VanVliet et al., 1995) (Level of evidence = III, Recommendation = Grade B), and there should be both short- and long-term goals. (Level of evidence = IV, Recommendation = Grade C) Goal setting should involve the patient (Blair,1995; Blair et al., 1995; Glasgow et al., 1996) (Level of evidence = III, Recommendation = Grade B), and the family if appropriate. (Level of evidence = IV, Recommendation = Grade C) Therapy approach / interventions Any of the current exercise therapies should be practised within a neurological framework to improve any patient function. (Basmajian et al., 1987; Jongbloed et al., 1989; Richards et al., 1993; Nelson et al., 1996; Dean & Shepherd, 1997). (Level of evidence = Ib, Recommendation = Grade A) Intensity / duration of therapy Patients should see a therapist each working day if possible. (Rapoport and Eerd, 1989). (Level of evidence = IIb, Recommendation = Grade B) 4 While they need therapy, patients should receive as much as can be given and they find tolerable. (Kwakkel et al., 1997, 1999; Lincoln, 1999; Parry et al., 1999). (Level of evidence = Ia, Recommendation = Grade A) Patients should be given as much opportunity as possible to practise skills. (Smith et al., 1981; Langhorne et al., 1996). (Level of evidence = Ia, Recommendation = Grade A) A. Goals of Physiotherapy According to AHCPR, SIGN, RCP, management of stroke patients begins as the acute care during acute hospitalization and continues as rehabilitative care as soon as patient’s medical & neurological status has stabilized. Moreover, community reintegration of patients continues during the community care stage (AHCPR, 95). 1. Acute Care Aims : 1) Prevent recurrent stroke 2) Monitor vital signs, dysphasia adequate nutrition, bladder & bowel function. 3) Prevent complications 4) Mobilize the patient 5) Encourage resumption of self-care activities 6) Provide emotional support & education for patient & family 7) Screen for rehabilitation and choice of settings 2. Rehabilitation care Aims : 1) Set rehabilitation goals; develop rehabilitation plan and monitor progress 2) Manage sensori-motor deficits 3) Improve functional mobility & independence 4) Prevent & treat complications 5) Monitor functional health conditions 6) Discharge planning (safe residence recommendation, patient & caregivers education & continuity of care) 7) Community – reintegration 5 3. Community care Aims : 1) Assist patient to reintegrate into community 2) Enhance family and caregivers functioning 3) Co-ordinate continuity of patient care. 4) Promote health and safety and prevent further hospitalization 5) Give advice on community supports, valued activities and vocational reintegrate B. Assessment The objectives of assessment are to (AHCPR, 1995): - document the diagnosis of stroke, its etiology, area of the brain involved, and clinical manifestations. - identify treatment needs during the acute phase. - identify patients who are most likely to benefit from rehabilitation. - select the appropriate type of rehabilitation setting. - provide the basis for creating a rehabilitation treatment plan. - monitor progress during rehabilitation and facilitate discharge planning. - monitor progress after return to a community residence. 1. Timing There is a strong correlation between poor outcome and delay in acute medical care and rehabilitation care. It is expected to start rehabilitation as soon as possible. Screening for post-stroke rehabilitation is performed when the patient is medically and neurologically stable. The initial physiotherapy assessment forms the basis of treatment planning, permitting goals to be set in conjunction with the patient, carer and other members of the multidisciplinary team. The assessment allows the selection of the most appropriate intervention strategies to resolve problems and achieve goals. A complete baseline assessment by physiotherapists should be completed for patients within 3 working days after admission to an rehabilitation program in an inpatient rehabilitation setting or within three visits for an outpatient or home rehabilitation program (AHCPR,1995). All information should be fully documented in the patient record. 6 Recommendation: • A baseline assessment by physiotherapists should be completed for patients within 3 working days after joining an inpatient rehabilitation program or within three visits for an outpatient or home rehabilitation program (Level of evidence = IV, Recommendation = Grade C). 2. Stages of assessment Assessment begins at the time of admission to acute care hospital. Screening for poststroke rehabilitation for patient who is medically and neurologically stable. Baseline assessment at time of admission to a rehabilitation program. Finally, periodic reassessment during rehabilitation documents progress and provides the information needed to adjust treatment and eventually to plan for discharge or transfer to another type of rehabilitation setting. After discharge from rehabilitation setting, assessment is performed to monitor adaptation to a community residence and maintenance of functional gains made during rehabilitation. Recommendations: • • Periodic assessment should be done. (Level of evidence = IV, Recommendation = Grade C) Screening for possible admission to a rehabilitation program should be performed as soon as the patient's neurological and medical conditions permit. (Level of evidence = IV, Recommendation = Grade C) 3. Principles of assessment Problems of patients can be assessed according to the ICIDH-2 model of disablement. There are four dimensions represented in the ICIDH-2, three levels of functioning and contextual factors. The three levels of functioning (at the body, person and social levels) in interaction with contextual factors yield as outcomes either positive or negative levels of functioning, and both can be classified in the ICIDH2. The negative levels of functioning are the three kinds of disablement: impairments, activity limitations and participation restrictions. 7 Contexual Factors at body level at person level at social level Functioning in interaction with environmental factors and personal factors Person’s daily Involvement in the Features of the Characteristics Body function Body structure activities situation physical, social attitudinal world and Activity Participation Facilitators Positive Aspect Functional structural integrity Activity limitation Participation Barriers Negative Aspect Impairment restriction 4. Contents Physiotherapy assessment includes: a) Patient characteristics Impairments Activities Participation         Demographics (age, gender). History of illness. Prior activity level (low to very high). Prior socialization (isolated to outgoing). Expectations regarding stroke outcomes and need for assistance. b) Family and caregiver characteristics Members of household and relationship to patient. Other potential caregivers. Capacity to provide physical, emotional, instrumental support. c) Impairments e.g. speech, seeing, tone, muscle strength, balance, and co-ordination. d) Activities e.g. communication, movement, use of assistive devices and technical aids. e) Participation e.g. mobility, personal maintenance, social relationships, work, leisure, hobby, economic life f) Environment factors e.g. personal support and assistance, social and economic institutions, physical environment such as access to building and key facilities within living quarters, safety considerations, access to resources and activities in community. 8 Recommendation: • The contents of assessment should include patient characteristics, family and caregiver characteristics, impairments domain, activities domain, participation domain, and environment domain (Level of evidence = IV, Recommendation = Grade C). 5. Special consideration Shoulder assessment Shoulder subluxation and pain is a major and frequent complication in patients with hemiplegia. (Joynt, 1992; Grossen-Sils, and Schenkman, 1985). As many as 80% of patients with cerebrovascular accident has been reported to show shoulder subluxation. Clinical examination of shoulder should include thorough evaluation of pain , range of movement, motor control, and shoulder subluxation. Recommendation: • Shoulder assessment should be done in the initial assessment (Level of evidence = IV, Recommendation = Grade C). 6. Setting rehabilitation goals Both short-term and long- term goals need to be realistic in terms of current levels of disability and the potential for recovery. Goals should be mutually agreed to by the patient, family, and rehabilitation team and should be documented in the medical record in explicit, measurable terms. (Level of evidence = IV, Recommendation = Grade C). 7. Developing the rehabilitation management plan The rehabilitation management plan should indicate the specific treatments planned and their sequence, intensity, frequency, and expected duration. Measures to prevent complications of stroke and recurrent strokes should be continued. (Level of evidence = IV, Recommendation = Grade C). 9 C. Interventions 1. Improving motor control a. Neurofacilitatory Techniques These therapeutic interventions use sensory stimuli (e.g. quick stretch, brushing, reflex stimulation and associated reactions) ,which are based on neurological theories, to facilitate movement in patients following stroke (Duncan,1997). The following are the different approaches: - i. Bobath Berta & Karel Bobath’s approach focuses to control responses from damaged postural reflex mechanism. Emphasis is placed on affected inputs facilitation and normal movement patterns (Bobath, 1990). ii. Brunnstrom Brunnstrom approach is one form of neurological exercise therapy in the rehabilitation of stroke patients. The relative effectiveness of Neuro-developmental treatment (N.D.T.) versus the Brunnstrom method was studied by Wagenaar and colleagues (1990) from the perspective of the functional recovery of stroke patients. The result of this study showed no clear differences in the effectiveness between the two methods within the framework of functional recovery. iii. Rood Emphasise the use of activities in developmental sequences, sensation stimulation and muscle work classification. Cutaneous stimuli such as icing, tapping and brushing are employed to facilitate activities (Goff, 1969). iv. Proprioceptive neuromuscular facilitation (PNF) Developed by Knott and Voss, they advocated the use of peripheral inputs as stretch and resisted movement to reinforce existing motor response (Kidd et al., 1992). Total patterns of movement are used in treatment and are followed in a developmental sequence. It was shown that the commutative effect of PNF is beneficial to stroke patient (Wong, 1994). Comparing the effectiveness of PNF, Bobath approach and traditional exercise, Dickstein et al (1986) demonstrated that no one approach is superior to the rest of the others (AHCPR, 1995). 10 b. Learning theory approach i. Conductive education Conductive education is one of the methods in treating neurological conditions including hemiplegic patients. Cotton and Kinsman (1984) demonstrated a neuropsychological approach using the concept of CE for adult hemiplegia. The patient is taught how to guide his movements towards each task-part of the task by using his own speech - rhythmical intention. ii. Motor relearning theory Carr & Shepherd, both are Australian physiotherapists, developed this approach in 1980. It emphasises the practice of functional tasks and importance of relearning real-life activities for patients. Principles of learning and biomechanical analysis of movements and tasks are important. (Carr and Shepherd, 1987) There is no evidence adequately supporting the superiority of one type of exercise approaches over another. However, the aim of therapeutic approach is to increase physical independence and to facilitate the motor control of skill acquisition and there is strong evidence to support the effect of rehabilitation in terms of improved functional independence and reduced mortality. Recommendation: • Physiotherapists with expertise in neuro-disabilty should co-ordinate therapy to improve movement performance of patients with stroke (AHCPR, 1995). (Level of Evidence = IV, Recommendation = Grade C) c. Functional electrical stimulation (FES) FES is a modality that applied a short burst of electrical current to the hemiplegic muscle or nerve. FES has been demonstrated to be beneficial to restore motor control, spasticity, and reduction of hemiplegic shoulder pain and subluxation. It is concluded that FES can enhance the upper extremity motor recovery of acute stroke patient (Chae et al., 1998; Faghri et al., 1994; Francisco, 1998). Alfieri (1982) and Levin et al (1992) suggested that FES could reduce spasticity in stroke patient. A recent meta- analysis of randomized controlled trial study showed that FES improves motor strength (Glanz 1996). Study by Faghri et al (1994) have identified that FES can significantly improve arm function, electromygraphic activity of posterior deltoid, range of motion and reduction of severity of subluxation and pain of hemiplegic shoulder. 11 Recommendations: • • Functional electrical stimulation should not be used as a routine after stroke (RCP, 1998). (Level of evidence = Ib, Recommendation = Grade A) FES should be considered in improving upper extremities functional (Faghri et al., 1994), (Level of evidence = Ib, Recommendation = Grade A), strength (Glanz, 1996) (Level of evidence = Ia, Recommendation = Grade A), reduction of hemiplegic shoulder pain and subluxations (Faghri et al.,1994) (Level of evidence = Ib, Recommendation = Grade A) and motor recovery (Chae et al.,1998), (Level of evidence = Ib, Recommendation = Grade A), (Franciso, 1998), (Level of evidence = Ib, Recommendation = Grade A); (Faghri et al., 1994) (Level of evidence = Ib, Recommendation = Grade A). d. Biofeedback Biofeedback is a modality that facilitates the cognizant of electromyographic activity in selected muscle or awareness of joint position sense via visual or auditory cues. The result of studies in biofeedback is controversial. A meta-analysis of 8 randomized controlled trials of biofeedback therapy demonstrated that electromyographic biofeedback could improve motor function in stroke patient (Schleenbaker, 1993). Another meta-analysis study on EMG has showed that EMG biofeedbcak is superior to conventional therapy alone for improving ankle dorsiflexion muscle strength (Moreland et al., 1998. Erbil and co-workers (1996) showed that biofeedback could improve earlier postural control to improve impaired sitting balance. Conflicting meta-analysis study by Glanz et al (1995) showing that biofeedback was not efficacious in improving range of motion in ankle and shoulder in stroke patient. Moreland (1994) conducted another meta-analysis concluded that EMG biofeedback alone or with conventional therapy did not superior to conventional physical therapy in improving upperextremity function in adult stroke patient. Recommendations: • • Biofeedback should not be used on a routine basis (RPC, 1998). (Level of evidence = Ia, Recommendation = Grade A) Biofeedback should be considered as an additional therapy in sitting balance retraining. (Level of evidence = IIa, Recommendation = Grade B) 12 (2) Hemiplegic shoulder management Shoulder subluxation and pain of the affected arm is not uncommon in at least 30% of all patient after stroke (RCP, 1998) ,whereas subluxation is found in 80% of stroke patients (Najenson et al., 1971). It is associated with severity of disability and is common in patients in rehabilitation setting. Suggested interventions are as follows: a) Exercise Active weight bearing exercise can be used as a means of improving motor control of the affected arm; introducing and grading tactile, proprioceptive, and kinesthetic stimulation; and preventing edema and pain. Upper extremity weight bearing can be used to lengthen or inhibit tight or spastic muscles while simultaneously facilitating muscles that are not active (Donatelli, 1991) (Level of evidence = IV, Recommendation = Grade C). According to Robert (1992), the amount of shoulder pain in hemipelgia was related most to loss of motion. He advocated that the provision of ROM exercise (caution to avoid imprigement) as treatment as early as possible. AHCPR (1995) recommended ROM exercise should not carry the shoulder beyond 900 of flexor and abduction unless there is upward rotation of scapular and external rotation of the humeral head. Recommendation: • Range of motion exercise should carry out as early as possible and caution to avoid excessive shoulder flexion (Level of evidence = III, Recommendation = Grade B). b) Functional electrical stimulation Functional electrical stimulation (FES) is an increasingly popular treatment for the hemiplegic stroke patient. It has been applied in stroke rehabilitation for the treatment of shoulder subluxation (Faghri et al.,1994), spasticity (Stefanovska et al., 1991) and functionally, for the restoration of function in the upper and lower limb (Kralji et al., 1993). Electrical stimulation is effective in reducing pain and severity of subluxation, and possibly in facilitating recovery of arm function (Faghri, et al., 1994; Linn, et al., 1999). Recommendation: • Functional electrical stimulation should be used to prevent shoulder pain and subluxation ( Faghri et al.,1994). (Level of evidence = Ib, Recommendation = Grade A) 13 c) Positioning & proper handling Proper positioning and handling of hemiplegic shoulder, whenever in bed, sitting and standing or during lifting, can prevent shoulder injury is recommended in the AHCPR & SIGN guidelines for stroke rehabilitation. Moreover, positioning can be therapeutic for tone control and neuro-facilitation of stroke patients (Davies, 1991). Braus et al 94 found shoulder hand syndrome reduced from 27% to 8% by instruction to every one including family on handling technique. Recommendations : • • • Positioning can be used to prevent shoulder pain and subluxation. (Level of evidence =IV, Recommendation = Grade C) Education on staff & carers on correct handling of hemiplegic arms. (Level of evidence = III, Recommendation = Grade B) All staff involved in rehabilitation should be trained by a named senior physiotherapist in techniques of handling and positioning to prevent the onset of painful shoulder (SIGN, 1998). (Level of evidence = IV, Recommendation = Grade C) • The prevention of shoulder injuries should emphasize proper positioning and support and avoidance of overly vigorous range-of-motion exercise (AHCPR, 1995). (Level of evidence = IV, Recommendation = Grade C) d) Neuro-facilitation Recommendations: • Based on the Bobath's approach, muscle tone that stabalises the shoulder can be facilitated and shoulder movement patterns, especially the scapula movements, can be enhanced by the various Bobath's techniques. • Shoulder subluxation can then be reduced and development of painful shoulder can be prevented (Davies, 1991). (Level of evidence = IV, Recommendation = Grade C) Brunnstrom advocated the activation of the cuff muscles of shoulder, especially the supraspinatus to prevent the subluxation of shoulder (Kathryn, 1992). (Level of evidence = IV, Recommendation = Grade C) e) Passive limb physiotherapy Maintenance of full pain-free range of movement without traumatising the joint and the structures can be carried out. At no time should pain in or around the shoulder joint be produced during treatment. (Davies, 1991). 14 Recommendation : • Range-of-motion exercises should not carry the shoulder beyond 90 degrees of flexion and abduction unless there is upward rotation of scapula and external rotation of the humeral head. (AHCPR, 1995). (Level of evidence = IV, Recommendation = Grade C) f) Pain relief physiotherapy Passive mobilisation as described by Maitland, can be useful in gaining relief of pain and range of movement (Davies, 1991). Other treatment modalities such as thermal, electrical, cryotherapy etc. can be applied for shoulder pains of musculoskeletal in nature. Recommendation : • Leandri et al. (1990) found high intensity TENS led to prolonged pain relief and increase ROM of hemiplegic shoulder. High intensity TENS should used to treat shoulder pain. (Level of evidence = Ib, Recommendation = Grade A) G) Reciprocal pulley/ OP The use of reciprocal pulley appears to increase risk of developing shoulder pain in stroke patients. It is not related to the presence of subluxation or to muscle strength. (Kumar et al., 1990) Recommendation : • Avoid the use of overhead pulley to prevent shoulder injury and pain. (Level of evidence = Ib, Recommendation = Grade A) H) Sling The use of sling is controversial. No shoulder support will correct glenohumeral joint subluxation. However, it may prevent the flaccid arm from hanging against the body during functional activities, thus decreasing shoulder joint pain. They also help to relieve downward traction on the shoulder capsule caused by the weight of the arm (Hurd, Farrell, and Waylonis, 1974 ; Donatelli ,1991). Recommendation : • Shoulder sling should not be used as routine. (Level of evidence = III, Recommendation = Grade B) 15 (3) Limb physiotherapy Limb physiotherapy includes passive, assisted-active and active range-of-motion exercise for the hemiplegic limbs. This can be an effective management for prevention of limb contractures and spasticity and is recommended within AHCPR (1995). Self-assisted limb exercise is effective for reducing spasticity and shoulder protection (Davis, 1991). Adams and coworkers (1994) recommended passive full-range-of-motion exercise for parlysed limb for potential reduction of complication for stroke patients. Recommendation : • Limb physiotherapy should be performed for prevention of contractures and spasticity of hemiplegia limbs (AHCPR, 1995). (Level of evidence = IV, Recommendation = Grade C) (4) Chest physiotherapy Evidence shows that both cough and forced expiratory technique (FET) can eliminate induced radioaerosol particles in lung field. Directed coughing and FET can be used as a technique for bronchial hygiene clearance in stroke patient. Recommendation • Directed coughing can maintain the bronchial hygiene clearance in stroke patients. (Bennet, 1981; Hasani et al., 1991). (Level of evidence = II, Recommendation = Grade B) (5) Positioning Consistent “reflex-inhibitory” patterns of posture in resting is encouraged to discourage physical complication of stroke and to improve recovery (Bobath, 1990). Meanwhile, therapeutic positioning is a widely advocated strategy to discourage the development of abnormal tone, contractures, pain and respiratory complications. It is an important element in maximizing the patient's functional gains and quality of life. Recommendation : • Physiotherapists should position patients to minimize the risk of complications such as contractures, respiratory complication, shoulder pain & pressure sores (RCP, 1998). (Level of evidence = IV, Recommendation = Grade C) 16 (6) Tone management A goal of physical therapy interventions has been to “normalize tone to normalize movement.” Therapy modalities for reducing tone include stretching, prolonged stretching, passive manipulation by therapists, weight bearing, ice, contraction of muscles antagonistic to spastic muscles, splinting, and casting. Research on tone-reducing techniques has been hampered by the inadequacies of methods to measure spasticity (Knutsson and Martensson, 1980) and the uncertainty about the relationship between spasticity and volitional motor control (Knutsson and Martensson, 1980; Sahrmann and Norton, 1977). Manual stretch of finger muscles, pressure splints, and dantrolene sodium do not produce apparent long-term improvement in motor control (Carey, 1990; Katrak, Cole, Poulus, and McCauley, 1992; Poole, Whitney, Hangeland, and Baker, 1990). Dorsal resting hand splints reduced spasticity more than volar splints, but the effect on motor control is uncertain (Charait, 1968) while TENS stimulation showed improvement for chronic spasticity of lower extremities (Hui-Chan and Levin, 1992). Recommendation: • Electrical Stimulation could be used for tone management (Level of evidence = Ia, Recommendation = Grade A) (7) Sensory re-education Bobath and other therapy approaches recommend the use of sensory stimulation to promote sensory recovery of stroke patients. Recommendation: • Yekutiel et al (1993) had demonstrated in a controlled study that statistically significant improvement in sensory recovery after 6 weeks of sensory retraining. (Level of evdence = IIa, Recommendation = Grade B) 8. Balance retraining Reestablishment of balance function in patients following stroke has been advocated as an essential component in the practice of physiotherapy (Nichols, 1997). Some studies of patients with hemiparesis revealed that these patients have greater amount of postural sway, asymmetry with greater weight on the non-paretic leg, and a decreased ability to move within a weight-bearing posture (Dickstein, Nissan, Pillar, and Scheer, 1984; Horak, Esselman, Anderson, and Lynch, 1984). Meanwhile, research has demonstrated moderate relationships between balance function and parameters such as gait speed, independence, wheelchair mobility, reaching, as well as dressing 17 (Dickstein et al., 1984; Horak et al., 1984; Bohannon, 1987; Fishman, Nichols, Colby, and Sachs, 1996; Liston and Brouwer, 1996; Nichols, Miller, Colby and Pease, 1996). Some tenable support on the effectiveness of treatment of disturbed balance can be found in studies comparing effects of balance retraining plus physiotherapy treatment and physiotherapy treatment alone. Recommendations: • Improvement in weight distribution of lower limbs, or better standing symmetry, has been demonstrated in study of Winstein and coworkers (1989) (Level of evidence = IIa, Recommendation = Grade B) and that of Shumway-Cook and colleagues (1988). (Level of evidence = Ib, Recommendation = Grade A). • Moreover, some researchers found that not only the standing symmetry but also the stance stability are improved after balance retraining (Hocherman, Dickstein, and Pillar, 1984). (Level of evidence = IIa, Recommendation = Grade B) 9. Fall prevention Falls are one of the most frequent complications in stroke rehabilitation ( Dromerick and Reading, 1994), and the consequences of which are likely to have a negative effect on the rehabilitation process and its outcome. According to the systematic review of the Cochrane Library (1999), which evaluated the effectiveness of several fall prevention interventions in the elderly, there was significant protection against falling from interventions which targeted multiple, identified, risk factors in individual patients (odds ratio 0.77; 95% CI 0.64 to 0.91). The same is true for interventions which focused on behavioural interventions targeting environmental hazards plus other risk factors (odds ratio 0.81; 95% CI 0.71 to 0.93). The effect of the exercise component in fall prevention was also evaluated in that systematic review. Based on the analysis of four trials, exercise alone did not establish protection against falling (odds ratio 1.05; 95% CI 0.74 to 1.48). (Level of evidence = Ib, Recommendation = Grade A) Likewise, there was also no evidence to support exercise in conjunction with health education classes for the prevention of falls (odds ratio 1.72; 95% CI 0.78 to 3.75) (Level of evidence = Ib, Recommendation = Grade A). Despite having such non-significant findings, the results have to be viewed with caution given the variation in the participants and in the research methodology of these clinical trials. 18 Recommendations: • It is concluded that an effective fall prevention programme should consist of a health screening of at risk elderly people, followed by interventions which are targeted at both intrinsic and environmental risk factors of individual patients. (Level of evidence = Ib, Recommendation = Grade A) (10) Gait re-education Recovery of independent mobility is an important goal for the immobile patient, and much therapy is devoted to gait-reeducation. Bobath assume abnormal postural reflex activity is caused of dysfunction so gait training involved tone normalization and preparatory activity for gait activity. In contrast Carr and Shepherd advocates task-related training with methods to increase strength, coordination and flexible MS system to develop skill in walking while Treadmill training combined with use of suspension tube. Some patient’s body weight can effective in regaining walking ability, when used as an adjunct to convention therapy 3 months after active training (Visintin et al., 1998; Wall and Tunbal 1987; Richards et al., 1993). Recommendations : • Treadmill training with partial (