Guide to Stroke Rehabilitation for Healthcare Professionals

Expert Committee on Medical Rehabilitation

Sri Lanka Medical Association

ii
 Cover Page and Illustrations:

Dr M Ladsiyan
MBBS (University of Jaffna)
Pre-intern Demonstrator

Editor:

Dr Ajini Arasalingam
MBBS(Col), MD(Med)(Col), MRCP(UK),
FRCP(Edin), FRCP (Lond), FCCP, FACP
Senior Lecturer in Medicine & Consultant Neurologist
Faculty of Medicine
University of Jaffna
Sri Lanka.

iii
 Advisory board

Dr Padma S Gunaratne Dr Gunendrika Kasthuriratne

MBBS, MD(SL), FRCP(Edin, Glasg, MBBS, MD(Med)(Col)
Lond), FCCP, Consutant in Rheumatology &
Hon FRACP, FAAN, FWSO Rehabilitation
Consultant Neurologist National Hospital
President Sri Lanka Medical Sri Lanka.
Association
Dr Ajini Arasalingam
Dr Champika Gunawardhana MBBS(Col), MD(Med)(Col),
MBBS(Col), MD(Med)(Col), MRCP(UK), FRCP(Edin), FRCP (Lond),
MRCP(UK), FCCP, FACP
MRCP- SCE Neuro (UK), MRCP(Lond) Senior Lecturer in Medicine &
Consultant Neurologist Consultant Neurologist
Teaching Hospital Ratnapura Faculty of Medicine
University of Jaffna
Dr Harsha Gunasekara Sri Lanka.
MBBS, MD(Med)(Col), MRCP(UK),
FRCP, FCCP Dr Shiromi Maduawage
Consultant Neurologist MBBS, MSc, MD(Community
Sri Jayewardenepura General Medicine)
Hospital Consultant Community Physician,
Sri Lanka. Ministry of Health

Dr Senaka Bandusena Mrs.M.B.C. Samanmalie

MBBS, MD(Med)(Col), FCCP RN, RM, Diploma in Management &
Consultant Neurologist Supervision, BScN, MScN(Adelaide),
National Hospital MPM(SLIDA), Director Nursing
Sri Lanaka. Medical Services,
Ministry of Health
Dr Gamini Pathirana
MBBS, MD(Med)(Col), FCCP Mr. Iranga N Aluthge,
Consultant Neurologist Bsc(Hons) PT, HDPT, Dip ES, CTHP,
National Hospital ACWS, CMT, CCRehab, FCSPSL,
Sri Lanka. LMSLSP.
Principal,
School of Physiotherapy and
Occupational therapy

iv
 Contributors

Ms G Thushari Anuruddhika Dr Harsha Gunasekara

BSc Nursing (Hons), Dip in MBBS, MD(Med)(Col), MRCP(UK),
Nursing, FRCP, FCCP
Dip in Teaching & Supervision Consultant Neurologist
Clinical Nursing Instructor Sri Jayewardenepura General
National Hospital Hospital
Sri Lanka. Sri Lanka.

Mr Chandana Ranaweera Dr Champika Gunawardhana

Arachchi MBBS(Col), MD(Med)(Col),
BSc.sp (Agri), MA(Sociology) MRCP(UK),
SLAS Class 1 MRCP- SCE Neuro (UK),
Director MRCP(Lond)
Department of Social Services Consultant Neurologist
Sri Lanka. Teaching Hospital Ratnapura
Sri Lanka.
Dr Senaka Bandusena
MBBS, MD(Med)(Col), FCCP Dr Shyamani Hettiarachchi
Consultant Neurologist BA(Hons)(Kelaniya),
National Hospital MSc(University College London),
Sri Lanaka. MSc (Oxon), MA(Roehampton),
PhD(City University)
Mr H G T Dilshan Senior Lecturer – Department of
HND(OT) (School of Disability Studies
physiotherapy and occupational University of Kelaniya
therapy) Sri Lanka.
Occupational Therapist
Institute of Neurology Dr Renuka Jayatissa
National Hospital MBBS, MSc, MD
Sri Lanka. Head
Department of Nutrition
Ms K Prabhani Dineshika Medical Research Institute
BSc in SLT (UoK) Sri Lanka.
Senior speech and Language
Therapist
National Hospital
Sri Lanka.

v
Dr H N N Kalyani Dr Gamini Pathirana
BSc(Hons)(Physiotherapy)(Col), MBBS, MD(Med)(Col), FCCP
PhD (Aus), Consultant Neurologist
CTHE(Col), SEDA(UK), FHEA (Aus) National Hospital
Lecturer in Physiotherapy Sri Lanka.
Faculty of Medicine
University of Colombo Dr S P Rathnayake
Sri Lanka. BSc in SLT (UoK), PhD (UoC)
Speech and Language Therapist
Dr Gunendrika Kasthuriratne Visiting Lecturer
MBBS, MD(Med)(Col) University of Keleniya
Consutant in Rheumatology & Sri Lanka
Rehabilitation
National Hospital Dr Sujatha Seneviratne
Sri Lanka. RN, BSc, BSc.N(Hons), MN
MPhil, PhD
Mr B A P Lakmal Senior Lecturer
HDPT (School of physiotherapy) Department of Nursing &
Physiothearpist Midwifery
Institute of Neurology Faculty of Allied Health Sciences
National Hospital University of Sri
Sri Lanka. Jayawardenepura
Sri Lanka.
Dr Wasana Marasinghe
MBBS, Msc, MD Mr Nandana Welage
Acting Consultant Nutrition Dip OT, BSc OT(SL), MSc OT(HK)
Physician Senior Tutor in Occupational
Medical Research Institute Therapy
Sri Lanka. School of Physiotherapy &
Occupational Therapy
Colombo
Sri Lanka.

vi
 Contents
Foreword ....................................................................................................... viii
Editor’s Preface ................................................................................................x
Chapter 01: Burden of Stroke and Essentials of Settings for
Stroke Care in Sri Lanka ................................................................................. 1

Chapter 02: Principles in Stroke Recovery and Rehabilitation ...................... 9

Chapter 03: Disabilities in Stroke and Rehabilitation Assessment ............... 15
Chapter 04: Post Stroke Complications and Prognostication........................ 20
Chapter 05: Stroke Rehabilitation: A Practical Approach ............................ 31
Chapter 06: Multidisciplinary Stroke Care ............................. ...................... 41
Chapter 07: Nursing Care for Stroke ............................. ............................... 44
Chapter 08: Physiotherapy in Stroke Rehabilitation...................................... 65
Chapter 09: Occupational Therapy for Stroke Rehabilitation........................ 74

Chapter 10: Person-centered Dysphagia and Communication Support

at the Stroke Unit ..................... .................................................................... 88

Chapter 11: Nutritional Management in Stroke ......................................... 118

Chapter 12: Intervention of the Department of Social Services for

Patients’ Welfare Services ........................................................................ 130

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 Foreword
Stroke is a clinical entity that medical professionals encounter quite often in
their day-to-day clinical practice. Over the last several decades, there has
been many scientific advancements in relation to the management of stroke,
out of which the most beneficial for better outcome being Stroke Unit care,
where post stroke patients receive coordinated rehabilitation by a
multidisciplinary group of caring professionals. The goals of rehabilitation are
to optimize how the person functions after a stroke and the level of
independence, and thereby to achieve the best possible quality of life.
Rehabilitation can substantially help a stroke survivor achieve the best long-
term outcomes.

There are many disabilities that may follow stroke. In addition to physical
disability, there could be impairment of cognitive functions, speech,
swallowing, sphincter functions, depression, and restricted participation in
social activities, all of which require the services of multidisciplinary
professionals for training and educating on coping strategies. Severity of the
brain injury, age, level of alertness, associated medical problems together
with the intensity of the rehabilitation programme, work environment, and
timing of the commencement of rehabilitation endeavour determine the
outcome following a stroke. Although the role played by every member of
the multidisciplinary team is relevant in rehabilitation, they may not be
available at each and every setting where patients are managed. Sharing of
roles become pertinent in that sort of resource limited settings.

As with many countries in the region, being a country with resource

constraints, Stroke Unit care is sparse for majority of the stroke patients in
Sri Lanka. It has been a challenge to establish coordinated multidisciplinary
team care even in locations where the members of the allied health
professions and nurses are available. Motivation of medical professionals,
particularly the Internal Medicine Physicians and Neurologists, would be
essential to improve hospital-based Stroke Unit care.

viii
The “Guide on Rehabilitation of Stroke for Healthcare Professionals”
is a book, published under the patronage of the Sri Lanka
Medical Association (2021) and the World Health Organization,
to guide clinicians providing rehabilitation for stroke patients. The book
consists of chapters contributed to by all members of the
multidisciplinary team, with diagrammatic elaborations for the
convenience of the readers from any of the categories of professionals
who would be called upon to deal with stroke patients.

I wish to communicate my sincere gratitude to the World Health

Organization Country office for the technical and financial support for
conducting the project and publishing the book,“Guide on Rehabilitation
of Stroke for Healthcare Professionals”. I wish all success to the training
programme that would lay the foundation to establish Stroke
Units, providing beds for care for every needy stroke patient in Sri Lanka.

Dr. Padma S Gunaratne

MBBS, MD(SL), FRCP(Edin, Glasg, Lond), FCCP,
Hon FRACP, FAAN, FWSO
Consultant Neurologist
President Sri Lanka Medical Association

ix
Editor’s Preface
Dr Ajini Arasalingam

“It doesn’t matter how slowly you go as long as you do not stop.”

Neurology per se has a major difference compared to many other fields of

medicine. Plagued by many progressive illnesses which benefit mostly from
rehabilitation, neurorehabilitation is a field of study which has to be taken up
as a specialty by itself. Amongst all the neurological conditions stroke is the
commonest with one among every five being affected. Stroke can affect
anyone irrespective of age and Asians have a higher risk of stroke, with
females having a higher propensity to have a stroke and die from it. It is
preventable; however, we need to think in terms of the next line of being
able to assist the stroke survivor to achieve the best level of social
integration. In addition to the physical disability, the psychological and
emotional effect on the patient and their carers cannot be overemphasized.
Within neurology the field of neurorehabilitation has evolved, and the
paradigm shifted significantly in Sri Lanka during the last two decades. The
aim would be to provide equality and equity in the provision of stroke
rehabilitation services to every province in this country, the pearl of the
Indian Ocean. This book is devoted to neurorehabilitation services that can
be offered to stroke survivors in Sri Lanka. The 12 chapters will address the
role of each member of the multidisciplinary team in achieving our goals in
rehabilitating a stroke survivor and the general principles required in the
development of stroke rehabilitation units.

This book begins with an up-to-date account on the burden of stroke and
essentials of settings for stroke care in Sri Lanka by Dr Senaka Bandusena.
The present status of stroke care, stroke rehabilitation including macrolevel
and microlevel strategies, community support services and new
developments have been addressed. In the next chapter, Dr Gamini
Pathirana provides an insight on the principles in stroke recovery and
rehabilitation and has gone on to explain the differences between recovery
and rehabilitation, phases of rehabilitation, predicting stroke recovery,
x
timing, intensity, and different options of stroke rehabilitation. He has
emphasized on the stroke rehabilitation team and also introduced some
newer concepts such as constraint induced therapy, melodic intonation
therapy, and electrostimulation in stroke rehabilitation.

Dr Gunendrika Kasthuriratne’s chapter on disabilities in stroke and

rehabilitation assessment gives us a clear picture on the disabilities and
impairments faced by a stroke survivor and outlines the different scales that
can be used to assess the impairments and disabilities which are of immense
use in the practice of rehabilitation. Post-stroke complications and
prognostication by Dr Champika Gunawardhana ensures that the readers are
kept abreast of the early identification of neurological deterioration and
complications such as venous thromboembolism, infections, post stroke
epilepsy, post stroke spasticity, pressure sores after stroke, post stroke
psychological disorders, and post stroke pain. he also briefly describes the
prognosis after stroke. Dr Harsha Gunasekara provides a review on aspects
of a practical approach in stroke rehabilitation where he emphasizes on the
organization of post stroke rehabilitation services (inpatient rehabilitation
facility, skilled nursing facility, outpatient rehabilitation, long- term care, and
early discharge settings). He has explicitly explained how to rehabilitate a
stroke patient in a five-step plan.

In the next article Dr Champika Gunawardhana introduces multidisciplinary

stroke care as an outset for the remaining chapters on the current and
evolving evidence for cutting edge restorative modalities that will improve
post stroke recovery. Dr Sujatha Seneviratne addresses the aspects of nursing
care for stroke in which she lays out the responsibilities of a nurse in stroke
care which includes monitoring of vital parameters, provision of physical
care, prevention of specific complications, psychological support, and
educating the family and caregivers, and helping to cope. Dr Nadeesha
Kalyani, in her chapter on physiotherapy in stroke rehabilitation describes the
neurophysiological techniques used in acute and rehabilitation care. Some of
the techniques include proprioceptive neuromuscular facilitation, Bobath
technique, and motor relearning techniques to mention a few. She has also

xi
described gait training, repetitive task training, and constraint
induced movement therapy.

In the next chapter, Mr Nandana Welage has given us great insight

in occupational therapy assessments to improve visual perception,
memory and cognition, sensory, motor, and upper limb functions. He has
reinforced the need of home assessment. Considering the therapeutic
interventions, he has focused on the neurodevelopment
technique, proprioceptive neuromuscular facilitation technique, motor
relearning technique, constraint induced movement therapy, mirror
therapy, and motor imagery. He has emphasized on workplace and
community reintegration. The chapter on person centered dysphagia and
communication support at the stroke unit by Dr Shyamani Hettiarachchi
describes the scope of practice establishing swallow safety, screening,
and diagnostic assessments for dysphagia. She has focused on objective
and instrumental assessments and intervention and management. Her
comprehensive article also includes communication assessments and
intervention and management. Further, she has touched on the topic of
management in the context of COVID-19 including tele-practice services.

Dr Renuka Jayatissa in her chapter on nutritional management in

stroke emphasizes on the detrimental value of suboptimal nutritional
intake, nutrition screening and assessment, and medical nutrition therapy.
Mr Chandana Ranaweera Arachchi in his chapter on intervention of the
Department of Social Services for patients’ welfare has highlighted the
social services support that can be given to stroke survivors.

I would like to express my sincere thanks to all the expert authors

contributing to this book and sharing their invaluable experience which will
help us provide the highest level of stroke rehabilitation care for post stroke
survivors beginning in the acute phase and continuing until they can attain
the best functional outcome. My sincere appreciation to Dr M Ladsiyan
(pre-intern demonstrator, University of Jaffna) for his expertise in the
graphic designing of this book, designing the cover page, typesetting and
producing
xii
the final compilation of the book. A special word of thanks to Ms
Gopikha Sivakumar (medical student, University of Jaffna) for proof
reading and assisting in the final compilation of the book. I also express
my gratitude to the World Health Organization Country office for the
technical and financial support for conducting the project and publishing
the book, which is of great value to advocate and improve rehabilitation
of post stroke survivors.

Dr Ajini Arasalingam
Editor

xiii
Chapter 1: Burden of Stroke and Essentials of Settings for
Stroke Care in Sri Lanka
Dr Senaka Bandusena

Sri Lanka’s Stroke Burden

Sri Lanka is an island nation in the Indian ocean with a land area of 65,610 km
and a population of 21.8 million. For administrative purposes it is divided into
9 provinces and 25 districts. It is a middle-income country with an estimated
per capita income of 3682 USD. Sri Lanka spent 3.9% of its GDP for healthcare
in 2019. Due to an admirable public health system, it is considered a country
with exemplary selected health parameters with an average life expectancy
of 78 years for females and 72 years for males and low infant and maternal
mortality rates.

In Sri Lanka, stroke is the leading cause of adult disability and the seventh
leading cause of hospital deaths. Two population-based prevalence studies
conducted in the Western province and published in 2007 and 2015 have
shown a stroke prevalence of approximately 10/1,000 population. However,
at present there are no population-based studies to provide incidence or
prevalence data outside the Western province.

Sri Lanka’s evolving population demography shows that over the last few
decades the percentage of elderly have increased and almost doubled from
1981 to 2019. This is due to improved life expectancy and reduced birth rates.
It is estimated that 16.4% of the population is over 60 years of age. Going by
the trends the percentage of the elderly is predicted to grow even further in
the coming years. As stroke is a disease with a higher incidence in older
people the number of stroke patients are also likewise expected to increase
in future, which in turn will lead to a greater demand for stroke services.

1
Present Status of Stroke Care in Sri Lanka
Sri Lanka has a state funded, free, and universal health care system which
consists of western and indigenous medical systems. In addition to the free
health services provided by the state-sector hospitals, there is also a private
health care system. While most stroke patients initially get admitted to a
government hospital for care, the follow-up care could take place either in
the state or private sector.

In 2019, Sri Lankan health institutes providing western medicine in the state
sector had a total of 86,589 hospital beds in 643 hospitals, while there were
4,686 beds in the private sector and 4,009 beds in the state indigenous
medicine sector. An audit conducted by the Association of Sri Lankan
Neurologists (ASN) in 2020 revealed that there were 36 neurology units in
the country with a total of 382 general neurology and 74 stroke beds. The 74
stroke beds were distributed in 9 hospitals (National Hospital Sri Lanka-10,
North Colombo Teaching Hospital-6, Sri Jayawardenepura General Hospital-
10, General Hospital Kalutara-6, National Hospital Kandy-4, Provincial
General Hospital Ratnapura-10, District General Hospital Matara-6,
Provincial General Hospital Kurunegala-16, and Provincial General Hospital
Badulla-6). There were 16 neurology units that did not have a single bed. In
addition, there were seven rehabilitation hospitals under the
rheumatologists which provided rehabilitation facilities for stable patients,
especially those requiring long-term rehabilitation (Ragama, Digana,
Jayanthipura in Polonnaruwa, Kandagolla in Badulla, Maliban Rehabilitation
Centre in Galle, Ampara, and Jaffna). In 2020, 45 neurologists were in active
service, which could be approximated to 1 neurologist per 480,000
population.

When we consider stroke care over the years Sri Lanka has made major
strides and improved in many spheres. The first step in organized stroke care
took place in 1998 with the establishment of the first stroke unit at the
Institute of Neurology, National Hospital of Sri Lanka (NHSL), Colombo. This
unit has grown in stature over the years and still functions as the role model
for training in stroke rehabilitation and Multi-Disciplinary Team (MDT) care

2
in stroke for the rest of the country. Another major landmark was the
establishment of the National Stroke Association of Sri Lanka in 2001, which
has contributed in a major way to improve public awareness on stroke risk
factors and care through advocacy and conduct of numerous programs.
Formation of the Association of Sri Lankan Neurologists (ASN) in 2007 was
another key driving force for coordinated improvement of neurology services
in the country which helped expansion of stroke services throughout the
country.

When considering acute care, the first stroke thrombolysis was performed in
Sri Lanka at the NHSL in 2008, while the first thrombectomy was performed
at the Central Hospital, Colombo, a private hospital, in 2013, and in the state
sector at NHSL in 2018.

The Government of Sri Lanka has shown great commitment to improve

stroke services and related activities. Sri Lanka is one of the few countries in
the region where rtPA is offered free of charge in the state sector to patients
requiring thrombolysis. As of now there are 22 state sector hospitals offering
thrombolysis with at least one hospital in each of the 9 provinces. In addition,
the diagnostic services have also improved tremendously with more
widespread availability of CT scanning facilities and other services required
for cardiac and vascular studies. CT scanning facilities are now available in the
state sector in all 9 provinces. In addition, for primary and secondary
prevention of stroke, risk factor monitoring and medication to treat
hypertension, dyslipidaemia, and diabetes are available free of charge in the
state sector.

Another major development that especially contributed to the acute stroke

care in the country was the establishment of a rapid-response, free
ambulance transport system – the Suwasariya 1990 ambulance service which
commenced in 2016 in the Western and Southern provinces. The Suwasariya
network now has 297 ambulances and has expanded to cover the entire
country. Initiation of this service was a generous gift from the Government

3
of India which provided the funding and technical assistance necessary for its
commencement.

While many advances have taken place in acute stroke care and prevention,
there are three areas which are still lagging - stroke rehabilitation,
community support services for patients and carers, and thrombectomy.

Stroke Rehabilitation
Following a stroke, a significant proportion of patients are left with a
disability requiring rehabilitation. Ideally it should be provided in a well-
equipped stroke unit with a multidisciplinary team led by a specialist trained
in stroke rehabilitation. However, there are only a few such stroke units in Sri
Lanka, and those too have limited bed capacity.

While neurologists lead stroke care throughout the country, most stroke
patients are still admitted to general medical units and would thus be
attended to by the general physicians. This is mainly due to lack of adequate
neurology/stroke beds. Patients are often prematurely discharged due to
heavy demand for beds. While some of these patients seek treatment at
centres providing indigenous medical therapies, others end up at home not
getting the required rehabilitation.

Sri Lanka Stroke Clinical Registry (SLSCR) data analysis for a period of 6
months from November 2016 from five major hospitals in Sri Lanka (NHSL
excluding the stroke unit, Teaching Hospital Kandy, Colombo South Teaching
Hospital, Teaching Hospital Jaffna, and Teaching Hospital Karapitiya)
revealed that the average hospital stays for a stroke patient even in major
teaching hospitals was 5 days. However, at the NHSL stroke unit, which is a
specialized one, the average stay for such patients was 21 days. While case
mix may partly account for the difference it is most likely due to the
availability of beds for rehabilitation and the commitment to rehabilitation in
the stroke unit. Therefore, to improve stroke rehabilitation services one
could think of macro and micro level strategies.

4
Macrolevel strategies involve prioritizing rehabilitation as an important
health care goal, developing infrastructure, setting up new units to improve
rehabilitation bed capacity, providing adequate facilities including
equipment and trained therapists and developing effective stroke care
pathways. These measures will require much funding and input from health
administrators and policy makers and often take time for implementation.

Microlevel strategies would involve reorganizing existing facilities to achieve

rehabilitation goals, starting an MDT meeting, introducing functional scales
like Barthel’s Index for assessment and monitoring, and allocating a few beds
in a demarcated area within the neurology or general medical ward with help
from medical colleagues. These measures would not require much funding
and can be done by any neurologist/physician who has the commitment to
improve rehabilitation.

Patient and doctor perception regarding rehabilitation is another aspect that

needs attention. It is important to educate medical personnel, especially
those in primary care such as family physicians and general practitioners who
would be the first contacts in most instances regarding the importance and
local availability of rehabilitation facilities. Additionally, it is important to
have a streamlined referral and transfer system from units which lack
necessary facilities.

Emphasis on high quality services at rehabilitation units is needed. Merely

allocating a bed and keeping a patient without proper input would not help
the stroke survivor. Therefore, it is important to have a coordinated approach
with proper assessments and goals with regular review to evaluate recovery
with treatment.

Both macro and micro level strategies should ideally be data driven and cost
effective. The cost of services would involve initial capital expenditure and
recurrent costs. Whether a patient would benefit from inward, or outpatient
therapy is determined by the patient’s clinical status, availability of in and

5
outpatient rehabilitation resources at the hospital, and transport and social
support available to the patient.

Discharge planning is also a crucial aspect that ensures a smooth transition

from hospital to home. This would involve carer education and engaging
carers early in patient care while the patient is receiving inward therapy. This
would boost the confidence of both patient and carer to manage domiciliary
care following discharge. Pre-discharge home assessments to ensure safety
are yet not regularly done in Sri Lanka.

Ideally clinical audits (structural/ process/ outcome) should be performed at

pre-determined regular intervals to ensure maintenance of standards and
optimal use of facilities. It is also important to keep patients and the stroke
team well motivated and focused on tasks at hand. This can be achieved by
conducting regular meetings with feedback and encouragement given to the
staff.

Community Support Services

Despite the best efforts in rehabilitation there are patients who are left with
significant disability and dependence. In such situations the burden often
falls on the extended family. However, there are many who do not have
family members or social support once they get home.
In situations where the family is not in a position to bear the burden of care
there are only very few institutions such as hostels, nursing homes, and
palliative care centres in Sri Lanka, available for service provision. Lack of
these facilities leads to delays in discharge of patients from hospitals. Also,
there is a need for centres which provide respite care to temporarily relieve
the burden of the carer.
The Department of Social Services, through the Divisional Secretaries does
provide social support for disabled stroke patients in the form of housing
grants, financial assistance for home modifications such as disability access,
construction of toilets with commodes, and obtaining electricity or pipe
borne water if not available already. In addition, they could also receive
grants for obtaining medicine unavailable in the state sector or assistive

6
devices such as wheelchairs, crutches etc. There is also provision for
vocational training and self-employment.

Thrombectomy Facilities
At present, endovascular thrombectomy for acute stroke patients is limited
to Colombo and is available in only two hospitals, the National Hospital of Sri
Lanka and the Central Hospital, a private hospital.

New Developments
Several new developments are expected to change the landscape of stroke
rehabilitation in the country in future. The first is the entry of Specialists in
Rehabilitation Medicine who are expected to play a dynamic role and guide
stroke rehabilitation along with the Neurologists. In 2017 the Post-Graduate
Institute of Medicine offered rehabilitation medicine as a post MD
subspecialty for the first time, to address a long felt need in the country. At
present there are 7 postgraduates in training and the first batch is expected
to commence work in 2023. The presence of rehabilitation specialists would
have a huge positive impact on rehabilitation services in the country.

The second is the establishment of the National Stroke Center, presently

being constructed at the Colombo East Hospital in Mulleriyawa which will
help bridge the treatment gap to a great extent in the Western province by
providing a comprehensive, multidisciplinary care centre with adequate
number of beds for stroke patients. This is expected to be commissioned in a
few years.The Ministry of Health in Sri Lanka in 2011 made a policy decision
to establish a stroke unit in each province. It is anticipated that this would
become a reality in the near future to streamline stroke rehabilitation and
provide essential, equitable services in this field to the periphery.

Stroke rehabilitation is an area with much scope for further improvement.

Improving capacity, better coordination within and between sectors, and
commitment are key aspects required to achieve the final objective, which is
to offer an optimal, comfortable setting for stroke patients to facilitate the
best possible recovery with dignity.

7
References
1. Ministry of Health, Sri Lanka (2019). Annual Health Statistics 2019 Sri Lanka.
2. Central Bank of Sri Lanka, Annual Report 2020.
3. UNICEF. Budget Brief: Health Sector Sri Lanka 2019.
4. Ranawaka UK, de Silva H, Balasuriya J, Ranawaka UM, Jayasekera B,
Wickramasinghe AR, et al. Prevalence of stroke in a Sri Lankan community – a
door-to-door survey. Neurology. 2007;68: A103.
5. Chang T, Gajasinghe S, Arambepola C. Prevalence of Stroke and Its Risk Factors
in Urban Sri Lanka: Population-Based Study. Stroke. 2015 Oct;46(10):2965–8.
6. Asian Development Bank. Growing old before becoming rich Challenges of an
aging population is Sri Lanka December 2019.
7. Ministry of Health, Sri Lanka (2017). Basement Report of the Institution Frame
of Private Sector of Western Medicine and State Indigenous Medicine Sector
2017.
8. Ranawaka UK. Stroke Care in Sri Lanka: The Way We Were, the Way We Are,
and the Way Forward. J Stroke Med. 2018;1(1):45–50.
9. Lanka Business Online. Sri Lanka launches first free pre-hospital care
ambulance service with Indian grant. Lanka Business Online [Internet} 2016 Jul
28. Available from: https://www.lankabusinessonline.com/sri-lanka-launch-
first-free-pre-hospital-care-ambulance-service-with-indian-grant/
10. Lanka Business Online. 1990 Suwaseriya ambulance service now covers entire
nation. Lanka Business Online [Internet]. 2019 June 23. Available from:
https://www.lankabusinessonline.com/1990-suwaseriya-ambulance-service-
now-covers-entire-nation/
11. Gunaratne PS. Stroke care. S Godage and Brothers (Pvt) Ltd, 2012. p. 69-70.
12. Postgraduate Institute of Medicine, University of Colombo Sri Lanka.
Prospectus Board Certification in Rehabilitation Medicine 2017.
13. Daily Financial Times. Foundation laid for National Stroke Centre in Colombo
East Hospital Mulleriyawa. Daily Financial Times [Internet] 2017 Nov 15.
Available from: https://www.ft.lk/healthcare/Foundation-laid-for-National-
Stroke-Centre-in-Colombo-East-hospital-Mulleriyawa/45-643349
14. Wijeratne T, Gunaratne P, Gamage R, Pathirana G et al. Stroke care
development in Sri Lanka: The urgent need for rehabilitation services.
Neurology Asia. 2011:16(2): 149-151.

8
Chapter 2: Principles in Stroke Recovery and
Rehabilitation
Dr Gamini Pathirana

Stroke recovery is best defined as spontaneous improvement across a variety

of outcomes including biological and neurologic changes that manifest as
improvement in performance and activity based behavioral measures. It does
not need a rehabilitation team.
Alternatively, stroke rehabilitation is stroke care that aims to reduce
disability and improve function with the goal of achieving the highest possible
level of independence (physically, psychologically, socially, emotionally, and
financially) within the limits of the persistent stroke impairments. Stroke
rehabilitation needs a team.

The three ways a human brain recovers from stroke are adaptation,
regeneration, and neuroplasticity. Adaptation is using alternative physical
movements e.g., using the non-dominant hand for feeding after dominant
hand function is lost following a motor stroke. Regeneration is the growth of
neurons to replace those damaged from stroke. This historically is the least
useful in stroke rehabilitation since it is believed that central nervous system
tissue does not regrow after injury. (Advances in stem cell treatment and
tissue growth factor treatments may make it a viable option in future).
Neuroplasticity, which is the rewiring of the neural network, is considered to
be the main process of stroke recovery.

There are three approaches to rehabilitation, namely restoration,

compensation and modification. Restoration includes an exercise
programme with the aim of retraining lost function. Compensation includes
various adaptations e.g., prisms to correct diplopia. Modification includes
changing the environment to promote function e.g., Installing rails on
walkways.

9
Phases of Stroke Rehabilitation
Four phases are recognized in stroke patients. They are the hyperacute,
acute, subacute, and community reintegration phases. Onset and offset of
these phases are not strictly demarcated. Hyperacute phase is the first 24
hours from stroke onset. This is the phase in which reperfusion therapies and
others are targeted towards salvaging penumbra. Acute phase begins about
24 hours from onset of stroke and lasts five to seven days. During this phase,
the interdisciplinary team ensures that the patient is medically stable and
initiates acute rehabilitation. Initiating rehabilitation within 48 hours from
stroke onset has beneficial effects on overall functional recovery. Subacute
phase begins when the patient is transferred to a full rehabilitation facility
usually about a week after stroke onset when the patient is medically stable.
Community reintegration phase begins once the person is discharged home.
During this phase patients are directed for home care services, outpatient
rehabilitation facilities, community organizations, and stroke associations.

From a pathophysiological point, initial improvement occurs from resolution

of edema and restoration of circulation to 'ischaemic penumbra'. Subsequent
restoration of functions usually is attributed to many factors inclusive of
dendritic sprouting, synaptogenesis, restoration of axonal transport,
remyelination, unmasking of alternate pathways, redevelopment of cortical
inhibition, resolution of diaschisis, alteration in neurotransmitters, and
bilaterality of brain functions. Shift of functions to neighboring areas which
has been shown in animals seems to occur in humans as well. However, this
neuronal reorganization can be maladaptive and give rise to spasticity and
seizures.

The degree and rapidity of stroke recovery depends on many factors. They
include severity and degree of damage to the brain; optimum acute
management including salvaging the penumbra tissue as much as possible,
early antiplatelet therapy, stroke unit care, age (degree of recovery is greater
in children and young individuals compared to the elderly) and Intensity of
rehabilitation programme, severity of concurrent medical problems,

10
supportive home, work and social environments; and finally, timing of
rehabilitation (sooner it begins the better).

Pathophysiological processes that underlie stroke recovery involves

unmasking of latent network representations, excitatory metabolic stress, an
imbalance in activating and inhibiting transmission leading to salient
hyperexcitability, or mechanisms that consolidate novel connections which
together may prime the plastic capabilities of the brain. These
pathophysiological processes are potentially influenced by rehabilitative
interventions.

The recovery process continues from plasticity into the ‘period of

consolidation’ which begins after the subacute phase and continues up to
several months following onset and then followed by the chronic phase
where recovery slows dramatically with time.

Among some of the principles of motor learning based on existing literature

are massed practice, spaced practice, dosage, task-specific practice, goal-
oriented practice, variable practice, increasing difficulty, multisensory
stimulation, rhythmic cueing, explicit feedback/knowledge of results, implicit
feedback/knowledge of performance, modulate effector selection, action
observation/embodied practice, motor imagery, and social interaction.
These principles are being used in scientific rehabilitation.

Swallowing, facial movement, and gait tend to demonstrate better recovery

than other deficits. One hypothesis to explain this observation is that these
deficits have bi hemispheric representation. On the other hand, cortical
functions, such as language and spatial attention as well as dominant hand
movement which are lateralized consequently recover more slowly.

Predicting Stroke Recovery

Motor recovery tends to begin in the proximal upper and lower extremities
and then progresses to other parts. Upper extremity recovery at 6 months
can be predicted with 98% accuracy by two simple bedside tests, the first

11
being voluntary finger extension and the second being shoulder abduction
present 48 hours after stroke. If these movements do not present by day 9
post stroke, likelihood of complete recovery drops to 14% (EPOS study: Early
Prediction of Functional Outcome after Stroke Study). Similar models are
available to predict lower extremity function recovery too.

Timing and Intensity of Rehabilitation

There is still uncertainty about the exact time to start rehabilitation. But most
stroke rehabilitation experts agree that shorter and more frequent early
mobilization is better (AVERT trial: A Very Early Rehabilitation Trial).

Different Options for Rehabilitation

Initial ‘in hospital’ rehabilitation is followed by any of the following - in home
rehabilitation (therapist comes home), in- independent rehabilitation facility
(IRF) rehabilitation, ‘outpatient’ rehabilitation (patient visits outpatient
rehabilitation clinic) or ‘skilled nursing home (SNF) facility’ rehabilitation
based on the stroke survivors’ requirements. Placement of rehabilitation
patients to these units is based on the nature and severity of stroke,
comorbidities, and level of social support. Admission into these facilities is
based on entry criteria e.g., independent rehabilitation facility (IRF) needs:
(1) ability for patient to participate in at least two disciplines of therapy from
physiotherapy, occupational therapy or speech and language therapy, (2)
ability to engage at least 3 hours per day and (3) reasonable expectation of
patient returning home following rehabilitation.

Rehabilitation Team
Interdisciplinary team is responsible for the rehabilitation of the stroke
survivor. Physiotherapist is responsible for ambulatory recovery (transfer in
and out of the chair or bed). The occupational therapist concentrates on the
upper extremity with activities of daily living. The speech and language
therapist (SALT) is responsible for language deficit or swallowing issues. The
neurologist, rehabilitation specialist, and psychiatrist too will be there in the
team. Others include social worker, vocational therapist, and
neurophysiologist. Patient and family too are included as they could help in
decision making and setting realistic goals.
12
Constraint Induced Therapy.
Once a stroke occurs, patients develop a phenomenon called ‘learned disuse’
where they underuse the affected side, being compensated by using the
intact side. Because of this phenomenon, the affected side does not recover
or recovers at a slower pace. In constraint induced therapy the unaffected
extremity is constrained with a restraining device which forces the patient to
use the affected side. Therefore, the patient is compelled to use the affected
side for activities. This has been shown to make improvement in the deficit.

Melodic Intonation Therapy

This means using musical elements of melody, rhythm, and emphasis to
improve language production. We are aware that language localizes to the
dominant hemisphere in the majority of human beings. If the dominant
hemisphere is affected, they may not be able to produce language. However,
singing and melody localize to the non-dominant hemisphere. So, a patient
who cannot talk with aphasia due to a stroke of the dominant hemisphere,
may be able to retain the ability to sing and carry out a melody. Speech
therapists use this technique to help the recovery of the damaged side and
to improve vocalization, tone, and verbal output.

Electrostimulation in Stroke Rehabilitation

This technique is primarily used with motor deficits. It involves applying
electrical stimulation to muscles of interest to produce a desired movement.
This can be used for both upper and lower extremity muscles. This is an
evidence-based therapy. Amount of stimulation can be adjusted depending
on the level of function and improvement.

Pharmacotherapy and Stroke Rehabilitation

Use of fluoxetine (antidepressant) 20 mg /day compared to placebo
beginning 5-10 days post stroke proved to improve recovery of upper
extremity motor deficit (FLAME trial: Fluoxetine for Motor Recovery after
Acute Ischemic Stroke trial). Use of cholinesterase inhibitors and
glutaminergic agents help improve post stroke aphasia. Dopaminergic
medications too have been used.

13
Certain antiepileptics e.g., phenobarbitone, diazepam, and phenytoin seem
to impede synaptic formation and hinder neuroplasticity in animal models,
so they tend to be avoided in stroke rehabilitation subjects. Furthermore,
antihistamines too may retard the neuroplasticity and excessive pain
medications should also be avoided. Dopamine blockers (typical
antipsychotics) too may hinder stroke recovery.

Spasticity and Stroke

Spasticity means velocity dependent resistance to movement resulting from
hyper excitability of stretch reflex. The underlying mechanism of the
hyperexcitable stretch reflex, however, remains poorly understood.
Experimental evidence has supported supraspinal origins of spasticity, likely
from an imbalance between descending inhibitory and facilitatory regulation
of spinal stretch reflexes secondary to cortical disinhibition after stroke. For
a long time, it was controversial whether spasticity is beneficial or harmful in
stroke recovery. Latest studies indicate that spasticity adversely affects
stroke recovery. Spasticity can limit motor function and lead to pain,
reduction in quality of life, deformities causing social isolation, and even
depression.

References
1. Dombovy ML: Stroke: Clinical course and neurophysiologic mechanisms of
recovery. Critical reviews in Physical and Rehabilitation Medicine 1991; 2:
171-188.
2. Nair KPS, Taly AB: Cortical reorganisation: Implications in functional
recovery and neurological rehabilitation. Reviews in Neurology 1999; 6: 51-
54.

14
Chapter 3: Disabilities in Stroke and Rehabilitation
Assessment
Dr Gunendrika Kasthuriratne

Rehabilitation remains the mainstay of treatment for most of the stroke

victims in spite of all the advances in acute stroke care. Thrombolytic therapy
is best received within the first 3 hours although the therapeutic window has
been extended up to 6 hours. Only a minority will be qualified for a successful
thrombolytic therapy and about one third of the survivors will have residual
disability. Severe strokes can place a great burden on the coping mechanisms
of caregivers and family as well as patients.

Stroke related disability almost always impairs mobility and independence in

the activities of daily living (ADL). Majority of the patients will have spastic
hemiplegia, while cerebellar ataxia may affect mobility in some. Persistence
of motor synergies and contractures and / or spasticity may affect mobility in
the long term. Those who recover with motor functions early can commence
learning ADL. Apraxia, hemianopia, hemineglect, and cognitive defects or
depressive mood will add to the severity of functional impairment and thus
prevent the functional recovery in a patient whose recovery of mobility is
satisfactory.

There are disabling pain syndromes characteristic to stroke patients. They are
caused by poor motor control and improper limb and gait biomechanics. The
pain can affect the shoulders, hips, muscles, and other parts of the body.
Hemiparetic shoulder pain (HSP) is a severe and disabling pain often
occurring on the affected side. HSP is frequently accompanied by limitation
in the range of motion at the shoulder. Central poststroke pain (CPSP) is a
condition where they feel an exaggerated distress in response to unpleasant
stimuli such as a pinprick and is difficult to treat. Some strokes may affect the
continence of bladder and/or bowel. Factors that contribute to post stroke
bladder incontinence include direct damage of the micturition centers in the
brain, which result in bladder hyperreflexia and urgency. Normal bladder

15
function may be intact post stroke, but impaired mobility and cognition may
be represented as incontinence.

Stroke may impair the cognitive abilities such as memory, reasoning, speech,
and problem-solving skills. Impaired cognition has a significant negative
impact on functional recovery. Aphasia is found in about one-third of patients
with acute stroke. Aphasia will affect stroke victims in different ways.
Speaking (expressive aphasia), understanding (receptive aphasia), reading,
writing, using numbers, handling money, and even telling the time can be
affected in an aphasic. It may resolve spontaneously but around half of the
affected may experience long-term problems. Dysphagia is very common
after a stroke. A bedside swallowing assessment is a must in the initial
evaluation of a stroke victim. Many undergo rapid recovery, but the rest will
continue to have high risk of aspiration and chest infections, and long-term
nutritional and hydration issues.

All currently available guidelines recommend all stroke survivors to be

assessed for rehabilitation during the stay in the acute stroke care unit,
unless they reach the pre-morbid level of function, or they are not fulfilling
the criteria to be enrolled into a rehabilitation programme. They may be
rehabilitated as inpatients, outpatients or at home. Generally, the criteria
used to select a candidate for inpatient rehabilitation are significant
persisting neurological deficit, stable neurological status, sufficient cognitive
function to learn, communication ability to engage with therapist, physical
ability to tolerate the active programme, achievable therapeutic goals, and a
proper discharge plan. The decision is taken after assessment by an inter-
disciplinary team.

A large number of stroke-assessment scales have been described in literature

aiming to quantify stroke related disability and to predict the functional
outcome. Different measures of functional outcome are used in the acute
clinical setting in view of thrombolytic therapy and in planning and
monitoring of a rehabilitation program. The World Health Organization’s
International Classification of Functioning, Disability and Health (WHO-ICF) is

16
a framework that aids classification of such scales. ICF helps decide on the
appropriate measure/scale for a particular purpose.

The WHO-ICF is a global instrument that provides a unified and standard

language and framework for the description of “functionality”. The ICF model
is based on the biopsychosocial approach that integrates the biological,
individual, and social dimensions of health. This model describes the
interaction of positive aspects among three main components: 1) body
functions and structures; 2) activity and participation; and 3) environmental
and personal factors. The environment is considered as either a facilitator or
a barrier to functional recovery. The components interact with each other
and there are feedback loops.

World Health Organization’s International Classification of Functioning, Disability and Health

Tools that assess stroke at all these levels are available. Only few studies have
explored post stroke functionality based on the ICF conceptual model. All
available outcome measures do not always fit neatly into a single category
and often, they assess elements belonging to more than one domain. Some
of the scales are general and are used to assess any disabling condition other
than stroke. Some are specific to stroke. The most commonly used, clinically
approved classic clinical scales for stroke patients are Mini-Mental State
Examination (MMSE), Fugl-Meyer Assessment of Motor function (FMA-M)

17
and Balance function (FMA-B), National Institute of Health Stroke Scale
(NIHSS), modified Rankin Scale (mRS), Functional Independence Measure
(FIM), and modified Barthel Index (mBI).

MMSE is specific to assess the cognition impairment. For activity limitation

or ADL assessment, the commonly used scales in the rehabilitation setting
are the mBI and the FIM. FIM contains a section on cognition as well. Studies
involving the comparison of the physical subtotal of the FIM and mBI scores
have shown that neither is superior to the other. In both scales higher scores
indicate higher independence in function.

Classification of stroke related outcome measures according to the WHO-ICF http://www.ebrsr.com/

Assessment by mBI or FIM can be done by anyone who knows the patient
well. Usually, the mBI or FIM scores are documented in the inter-disciplinary
team meeting. The scores are documented at the commencement of the
programme and are compared at each regular team meeting. The discharge
score is a must at the time of discharge from rehabilitation.

18
The participation restriction or handicap section of the WHO-ICF is assessed
by scales which concentrate more on health-related quality of life. This
section includes outcome measures that reflect an individual’s involvement
in life events such as social functioning. Those tools are mostly interviewer
administered questionnaires and they are used more in the research setting
than in a clinical one.

References
1. Ebrsr.com. (2018). Introduction | EBRSR - Evidence-Based Review of Stroke
Rehabilitation. [online] Available at: http://www.ebrsr.com/.
2. Zhang, T., Liu, L., Xie, R., Peng, Y., Wang, H., Chen, Z., Wu, S., Ni, C., Zheng,
J., Li, X., Liu, H., Xu, G., Fan, J., Zhu, Y., Zhang, F., Du, Y., Wang, X., Wang, Y.,
Xiao, W. and Liu, M. (2018). Value of using the international classification
of functioning, disability, and health for stroke rehabilitation assessment.
Medicine, [online] 97(42), p.e12802. Available at:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6211934/ [Accessed 22
Nov. 2019].
3. Silva, S.M., Corrêa, F.I., Faria, C.D.C. de M., Buchalla, C.M., Silva, P.F. da C.
and Corrêa, J.C.F. (2015). Evaluation of post-stroke functionality based on
the International Classification of Functioning, Disability, and Health: a
proposal for use of assessment tools. Journal of Physical Therapy Science,
[online] 27(6), pp.1665–1670. Available at:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4499957/ [Accessed 13
Apr. 2019].
4. Quinn, T., Harrison and McArthur (2013). Assessment scales in stroke:
clinimetric and clinical considerations. Clinical Interventions in Aging,
[online] p.201. Available at:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3578502/ [Accessed 16
Oct. 2019].

19
Chapter 4: Post-Stroke Complications and
Prognostication
Dr Champika Gunawardhana

Introduction
Post stroke complications are common after acute stroke and they contribute
to poor clinical outcomes, delayed functional recovery and increased
morbidity and mortality. Post stroke complications are defined as medical or
neurological conditions that necessitate a physician’s involvement and
require monitoring by the medical staff. Prevalence of patients experiencing
one or more medical complications after acute stroke varies widely, from 44
to 95%. The most predominant independent risk factors for adverse post
stroke complications are older age and stroke severity.

Post stroke complications are both dynamic and transitional in their onset
and are heterogeneous in nature. In general, complications which develop
after stroke vary according to the chronicity of the illness and initial
neurological deficits. Acute complications are mainly neurological conditions
which occur as a direct consequence of the brain infarction. The infarction
related acute events include cerebral oedema, haemorrhagic transformation
of infarction, seizure activity, and death subsequent to brain herniation. The
common complications which develop as a consequence of impairments
related to stroke include venous thromboembolism, urinary tract infections,
aspiration pneumonia, pressure sores, spasticity and falls. Post stroke
depression, delirium, cognitive impairment, and anxiety are the prominent
neuropsychiatric complications associated with stroke. Hence, it is important
to continue close monitoring and vigilant observations of patients with
stroke, for early detection and timely intervention of these complications.

Preventative strategies and treatments are available and should be used

when appropriate. Prevention and specialist management of complications
that arise following stroke may improve both short-term and long-term
outcome of stroke survivors. Anticipating potential post-stroke complications
may also expedite initiation of preventative and therapeutic measures in

20
high-risk patients. Multidisciplinary stroke unit care provides the best
environment to prevent and manage these complications effectively.

Early Neurological Deterioration

Early neurological deterioration is generally seen in the very early stage of
the post stroke period and is relatively common after acute strokes. These
complications are associated with increased disability and mortality. There
are a number of mechanisms involved with neurological deterioration
including, neurological causes as a direct consequence of the neurological
insult to the brain, and non-neurological causes such as abnormal
physiological parameters. Both of these mechanisms can lead to secondary
neuronal damage within the ischaemic penumbra. Acute neurological
deterioration is predominantly due to brain parenchymal involvement and
common complications include haemorrhagic transformation of infarction,
seizure activity, cerebral oedema and death subsequent to brain herniation.

Many of these factors are potentially reversible, and therefore it is crucial

that appropriate monitoring is undertaken to identify high risk patients.
There is substantial evidence that offering high dependency unit care for
patients with higher potential risk of developing early neurological
complications after acute stroke, will dramatically improve the mobility and
mortality.

Venous Thromboembolism in Stroke

Venous thromboembolism (VTE) is a common and potentially life-
threatening condition seen after stroke and there are a number of different
mechanisms described for heightened risk of venous thrombosis after stroke
which include loss of muscle pump, blood stasis in paralytic limb and
underlying prothrombotic conditions. The risk of VTE is common in first
month to three months following the initial event of stroke predominantly
due to immobility. Deep vein thrombosis (DVT) is a serious complication in
patients with stroke in which blood clots form in deep veins of paralytic lower
limbs and may lead to the devastating consequences of a pulmonary
embolism (PE) if these clots embolize to lungs. The common risk factors for
DVT after stroke include older age, high National Institute of Health Stroke
21
Scale (NIHSS) score, hemiparesis, immobility, female gender and atrial
fibrillation.

The signs and symptoms of PE are usually nonspecific and can include sudden
onset pleuritic chest pain, shortness of breath, tachycardia, tachypnea,
hypoxia and hemoptysis. This is even more applicable in stroke patients as
they often find it difficult to communicate their symptoms accurately. As a
result of these diagnostic challenges, PE may be mistaken for pneumonia,
which is relatively common after stroke. The gravity of PE after stroke is even
greater as there are subclinical and silent events which are often clinically
unrecognized and cause sudden death. Hence, a high degree of clinical
suspicion is of paramount importance in early diagnosis and appropriate
management of PE.

Prophylactic anticoagulant therapy for preventing DVT and PE is widely used

in many patients hospitalized with different medical conditions including
stroke. Usage of prophylactic anticoagulation, even at lower doses, can result
in significant complications due to increased risk of bleeding especially in post
stroke patients. The recommendations on usage of prophylactic
anticoagulation in post stroke patients remain controversial in different
guidelines and majority of them do not recommend it for universal use. The
clinical decision should be made considering the benefits of anticoagulation
and the risk of bleeding. Meanwhile, the usage of mechanical DVT
prophylaxis is more popular among clinicians even though the evidence is
scant. According to the available evidence, the graduated compression
stockings are not very beneficial, but intermittent pneumatic compression
showed more robust evidence in preventing deep-vein thrombosis and
reducing mortality. The events of venous thromboembolism should be
managed as a matter of urgency with anticoagulation or an inferior vena cava
filter if the risk of bleeding is high.

22
Infections after Stroke
Even with the recent advancement of stroke care and sophisticated facilities,
infection remains the most common and clinically important medical
complication during the post stroke period. Pneumonia and urinary tract
infections are the most frequent post-stroke infections and are often
attributed to post stroke neurological impairments such as motor paralysis,
immobilization, incontinence and dysphagia. Stroke-induced impairment of
immunological competence has also been described as a cause for increased
risk of infections among stroke survivors, further, older age and associated
co-morbidities also play a vital role in post stroke infections. These
complications are commonly associated with poor outcomes including
deterioration of disability, prolongation of hospital stay and eventually death
in complicated patients.

The commonest infection after stroke is pneumonia and the incidence ranges
between 3% to 12 % in stroke units. Post-stroke pneumonia is usually caused
by aspiration due to neurological deficits, such as impaired level of
consciousness, disturbed protective reflexes or dysphagia. In addition,
aspiration, stroke severity, age, medical comorbidities, and stroke induced
immune depression also contribute to a larger extent in post stroke
pneumonia. Conventionally, the diagnosis of pneumonia is based on clinical
assessment, radiological imaging and relevant microbiological analysis;
however, in the practical setting the diagnosis is mostly based on clinical
evaluation. In complicated cases and in clinical doubts it is always
recommended to obtain specialist opinion and request for advanced
investigations. Commencement of empirical antimicrobial therapy based on
local microbiological recommendations, in the earliest stage of presentation
is of evident importance in minimizing life-threatening complications.

Urinary tract infections (UTI) are one of the commonest infections often seen
in stroke survivors and the incidence is usually around 3 to 9%. Bladder
dysfunction is a frequently seen complication among stroke patients and out
of them, urine-storage disorder due to bladder hyper-reflexia seems to be
more common. As a result of bladder dysfunction, most post stroke patients

23
develop urinary incontinence which is one of the most important risk factors
for UTI. There are a number of other risk factors for UTI after stroke such as
female sex, age, stroke severity, poor cognitive function, and catheterization.
Clinical suspicion is essential in timely diagnosis and prompt treatment as
subtle, nonspecific presentations are frequently seen in UTIs of post stroke
patients. Appropriate antimicrobials should be commenced based on local
guidelines.

Even in dedicated stroke units with standard management protocols, post-

stroke infections remain the most responsible factor for poor outcome.

Post Stroke Epilepsy

Even though the incidence and prevalence rates are highly variable in
different studies, it is well understood that epilepsy after stroke is a relatively
common phenomenon. According to most of the prevalence studies, the
incidence rates of post stroke epilepsy are between 2.5 and 6.5 %. Since, the
brain parenchyma gets damaged and scarred as a result of cerebral
infarction, there will be a permanent structural abnormality in the brain
following any type of stroke and theses structural abnormalities may create
a seizure activity at any time after a stroke. Higher incidence of post stroke
seizures occurs in subarachnoid haemorrhage (SAH), intracerebral
haemorrhage (ICH), and large-volume cortical infarct.

Investigations should be undertaken to rule out alternative diagnoses such

as cardiac disease-causing syncope and non-stroke causes of seizures
including electrolyte and metabolic abnormalities, malignancy, and drug or
alcohol withdrawal. Due to the large number of possible causes for seizure-
like activity, magnetic resonance imaging, electroencephalogram (EEG) and
video telemetry may be considered to support the probable diagnosis of
post-stroke epilepsy when the clinical scenario is complex.

Once the diagnosis of epilepsy is confirmed after a detailed clinical

assessment, appropriate antiepileptic medications should be started
considering relevant patient factors. Even though epilepsy has been

24
considered as an independent risk factor for greater mortality following
stroke, majority of patients achieve successful seizure remission with
treatment.

Post Stroke Spasticity

Spasticity is a clinical phenomenon of upper motor neurone pathology and is
commonly associated with pain, stiffness, and spasm which results in a
massive impact on physical, functional, and emotional lifestyle of affected
patients. According to prevalence studies spasticity occurs in 17 to 38% of
patients following stroke and it can develop within the first few weeks to
months after stroke. The onset of the spasticity is mostly variable, and it can
develop in the early, late, or very late stages of the post stroke period. A
number of neurological factors affect the onset and severity of spasticity in
stroke which include size and location of the infarction and age of the lesion.
The common pattern of spasticity in upper limb is adduction and internal
rotation of shoulder together with flexion at elbow, wrist, and fingers. In
lower limbs, the most frequently seen pattern is adduction and extension of
knees together with inversion of foot.

In the context of any motor weakness, spasticity can be either be beneficial

or detriment depending on the degree of involvement. Spasticity sometimes
positively contributes to maintenance of mobility and posture, preservation
of muscle mass and bone health, and prevention of venous thrombosis.
However, when spasticity is extreme, it can interfere negatively with
positioning, mobility, functional movements, and hygiene. Therefore,
clinicians managing patients with spasticity must consider components of the
functional disability and effects of spasticity before introducing the
management plan. The reduction of beneficial effect of spasticity would be
counterproductive. Hence, the appearance of spasticity following stroke
does not always warrant treatment.

Reduction of negative functional complications, minimizing caregiver

burden, improvement of posture, and achieving early independence in
Activities in Daily Living (ADL) are the key treatment goals for disabling post-

25
stroke spasticity. A multidisciplinary approach is absolutely important in the
process of management of spasticity arising after stroke. Especially a
cooperative team approach with involvement of physicians, nurses,
physiotherapists, occupational therapists, and orthotists would be essentially
important for a successful outcome. Conventionally, spasticity is managed in
a sequential manner with step wise approach and treatment must be tailored
according to the functional impairments of individual patients.

Usually, the management of spasticity is combined with both physical

therapy and pharmacological treatments. The commonly used
pharmacological treatments include systemic anti spastic medications and
locally acting agents. There is substantial evidence to support the use of
botulinum neurotoxins for focal spasticity and it has proven efficacy in
reducing muscle tone in administered groups. There is emerging evidence of
effectiveness of physical therapy including electric stimulation delivered to
muscles after botulinum toxin injections, serial casting of ankle and elbow
joints, partial body weight support gait training, and limb neuroprosthesis.

Timely detection and appropriate management of post-stroke spasticity will

improve functional capacity, independence, and quality of life in patients
with spasticity while minimizing care burden.

Pressure Sores after Stroke

Stroke patients are a group at high risk for pressure sores due to many
different disease and patient related factors. It is important to identify risk
factors for pressure sores in post stroke patients in order to facilitate early
adoption of appropriate preventive and treatment measures. Severity of
neurological disability, older age, history of diabetes mellitus, and peripheral
vascular disease are the predominant predisposing conditions for pressure
sores in patients after stroke. Additionally, immobility, reduced attention,
sensory loss, and tonal changes will make it further complicated. Positioning
and pressure care are important components of post stroke management
and has significant impact on minimizing the development of pressure sores.

26
There are a number of recommended strategies for effective positioning of
post stroke patients that will remarkably prevent the complications related
to pressure sores and eventually improve the rehabilitation process. Every
patient after stroke should be considered as potentially high risk for
developing pressure sores and positioning and pressure care plan should be
designed based on the patient’s individual risk factors.

Post Stroke Psychological Disorders

Stroke related neurological and functional disability directly affect the
individual’s psychology after an acute stroke. The commonest psychological
disturbances include depression, anxiety, emotionalism, and cognitive
impairment. Post stroke psychological disorders affect over half of the stroke
patients at some point after their stroke. These psychological issues are
associated with higher mortality and disability rates, poor quality of life and
impaired personal relationships. The independent predictors of depression
after stroke include severity of stroke, functional disability, and past history
of depression. Apparently, depression itself is the main risk factor for anxiety
after stroke. Cognitive impairment is common after stroke and deficits may
affect specific cognitive domains such as language or may be more global.
Each of these psychological impairments has a huge impact on the
rehabilitation process and is directly associated with poor functional
outcome and impaired quality of life.

Clinicians involved in the care of stroke patients should be able to diagnose

depression, anxiety, and cognitive impairments accurately in early stages.
Every standard stroke care team should have a dedicated psychologist who
will play a vital role in recognition and delivering non-pharmacological
interventions for post stroke psychological disorders. Liberal use of
antidepressants should be considered for the management of depression,
anxiety, and emotionalism after stroke which has shown clear benefits in
rehabilitation outcomes.

27
Post Stroke Pain
Pain is a common and often distressing complication of stroke, which can
have a negative impact on rehabilitation and recovery. Post stroke pain
frequently affects the shoulder and upper limb and is usually classified as
either central post-stroke pain or post-stroke shoulder pain. Other common
types of pain experienced by post stroke patients include spasticity-related
pain, tension-type headaches, limb pain exacerbated by immobility, and
widespread pain syndromes. Previous painful disorders and post stroke
depression are well recognized risk factors that will contribute to post stroke
pain.

Careful clinical assessment is needed to ascertain the underlying causes and

commence appropriate treatment and monitoring. All members of the
multidisciplinary team, both in hospital and after discharge, need to be aware
of the problems associated with post-stroke pain and the need for specialist
referral where necessary.

There are several other minor medical complications frequently seen during
post stroke period such as post stroke fatigue, post stroke insomnia, and falls
after stroke. All these complications directly affect the rehabilitation process,
morbidity, mortality, quality of life, and caregiver burden. Hence, it is evident
that treating clinicians and members of multidisciplinary team should pay
adequate attention and make observations for early recognition and
implementation of appropriate treatment of post stroke complications.

Prognosis after Stroke

Stroke is the second leading cause of death across the globe, although the
mortality rate is slowly declining. More than 75% of patients with acute stoke
will survive for one year and five-year survival rate is over 50%. The majority
of patients who survive a stroke recover their independence, although
around 25% are left living with minor disabilities and around 40% have more
severe disabilities.

The patient prognosis after an ischemic stroke is much more positive than
after a haemorrhagic stroke during acute presentation. In addition to brain
28
parenchymal damage, haemorrhagic stroke increases the risk of critical
complications such as cerebral oedema, increased intracranial pressure, or
spasms in the brain vasculature which led to relatively higher mortality in
haemorrhagic stroke during the initial 30 days after stroke. Hence, the
mortality after acute stroke is commoner in haemorrhagic than ischaemic
stroke. The predictive factors for poor prognosis and delayed rehabilitation
outcome include, severity of neurological damage, initial functional
impairment, presence of post stroke depressive disorder, and urinary
incontinence. In addition, there are several non-neurological factors such as
age, socioeconomic background, family support, and previous personality
type which affect the prognosis both positively and negatively.

There have been major advances in acute stroke management, critical care
and stroke rehabilitation over the last couple of decades and that has made
a remarkable positive impact on mobility and mortality. In addition, more
importantly it has created a huge attitude shift towards positive directions in
stroke as a disease.

Accurate and elaborative data on post stroke complications and prognosis

after stroke is of vital importance in planning acute stroke management,
rehabilitation process, and long-term care.

29
References
1. Bhalla, Ajay & Birns, J.. (2015). Management of Post-Stroke Complications.
10.1007/978-3-319-17855-4.
2. Kumar S, Selim MH, Caplan LR. Medical complications after stroke. Lancet
Neurol. 2010 Jan;9(1):105-18. doi: 10.1016/S1474-4422(09)70266-2.
3. Khan MT, Ikram A, Saeed O, et al. Deep Vein Thrombosis in Acute Stroke -
A Systemic Review of the Literature. Cureus. 2017;9(12).
4. Liao X, Ju Y, Liu G, Zhao X, Wang Y, Wang Y. Risk Factors for Pressure Sores
in Hospitalized Acute Ischemic Stroke Patients. J Stroke Cerebrovasc Dis.
2019 Jul;28(7):2026-2030.
5. Stefan Sennfält, Bo Norrving, Jesper Petersson, Teresa Ullberg Long-Term
Survival and Function After Stroke. Stroke. 2019 Dec;50:53–61.
6. Alawieh A, Zhao J, Feng W. Factors affecting post-stroke motor recovery:
Implications on neurotherapy after brain injury. Behav Brain Res. 2018 Mar
15;340:94-101.

30
Chapter 5: Stroke Rehabilitation: A Practical Approach
Dr Harsha Gunasekara

Introduction
Stroke is infamous in its notoriety for dealing a critical blow to an individual’s
ability to perform the crudest and simplest of bodily movements and has
claimed a name of its own in being one of the most common causes of adult-
onset disability. Statistics reveal that 70-85% of first strokes are accompanied
by hemiplegia and only 60% of people with hemiparesis who need inpatient
rehabilitation achieve functional independence in simple activities of daily
living (ADL) 6 months post-stroke. Patients with sensorimotor and visual-field
losses tend to be dependent on caregivers on a much higher degree in
comparison to those with pure motor impairments.

Stroke rehabilitation can be defined as the process of post-stroke care that

aims to reduce disability and improve patient participation in activities of
daily living (ADL), and it incorporates organized, multidisciplinary, and
supportive services that commence within 24 hours after onset, in patients
who have reached stability. Functional recovery and achievement of
independence are promoted in patients with acute stroke utilizing
rehabilitation as the primary mechanism.

Organization of Post-Stroke Rehabilitation Services- Levels of

Care
It is implied by firm evidence that an organized multidisciplinary stroke care
regimen tends to succeed not only in reducing mortality rates, likelihood of
institutional care, and long-term disability, but also enhances recovery, while
promoting ADL independence. A majority of the research works conducted
on stroke, however, have had their focus on acute and post-acute care, with
a lesser degree of attention towards the more chronic recovery phase. The
ensuing discussion attempts to describe the different levels of care available
for stroke rehabilitation.

31
Inpatient Rehabilitation Facility (IRF)
IRF offers care at the level of the hospital to those patients who are in need
of intensive, multidisciplinary rehabilitation programs to improve their ability
to function, and all stroke units and neurology units with dedicated stroke
beds are ideally expected to offer IRF level care. Listed out below is a
standard set of recommendations for IRF level care.

Admissions to an IRF are justified only when the rehabilitation team deems
significant functional improvement possible within a reasonable time period.

Standard set of recommendations for IRF level care

Ideally suited for acute stroke patients with medical comorbidities.

24-hour availability of Neurologist/Physician/Medical Officer

Close supervision by nursing officers specially trained and/or experienced

in rehabilitation.

Availability and provision of physical therapy (PT) and occupational therapy

(OT). Intensity and duration of therapy varies according to patient needs
but standard recommendations specify a minimum of 45 minutes to 3
hours for at least 5 days a week.

Availability of other skilled rehabilitation modalities – speech and language

pathology (SLP), prosthetic and orthotic services, psychological services,
and social services.

Documentation of medical interventions, patient progress, review of initial

rehabilitation goals, and discharge planning every 2-3 days and through
weekly multidisciplinary team (MDT) conferences.

32
Skilled Nursing Facility (SNF)
Another inpatient rehabilitation setting is the skilled nursing facility, an
institution or a distinct part of an institution in which the primary focus is the
provision of skilled nursing care and rehabilitation services to residents
requiring medical or nursing care. Even in the absence of expectations that
the stroke survivor would reach full or partial recovery, skilled services within
a skilled nursing facility can be requested to maintain or prevent further
deterioration of the patient’s current medical status.

Examples for situations in which there is a need for skilled nursing services
include bowel and bladder impairment, skin breakdown or high risk for skin
breakdown, impaired bed mobility, dependence for activities of daily living
(ADLs), and high risk for nutritional deficits. It should be kept in mind that
nursing services are not limited to the above-mentioned circumstances.

Outpatient Rehabilitation
In the Sri Lankan context, the available outpatient rehabilitation services are
usually based on hospitals whereas there seems to be a lack of those that are
home-based. In an ideal situation, a periodically reviewed plan for therapy
services, with the input of therapists with a minimum frequency of every 30
days should exist, along with a physician referral specifying the therapies
needed.

Services are required to possess the features of being reasonable, necessary,

restorative, complex, and sophisticated enough to necessitate the
supervision of a qualified healthcare professional (HCP), only by or under
whom it can be performed in a safe and effective manner.

Long Term (chronic) Care Settings

The successful management of the stroke survivor’s level of health may
require the provision of support and external resources, which becomes the
main focus of care in the long-term setting. These services may be
preventive, diagnostic, and/or therapeutic, and may include counseling and
educational services. It is of utmost importance that these services be
prescribed by a physician or other qualified HCP.

33
Early Supported Discharge (ESD) Rehabilitation Services
It is wise to consider ESD for patients with mild to moderate stroke, in the
presence of adequate community services for both rehabilitation and
caregiver support, with the possibility of providing the desired level of
intensity of rehabilitation.

Stroke Rehabilitation- How to do it?

Three different approaches are adapted in the process of stroke
rehabilitation, the primary goal being the improvement of functional
recovery. The first of these is restoration, which involves re-training of the
central nervous system (CNS) to engage in the impaired function in order to
restore the function subserved by the injured brain tissue. Compensation is
considered next, and it involves adaptation through the use of devices or
specific behaviors to perform the lost/impaired function. Finally,
modification attempts to alter the patient’s environment to promote
function and ADL.

The rehabilitation process can be broken into five essential steps which are
discussed in the subsequent sections.

Step One- Organized Care Setting and Multidisciplinary Team

Based on Standard Recommendations
Securing a defined geographical area for the purpose of establishing a stroke
unit has proven to be quite challenging in Sri Lanka, as factors such as limited
space availability in hospitals belonging to the state sector and other
procedural issues cause significant impedance. In such a framework, it
becomes more practical to allocate a few beds from a unit or ward to serve
the purpose. The latest recommendations on Stroke Systems of Care can be
found in Stroke. 2019;50: e187-e210. Staffing requirements for stroke units
can be found in British Association of Stroke Physicians (BASP) Stroke Services
Standards- June 2014.

34
Composition, functions and service requirements of the MDT in stroke rehabilitation.

Discipline Description of Duties

Neurologist/Physician/Medical Usually coordinate the rehabilitation
Officer team and manage medical conditions
pertaining to stroke and comorbidities.
Nursing Officer Manage medical issues, continence,
skin, nutrition, hydration, provide
ongoing patient and caregiver
education, and establish care plans to
maintain optimal wellness.
Physiotherapist Experts in examining and treating
neuromuscular problems that affect
the abilities of individuals to move.
Occupational Therapist Focus on improving the skills of ADL
Speech & Language Pathologist Assess speech, language, and other
cognitive functions, as well as
swallowing, and provide interventions
and counseling/education to address
language and speech disorders
Social Worker Assist individuals, groups, or
communities to restore or enhance
their capacity for social and economic
functioning, while creating social
conditions favorable to their goals. Also
assist in vocational barriers.
Psychologist Improves patient participation in the
rehabilitation process through
motivation and also address the
psychiatric comorbidities
It is recommended that all stroke rehabilitation services incorporate
organized training for all categories of staff and caregivers involved.

35
Step Two- The Rehabilitation Assessment
A comprehensive assessment of the patients’ needs within 24 hours of
admission should be carried out concurrently with other diagnostic tests,
depending on the patient’s medical stability, to all admissions received at the
stroke unit. The rehabilitation assessment should direct its attention towards
three essential requirements. They include identification of extent and
severity of disability and assessment and documentation of functional
capacity using the Barthel Score, screening for post-stroke complications, and
referral to appropriate therapy services.

The medical officers are duty bound to ensure that all admissions to the
stroke unit are referred to the appropriate therapy services within 24 hours,
using referrals whose reception by the MDT members and initiation of
therapy is seen to by the nursing officers. On admission to the stroke unit,
patients should be assessed for post-stroke complications with the
assessments described below, using screening tools whenever appropriate.

Dysphagia Assessment
On suspicion of dysphagia or risk of aspiration, a bedside water swallowing
screen should be performed by the speech and language pathologist (SLP) or
nursing officer and appropriate feeding adjustments should be made in
accordance with the advice provided by the SLP.

Assessment for Skin Breakdown

This involves identification of at-risk patients via application of screening
tools (Barden or Waterlow scale), following which regular assessments and
suitable interventions which include turning every 2 hours, using support
surfaces, avoiding excessive moisture, and maintaining hygiene, should be
carried out.

Assessment of Risk of Deep Vein Thrombosis (DVT)

Aided once again by appropriate scales for risk assessment, patients who are
at high risk for DVT should be identified and recommended preventive
measures such as the use of low molecular weight heparin (LMWH) and
pneumatic compression should be undertaken.

36
Assessment of Bladder and Bowel Functions
The risk of skin breakdown is elevated in the case of urinary and faecal
incontinence, and it is well advised to avoid the use of urinary catheters for
a prolonged period of time.

Assessment of Nutrition and Hydration

Nutritional supplementation becomes a requisite, only in the presence of
malnutrition. The correction of dehydration and the prevention of over
hydration, especially avoidance of 5% dextrose, is essential in all stroke
patients.

Assessment of Depression and Emotional and Behavioural Disturbances

It is of the highest importance that diagnosed patients should undergo
pharmacological treatment and psychological counseling, as patient
motivation, and the outcome of the rehabilitation itself could be subject to
adverse effects by depression, emotional lability, and behavioural issues.

Step Three- Rehabilitation Goal Setting

Goal setting, or goal planning in other words, is the corner stone of effective
stroke rehabilitation and a prerequisite for multidisciplinary teamwork. Goal
setting should have the patient as its center of focus and should be done
through discussion in concert with the MDT at the initial case conference.
Goal planning in stroke rehabilitation is vital as it has the capacity to improve
patient outcome and to enhance patient autonomy, in addition to which it
also helps in the evaluation of outcomes.

The principle of being “SMART” applies to rehabilitation goals, as they too

are required to possess the characteristics of being Specific, Measurable,
Achievable (rather than challenging), Realistic (rather than hopeful), and
Timebound. It is to be expected of the patient to direct his focus at tasks
which matter the most, and the therapist should be able to select goals that
are manageable or tasks that are of a lower order and then initiate therapy
plans to achieve them. The stroke MDT members should encourage the
active involvement of the family/caregivers in day-to-day care and
rehabilitation.

37
Examples of rehabilitation goals
Goal Theme Specific Goal Responsible MDT
Improve mobility Walk without support PT
Improve Hand Function Increase use of left OT
hand

Improve skill in using

right hand
Improve speech Improve functional SLP
communication

Learn strategies to
assist with word
finding

Step Four- Implementation of Interventions, Overcoming Barriers,

and Evaluation of Progress.
It is recommended that stroke survivors receive rehabilitation at an intensity
commensurate with anticipated benefit and tolerance. Intensive and very
early mobilization within 24 hours of stroke onset can reduce the odds of a
favourable outcome at 3 months and is not recommended.

Barriers to patient compliance to rehabilitation should be recognized and

corrected. Common problems that arise include pain which may be post-
stroke shoulder pain or pain due to spasticity or osteoarthritis, depression,
and socio-economic factors.

The multidisciplinary team collectively plays a pivotal role in enhancing the

ability of stroke patients to progress in the rehabilitation process via
implementing the therapies needed to achieve the short- and long-term
goals. Although each discipline has its own unique contribution, weekly
conferences facilitate individualization of care approach and evaluation of
care plan and outcome parameters.

38
Traditionally, it is the duty of the nurses to ensure consistent and timely
implementation and evaluation of the recommendations presented and
whilst members of each discipline treat particular body structures and
functions, the nurse tends to the patient as a whole, thus providing continuity
and integrity to both the patients’ and their families’ rehabilitation
experience. As the nurses are the ones caring for patients 24 hours a day, 7
days a week, they naturally become the primary professionals who are
expected to communicate and collaborate effectively with all parties
involved, to achieve the patients’ individualized care needs.

Step Five- Discharge Planning and Continuum of Care

The inpatient care to home transition after a stroke event can indeed be quite
challenging to both the patient and the caregiver. Those patients who require
ongoing rehabilitation after discharge should continue to be followed up by
a care team with expertise in stroke rehabilitation, whenever possible.
Patients who do not require additional rehabilitation services are discharged
to their homes, and early supported discharge (ESD) should be offered as an
option to all eligible stroke patients. Those who are profoundly and
permanently disabled and are discharged to long-term care settings, can be
managed by a primary care provider.

In accordance with statistics which reveal that one in four stroke patients
experience recurrence, it is essential that all patients receive health
education and medications for secondary prophylaxis. Family and caregivers
should be provided with information on outpatient and community
rehabilitation and follow ups should be arranged to ensure continuity of care.

Conclusion
Stroke rehabilitation is in essence, a massive process which requires a
sustained and coordinated effort from a large team including the patient,
family, or other caregivers such as personal care attendants, physicians,
nurses, physical and occupational therapists, speech and language
pathologists, psychologists, social workers, and others. Communication and
coordination among these team members are paramount in maximizing the
effectiveness and efficiency of rehabilitation, without which the isolated
efforts to rehabilitate the stroke survivor are unlikely to achieve their full
potential.
39
References
1. Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation
Care of the Stroke Patient. Stroke. 2010;41:2402-2448
2. Strategies for stroke rehabilitation. Lancet Neurol. 2004 September; 3(9):
528–536
3. Recommendations for the Establishment of Stroke Systems of Care: A 2019
Update. Stroke. 2019;50:e187-e210
4. Guidelines for Adult Stroke Rehabilitation and Recovery - A Guideline for
Healthcare Professionals from the American Heart Association/American
Stroke Association. Stroke. 2016;47:e98-e169
5. European Stroke Organization Recommendations to Establish a Stroke Unit
and Stroke Center. Stroke. 2013;44:828-840
6. Patient-Centered Goal Setting in a Hospital-Based Outpatient Stroke
Rehabilitation Center. http://dx.doi.org/10.1016/j.pmrj.2016.12.004
7. STROKE SERVICE STANDARDS – June 2014. British Association of Stroke
Physicians

40
Chapter 6: Multidisciplinary Stroke Care
Dr Champika Gunawardhana

Introduction
The neurological impairment, functional disability and psychological distress
of stroke can have a profound effect on recovery process, quality of life,
overall patient outcome, and caregiver burden. Despite the recent
advancements in the field of hyper-acute and acute stroke management, the
vast majority of stroke survivors remain functionally disabled. Therefore,
rehabilitation represents a key part of stroke care for the majority of post
stroke patients and can create a significant contribution for improving their
quality of life.

Stroke rehabilitation should begin with the patient's hospital admission.

Obviously, the degree of recovery is impacted by many factors including the
quality of stroke rehabilitation process.

Coordinated Stroke Rehabilitation

Rehabilitation is a scientific, structural, and dynamic goal-oriented approach
to provide optimal functional recovery and independence in patients. Since
it is a complex process, it is impossible to manage with the involvement of an
individual professional and essentially requires the development of a
professional rehabilitation team. Teamwork is the key factor in rehabilitation
process to achieve holistic goals in complicated, disabled post stroke patients
and this approach facilitates the achievement of the best possible and
desirable outcome in rehabilitation.

It is a well-recognized concept that collaboration and coordination are the

most successful mechanisms to achieve challenging rehabilitation objectives
in the real world. Communication and collaboration among multidisciplinary
team members is one of the key elements which develop the habit of
constant discussions about patients and continuous information exchange
during the management process. Coordination is the other element which

41
facilitates efficient group work based on structured plans and systematic,
target oriented interventions.

Professionals in different fields in rehabilitation should function together to

provide the best expertise to the process and enhance the quality of life in
disabled patients. The definition of Multi-Disciplinary Team (MDT) refers to
activities that involve the efforts of individuals from a number of disciplines.
These efforts are discipline-orientated and, although they may impinge upon
clients or activities dealt with by other disciplines; they approach them
primarily through each discipline relating to its own activities.

The MDT in stroke include the neurologist/stroke physician, physiatrists,

stroke nurse, physical therapist, speech and language pathologist,
occupational therapist, clinical psychologist, orthotist, and social worker. This
group of professionals assess and analyses the disabilities of patients and set
specific, achievable goals to provide the best possible care. The common
platform designed for the professionals to develop a patient centered and
goal-oriented rehabilitation process based on detailed discussions is the
MDT. Every professional involved in the MDT process has a shared
responsibility and equal opportunity to provide the best and evidence based
therapeutic options to achieve holistic patient care. This will only be
reachable with commitment, cooperation, and appropriate communication
with each member of the MDT team for the betterment of patient care.

Effectiveness of Multidisciplinary Stroke Care

There is unequivocal evidence of improved outcomes when patients are
treated in stroke units by multidisciplinary teams. In comparison to
conventional stroke care, structured inpatient stroke management has
clearly shown reduction in long-term dependency, improved quality of life,
and mortality. There is also substantial evidence that involvement of MDTs
in post stroke rehabilitation facilitate early discharge and increase regaining
independence.

42
There is a dire need to improve stroke rehabilitation care and MDT approach
in Sri Lanka. An acceptable, feasible, and economical multidisciplinary stroke
care model should be introduced to the local health system as early as
possible. Implementation of a multidisciplinary stroke care model will
definitely enhance the patient out comes after stroke.

References
1. Clarke, David. (2013). The role of multidisciplinary team care in stroke
rehabilitation. Progress in Neurology and Psychiatry. 17. 10.1002288.
2. Tyson SF, Burton L, McGovern A. The effect of a structured model for
stroke rehabilitation multi-disciplinary team meetings on functional
recovery and productivity: a Phase I/II proof of concept study. Clin Rehabil.
2015 Sep;29(9):920-5.

43
Chapter 7: Nursing Care for Stroke
Dr Sujatha Seneviratne & Ms G Thushari Anuruddhika

Nurses render health services to the individual, the family, and the
community and coordinate their services with those of related groups
[International Council of Nurses (ICN), 2012]. The four fundamental
responsibilities of nurses include promotion of health, prevention of illness,
restoration of health, and alleviation of suffering which exemplifies the
delivery of safe, competent, and ethical nursing care for stroke within the
multidisciplinary team. Nurses who work in stroke units have a wide range of
functions and responsibilities including assessment, identification of life-
limiting and life-threatening problems, monitoring, rehabilitation, and
providing psychological support to enhance recovery. The wide range of
responsibilities and functions a nurse would perform incorporates the
fourteen Basic Human Needs of a patient described by Henderson and the
International Council of Nurses (1998). Accordingly, nursing care must be
tailored for individual needs of a patient based on cognitive and physical
functional level of each individual from the onset of stroke. This article provides
an overview of the functions and responsibilities of nurses in the care for
stroke to assist the affected persons in fulfilling their needs and to achieve
optimum health within their scope of practice.

Nurses’ Responsibilities in Stroke Care

Nurses are responsible to provide comprehensive care round the clock
focusing on nursing assessment and recording of vital signs and level of
consciousness from admission onwards and making on-going observations as
required and throughout their stay in hospital, taking care of the patients’
general health including physical care, the provision of a favourable
environment (both physical and psychological), administration of
medications as prescribed, assisting in optimal positioning, maintaining
nutrition, bladder and bowel functions, rehabilitation and preventing
complications. It is essential for nurses to anticipate, prevent, and recognize
as early as possible, the risks for complications in stroke patients at the acute
phase because complications may affect the patient outcomes. In such

44
instances, timely interventions and care will be delivered by the nursing staff
coordinated with the members of the multidisciplinary team. Further, nurses
are in constant contact with the patient and family members to provide
necessary information and support. Nurses have to be mindful about
problems in vision that can occur in patients who have weakness on the right
side. Nurses have to approach such patients from his/her left side in
providing care, because the patient will not notice the nurse approaching
from his/her right.

Monitoring and Recording of Vital Signs and Level of

Consciousness
Assessment is performed initially on admission, immediately following the
treatment modalities, and throughout the hospital stay to identify the risks
and priority needs in providing nursing care. Nurses play a vital role in
observation of the patient in order to detect and inform the medical officers
of any deterioration of health status for timely action. The main vital signs
monitored and recorded by the nurses are body temperature, blood
pressure, respiration rate and pattern, oxygen saturation, pupils, capillary
blood sugar, and level of consciousness using the Glasgow Coma Scale (GCS).
The regularity of observation of GCS will depend on the severity of the
patient’s condition and according ot the guidelines provided. Nurses
implement the prescribed treatment and nursing care soon after the initial
assessment. For example, Oxygen will be administered immediately through
a face mask if a patient is having difficulty in breathing.

Provision of Physical Care

Nurses are responsible for preparation of the patients’ environment and
maintaining personal hygiene including mouth care, selecting suitable
clothes, grooming, assisting in maintaining body posture, and mobilization.

Preparation of the environment of patient

Preparing an environment which promotes recovery of a patient is a prime
responsibility of nurses. On receiving a patient to a stroke unit/ward nurses
prepare the patients’ physical environment considering the needs identified
during their initial brief assessment. In many wards the beds are arranged in

45
an open area, around a central station for staff. A patient’s unit consisting of
a bed with railings and facilities to elevate at least the head end, a locker or
a bedside cupboard, a bed-side table, and an armchair are arranged. The
distance between two beds in a ward should be at least one metre for easy
access and for the movement of equipment such as x-ray machines. Easy
access to the bathrooms is considered in relation to the activity level of each
individual patient. Nurses take measures to minimize environmental hazards
considering the potential visual and physical impairments. In addition to the
provision of clean bed linen and supplies, nurses maintain the patient care
environment with minimal noise levels, making sure not to talk aloud, having
a clear structure of the day, and ensuring undisturbed sleep to support the
healing process. A clear wall clock and a day calendar large enough to be read
at a distance would be essential in the recovery process of those who are
having cognitive impairments. The photographs or drawings/paintings on the
walls (if available) should be large with pleasant light colours and clear
enough for them to understand.

Maintaining personal hygiene

The level of nursing care in maintaining personal hygiene is decided on the
patient’s ability for self-care. The Barthel index is used to assess the activities
of daily living. Nurses will provide the necessities to the bedside and assist
the patient to perform the tasks such as brushing teeth. If the patient does
not have energy, physical ability, or if the patient is unconscious, nurses will
perform hygienic care including oral care, bed bath, maintaining skin
integrity, perineal care, hair care, and nail care. Additional precautions such
as goggles, mask, disposable apron, and gloves should be worn when the
patient is immunosuppressed or for safety of both the patient and staff.

Maintaining oral hygiene / mouth care

Providing oral care is aimed at promoting patients’ wellbeing and comfort by
removing offensive odours, food debris and plaques, preserving cleanliness
of teeth, gums, and mouth, and preventing infections. Oral care stimulates
circulation to the gums and helps to preserve their integrity. It also prevents
dryness of the oral mucosa and lips, freshens breath, and improves appetite.

46
Thus, oral care contributes to improve the quality of life of a stroke patient
and maintain self-esteem while enabling them to communicate better.

Nurses are aware of the risks associated with poor oral hygiene and are well
trained to assess and help patients to maintain or provide oral health. The
nurse has to choose the appropriate devices and cleaning products. A
conscious patient is made to sit in the Fowler’s (upright) position to prevent
aspiration during mouth cleaning and to inspect the oral cavity for any sign
of dryness, oedema, redness, bleeding, or debris. An oral airway can be used
to keep the mouth open for the procedure if the patient is unconscious. An
unconscious patient may need oral care four times a day. A Yankauer suction
can help in removing any excessive secretions in the mouth. Unconscious
patients mostly breathe through their mouths and because of that the
secretions get dry and stick on the surfaces of the mouth. If persistent
mucous is present or if the mouth is crusted, it is recommended to use
Sodium bicarbonate solution (prepared using one teaspoon of Sodium
bicarbonate dissolved in 500 ml of warm water). The solution should be
discarded once used. A lip moisturizer or glycerine can be applied to prevent
lips cracking.

Yankauer suction

Maintaining nutrition
The blood investigations at the initial screening including haemoglobin levels,
serum proteins, and electrolytes are helpful to make decisions by the
multidisciplinary team regarding the nutritional level and the dietary
requirements that need to be fulfilled. Risk of dysphagia should be screened
for within four hours of admission before administering any food, drink, or

47
oral medication. A water swallow test will be done to assess the patient’s
pharyngeal reflexes. Paroxysmal coughing, food dribbling out or pooling in
one side of the mouth, food retained for long periods in the mouth, or nasal
regurgitation when swallowing liquids must be observed.

If the patient is allowed to take food, nurses assist the patient with meals.
When feeding the patient, the food should be placed on the unaffected side
of the mouth and ample time should be allowed for eating. When there is a
difficulty in swallowing, nasogastric (NG) feeding should be continued until
the patient is able to swallow fluids.

Placing a NG tube has to be done by a skillful nurse. Explaining the procedure

to the patient is helpful in gaining his/her cooperation. Fowler’s position is
recommended for this procedure. Giving a sip of water to swallow the tube
when it reaches the pharynx is not encouraged in stroke patients. Only three
attempts should be made in inserting the NG tube at a time to prevent
trauma to nasal and oesophageal mucosa (University of Glasgow, n.d).
Checking of the placement of NG tube is traditionally done by auscultation of
the upper abdomen while pushing air through the tube with a syringe to
detect the “whoosh” sound, checking whether there is bubbling when the
distal end of the tube is put into a cup of water, or by checking the acidity of
aspirated gastric contents with pH paper. The aspirated contents from the
tube should be acidic with a pH less than 5.

Fowler’s position

It is important to take extra care in confirming the placement because the

above tests could be misinterpreted on the basis that stomach and lungs are

48
both resonant organs that can transmit sounds, and it can be difficult to
detect the difference, which could be misleading. However, evidence-based
practices to verify NG tube placement recommend aspiration and pH testing
(and x-ray if necessary) to be carried out to confirm the NG tube placement
before giving any fluids (National Institute for Health and Care Excellence,
2021). The precautions proposed include measuring of the NG tube by
placing the exit port at the tip of the nose, extending the tube to the ear lobe,
and then to the xiphisternum. Before giving each feed nurses need to check
the placement of the NG tube and the amount of gastric aspiration. Retained
feeds increase the risk for aspiration. The head of the bed should be kept
raised at 30 degrees or higher to prevent risk of aspiration.

Measurements for NG tube insertion

Bladder and bowel care

Urinary continence may be affected due to altered psychological status,
inability to communicate the need to urinate, or inability to use a bedpan or
urinal due to impaired motor control. Similarly, bowel control is a problem in
stroke with the most common problem being constipation. Management of
bladder and bowel functions is an essential part of rehabilitation. A high fibre
diet should be provided with adequate fluid intake (2-3 litres per day) for
those who have constipation, unless it is contraindicated. It is helpful for the
patient if a regular time is established for toileting.

49
Care of the urinary catheter
Urinary catheterization is done only when it is essential, and the catheter
should be removed as soon as possible. Nurses’ responsibilities include
making the autoclaved catheterization sets and other necessary supplies
readily available, selecting and providing the appropriate size (usually the
narrowest gauge) of catheter, maintaining the sterile technique during
insertion, adhering to infection control guidelines (College of Microbiologists
Sri Lanka, 2005) in care after insertion, and educating the caregivers on
catheter care if the patient has to be discharged with the catheter.

Closed drainage system

After insertion, the catheter tube is secured to the patient’s leg to prevent
catheter movement and urethral damage. The catheter tube and the urine
collection bag are kept from kinking to prevent obstruction. The drainage bag
should be placed below the level of the patient’s bladder at all times. The tip
of the drainage bag or tubing should not touch the floor or other surfaces. A
closed system is maintained by not disconnecting the catheter from the bag
other than the routine bag changes to prevent Catheter-Associated Urinary
Tract Infections (CAUTI). The sampling port should be used to take urine
samples from a catheterized patient, and it must be disinfected prior to
drawing the sample using a sterile syringe.

50
 Sampling port

Nurses ensure that the urethral meatus and the catheter tube are cleaned
daily with soap and water. Antiseptic solutions should be avoided. In females,
the labia should be separated, and the perineal area should be cleaned
downwards to prevent infection. In males cleaning should be done under the
foreskin. The urinary catheter is cleaned from the tip where it enters the
urethra, and then downwards away from the meatus. It is important to
maintain a record of intake and output to ensure adequate hydration in a
patient with an indwelling catheter.

If a urinary catheter is kept in-situ for more than two weeks, the catheter
should be clamped intermittently for 03 days prior to catheter removal to
improve bladder tone and bladder capacity. The patient should be informed
about the process of removal of the catheter and the expected problems
such as burning sensation when urinating. The catheter must be removed
slowly after deflating the balloon to minimize trauma. After removal, nurses
should assess and report inability or difficulty to pass urine, haematuria, or
any new incontinence or bladder distension.

Prevention of Specific Complications

Preventing aspiration
Maintaining airway and promoting adequate ventilation are first priorities
when caring for an unconscious stroke patient. Nurses look for any snoring
or harsh breathing sounds that may be a sign of the airway being
compromised. Appropriate positioning of the patients by the nurse i.e.,
turning them onto their sides, will facilitate drainage of secretions or vomitus

51
that may obstruct the airway and cause aspiration. The risk of aspiration is
assessed by a nurse initially through water swallowing test and also with the
Language and Speech Therapist. Further, nurses should remove secretions
collected in the mouth through suction, ensuring that the air way is
maintained patent; inspect the mouth and teeth and remove dentures if
present; and make a note on loose teeth that can be potentially dislodged,
obstructing the airway. When a patient is being fed through a NG tube
checking for the placement of the tube before each and every feed is a major
responsibility of the nurse.

Prevention of pressure sores

Nurses are responsible for prevention of pressure ulcers, and presence or
absence of pressure ulcers has been generally considered a performance
indicator for measuring the quality of nursing care. Assessment of risk of
pressure ulcers must be carried out using a standard procedure, for example
the Waterlow Pressure Ulcer Risk Assessment Chart as recommended by the
guideline for stroke care for Sri Lanka by Gunaratne et al. (2017).

Nurses’ routine care focuses on maintaining cleanliness of the patient

including assisting bathing or performing a bed bath for patients according to
their activity level. Maintaining skin integrity is a major concern and nurses
should provide skincare by cleansing and drying the skin followed by
massaging common pressure points using a lubricant cream. Pressure
relieving devices such as water/air mattresses can be used.

Common sites of pressure ulcers

52
If a patient is unable to turn or reposition him/herself in bed, nurses will
change the position every two hours to reduce the mechanical load of the
patient. Care must be taken to minimize shear and friction forces which cause
damage to skin when a patient is turned or positioned in bed. The skin areas
especially over bony prominences have to be observed regularly while
changing the position and urgent measures have to be taken if signs of
developing a pressure ulcer are evident. A standard turning chart/positional
change chart could be maintained with a column to record any risk of
developing a pressure ulcer and the observations could also be recorded in
the nurses’ notes.

Optimal positioning and prevention of shoulder pain

Nurses should change the patients’ position every two hours. When placing
a patient in the side-lying position, a pillow should be kept between the legs
before the patient is turned. The upper thigh should not be flexed completely
to prevent oedema and to promote venous return. If sensation is impaired
the amount of time spent on the affected side should be limited. Further,
nurses should encourage and remind the patients to engage in short periods
of exercise frequently and regularly to improve muscle strength and maintain
the range of motion. A written schedule for exercise would be helpful.

Proper positioning of the paralyzed arm or leg is essential to prevent pain and
further damage. The main goal of arm care after a stroke is to prevent partial
separation or subluxation of the shoulder joint. Nurses should take correct
measures when moving the patient in bed by supporting the affected arm
and asking the patient to support the affected arm with the unaffected arm
to prevent muscles, tendons, or ligaments from overstretching. In order to
prevent dislocation, the affected extremities should never be pulled. The
team should be made aware of any pain in the joints of the affected
extremities.

A patient who is paralysed can be positioned on the unaffected side as well

as the affected side. The side-lying position is most comfortable for a patient
when attention is given to appropriate body alignment. Nurses need to place
53
the arm in the correct position when the patient is lying in bed on the affected
or unaffected side and when sitting on a chair.

When lying on the unaffected side, the patient’s head should be supported
with a pillow and the affected shoulder should be forward and the arm
should be supported on one or two pillows. The affected leg should be well
supported using pillows, with the hip and knee bent and another pillow may
be used behind to prevent the patient from rolling backward.

Lying on the affected side Lying on the unaffected side

When lying on the affected side, the patient’s affected shoulder should be
positioned comfortably, supporting the entire arm on the bed and the
affected leg should be straight with knee slightly bent while the unaffected
leg is supported on a pillow.
When lying on the back or sitting up, pillows should be placed under the head
and under the affected shoulder, elbow, forearm, wrist, and hand.

54
 Lying on patient’s back or sitting up

Elevation of the arm and hand is also important in preventing dependent

oedema of the hand. Further, Pressure stockings are applied to paralyzed legs
to prevent thromboembolism as prescribed, and nurses need to observe the
status of the skin before its application.

Psychological Support and Care

Stroke is a life-changing event and the patients experience restricted physical
abilities as well as emotional problems. As a result, they experience low
moods, anxiety, and depression. Nurses caring for stroke patients are well
positioned to provide psychological support. The technological procedures,
medical equipment, investigations, and interventions intimidate the patients
and their families. The lack of knowledge on the disease and recovery process
which takes longer than they expect, misconceptions among people
regarding stroke as ‘the end of their lives’, and the limitations of time for staff
members to talk with the patients and their families may contribute to
elevated stress levels. Therefore, a supportive culture should be fostered by
nurses for the physical, intellectual, social, and spiritual well-being of
patients, family members, and staff in order to cope with the stress created
due to the sudden illness and hospitalization.

Nurses should discuss patients’ concerns, while giving adequate time to

express their emotions, needs, fears or opinions. They should be able to
identify the patients who need further psychological support by the

55
specialized team members during their encounters with patients while
providing physical care. Further, patients’ family members may need
psychological support especially when they have not been informed
adequately about the changes that have occurred in the patient. The family
members may have concerns regarding the treatment and care provided as
they may anticipate a speedy recovery. They need to be provided with
information on the nature of the existing problems as well as the
rehabilitation process.

Nurses may identify sources of support or connect them with family and
friends they wish to talk to, especially if a patient is not visited by his/her
relatives. They may encourage the family members to visit the patient, taking
turns, so that the patient has opportunities to make constant social contact.
Nurses are in a position to find out the persons preferred by the patient and
those who have the ability to support the patient and ask them to visit the
patient frequently. It will be helpful if the nurses could provide explanations
to the visitors regarding refraining from expressing sympathizing remarks
and discussing any negative aspects of recovery at the patients’ bedside as
such actions may affect their moods.

Patients may have problems related to cognitive, behavioural, and emotional

deficits following a stroke. Nurses play a supportive role in improving the
patients’ thought process, by reviewing the results of neuropsychological
assessments, observing the patients’ progress of performance, providing
positive feedback, building confidence in their strengths, and giving hope.

Helping to express/communicate
Patients with aphasia can be depressed due to inability to speak and express
themselves, and this inability to ask or answer a question, may result in
anger, frustration, fear of the future, and hopelessness. The speech and
language therapist will assess the patient and plan rehabilitation and the
nurses too, need to learn how to help the patients as a key role player in the
team. Nurses need to provide moral support and create a conducive
atmosphere to enable patients to communicate by being sensitive to their

56
needs and should try to respond appropriately. Nurses must talk to patients
with aphasia while rendering care to the patient, to provide social contact.
Maintaining the dignity of the patient and treating them as an adult at all
times is most important. Trying to complete the sentences spoken by the
patient is a common problem and should be avoided because it can cause
more frustration to the patient.

Nurses need to gain the patient’s attention when talking to them, and should
speak slowly, giving one instruction at a time. Time should be allowed for the
patient to process what was told, as it takes time to understand and
formulate an answer. Therefore, patience is an essential quality to develop
when communicating with such patients.

Enhancing self-care
Enhancing self-care is an essential component in the rehabilitation process.
Activities related to personal hygiene are encouraged by nurses as soon as
the patient has the strength to sit up. First the self-care activities such as
brushing teeth, shaving, eating, and combing hair are encouraged with the
unaffected hand. At the same time the patient is encouraged to perform the
exercises on the affected side as well. The need to repeat motor skills in order
to gain them has to be explained to the patient and family.

Educating the Family/Caregivers and Helping to Cope

Persons who take care of the patient after discharge, family members or
caregivers play an important role in the recovery of the patient. Post stroke
care and rehabilitation can be considered as the most significant stage of
stroke rehabilitation because this is the phase that decides the improvement
of the quality of life of the stroke survivors. It needs to be explained to the
family that rehabilitation may take months and the progress can be slow. The
family should be taught regarding the signs and symptoms of a stroke, risk
factors, and prevention of stroke, so that they will be able to identify its early
signs. Further, the family should be made aware of the emotional problems
such as laughing or crying, being easily irritable, or being confused. Family
and caregivers experience challenges such as increased workload, restricted
social life, physical problems, and knowledge and financial deficits. Nurses

57
need to understand the burden of family/care givers and the necessity to
provide knowledge and skills to maintain patients’ personal hygiene, manage
stress, look after their own health, and facilitate family coping. In educating
the family, nurses have to specifically consider the disabilities of the patient
and the knowledge of the person taking over care at home. Nurses are
expected to provide training on maintaining personal hygiene, mobilization,
and nutritional needs of the patient, as well as care for NG tubes, NG feeding,
and providing proper hydration. Further, nurses should guide them on bowel
care and on care related to urinary catheters, emptying drainage bags,
identifying catheter related complications, and when to seek professional
advice.

The Way Forward

Nurses are uniquely positioned to deliver care for early rehabilitation of
stroke survivors, but insufficient knowledge and skills in carrying out the
specific functions was identified as the major barrier. Further, demand for
more nurses and most importantly the ‘misdistribution of nurses’ has been
identified as a major challenge globally to address staff shortages and their
competencies. It is emphasized that nurses in stroke services should
complete stroke-specific training in order to deliver competent care for
better health outcomes. Provision of specific training at national level for Sri
Lankan nurses on stroke care to further nurses’ competence would maximize
the quality of care and patient satisfaction. The newly established Public
Health Nursing services in Sri Lanka (ICN, 2020), could be effectively utilised
to identify the unmet care needs of the stroke patients and their caregivers
for continuity of care in the community.

58
59
60
61
 Positional Change chart
Patient Name Hospital number
Ward Plan- frequency of positional changes as per care plan
Date and Time Patient Skin condition Signed
Time position position
changed

62
References
1. Brunner, L.S., 2010. Brunner & Suddarth's textbook of medical-surgical
nursing (Vol. 1). Lippincott Williams & Wilkins.
2. Chen, H., Nakatani, H., Liu, T., Zhao, H. and Xie, D., 2020. The Core
Knowledge and Skills of Nursing Competency Regarding Mealtime
Assistance for Hemiplegic Patients in China. Asian nursing research, 14(2),
pp.129-135.
3. Clare, C.S., 2020. Role of the nurse in acute stroke care. Nursing standard
(Royal College of Nursing (Great Britain): 1987), 35(4), pp.75-82.,
4. Clare, C.S., 2018. Role of the nurse in stroke rehabilitation. Nursing
Standard. 33, 7, 59-66. doi: 10.7748/ns. 2018.e11194
5. Daemen, E., Van Loenen, E. and Cuppen, R., 2014, November. The impact
of the environment on the experience of hospitalized stroke patients–an
exploratory study. In European Conference on Ambient Intelligence (pp.
114-124). Springer, Cham.
6. Edmonson, C., McCarthy, C., Trent-Adams, S., McCain, C. and Marshall, J.,
2017. Emerging global health issues: A nurse's role. Online Journal of Issues
in Nursing, 22(1).
7. Etafa, W., Argaw, Z., Gemechu, E. and Melese, B., 2018. Nurses’ attitude
and perceived barriers to pressure ulcer prevention. BMC nursing, 17(1),
pp.1-8.
8. Geraghty, M., 2005. Nursing the unconscious patient. Nursing
standard, 20(1), pp.54-64.
9. Green, T.L., McNair, N.D., Hinkle, J.L., Middleton, S., Miller, E.T., Perrin, S.,
Power, M., Southerland, A.M., Summers, D.V. and American Heart
Association Stroke Nursing Committee of the Council on Cardiovascular
and Stroke Nursing and the Stroke Council, 2021. Care of the Patient with
Acute Ischemic Stroke (Posthyperacute and Prehospital Discharge): Update
to 2009 Comprehensive Nursing Care Scientific Statement: A Scientific
Statement from the American Heart Association. Stroke, 52(5), pp. e179-
e197.
10. Gunaratne, P., Ranawaka, U., Chang, T., Bandusena, S., Wijekoon, S.,
Wijekoon, N., Arasalingam, A., Jeevagan, V. and Withana, W., 2017. CCP
Stroke Guidelines 2017. [online] Ccp.lk. Available at:
<https://www.ccp.lk/wp-content/uploads/guidelines-ccp-stroke-
guidelines-2017.pdf> [Accessed 1 June 2021].
11. Gunaratne, P., 2018. Stroke care, Sri Lanka Stroke Association. [online]
Stroke.lk. Available at: <https://www.stroke.lk/wp-
content/uploads/2020/09/Book-on-Stroke-Care.pdf> [Accessed 1 June
2021].

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12. Henderson, V., and International Council of Nurses. 1997, Basic principles
of nursing care. Amer Nurses Pub.
13. International Council of Nurses, 2012. The ICN Code of Ethics for Nurses,
Geneva, Available at: https://www.icn.ch/sites/default/files/inline-
files/2012_ICN_Codeofethicsfornurses_%20eng.pdf
14. International Council of Nurses, 2020. Public health nursing officers
working with non-communicable diseases in Sri Lanka, case study of the
week (August 4), International Council of Nurses, Available at:
https://2020yearofthenurse.org/story/public-health-nursing-officers-
working-with-ncds/
15. Lyman, B., Peyton, C. and Healey, F., 2018. Reducing nasogastric tube
misplacement through evidence-based practice: is your practice up-to-
date. American Nurse Today, pp.6-11.
16. Melnikov, S., 2020. The need for knowledge and skills in the care of post-
stroke patients, European Journal of Cardiovascular Nursing 19(6),
17. Mooney, G.P., 2007. Mouth care, Nursing Times, Available at :
18. https://www.nursingtimes.net/roles/practice-nurses/mouth-care-21-06-
2007/
19. National Institute for Health and Care Excellence, 2021, Nutrition support
in Adults; Enteral feeding,
http://pathways.nice.org.uk/pathways/nutrition-support-in-adults
20. Potter, P.A., Perry, A.G.E., Hall, A.E. and Stockert, P.A., 2009. Fundamentals
of nursing. Elsevier mosby.
21. Rodgers, M.L., Fox, E., Abdelhak, T., Franker, L.M., Johnson, B.J., Kirchner-
Sullivan, C., Livesay, S.L., Marden, F.A. and American Heart Association
Council on Cardiovascular and Stroke Nursing and the Stroke Council,
2021. Care of the Patient with Acute Ischemic Stroke
(Endovascular/Intensive Care Unit-Postinterventional Therapy): Update to
2009 Comprehensive Nursing Care Scientific Statement: A Scientific
Statement from the American Heart Association. Stroke, 52(5), pp. e198-
e210.
22. Stout, M. et al (2009) Developing and implementing an oral care policy and
assessment tool. Nursing Standard. 23, 49, 42-48
23. University of Glasgow, (n.d.) Nasogastric Tube Insertion Clinical Skills
Guidance, School of Medicine, Dentistry & Nursing: available at:
https://www.gla.ac.uk/media/Media_678213_smxx.pdf
24. Wagachchige Muthucumarana, M., Samarasinghe, K. and Elgán, C., 2018.
Caring for stroke survivors: experiences of family caregivers in Sri Lanka–a
qualitative study. Topics in stroke rehabilitation, 25(6), pp.397-402.

64
Chapter 8: Physiotherapy in Stroke Rehabilitation
Dr H H N Kalyani & Mr B A P Lakmal

Introduction
The innate human nature never ceases to seek ways in which what is lost can
be re-possessed and the aftermath of a stroke is no exception. It falls in the
hands of healthcare providers to offer that initial stimulus which can have
monumental impacts on the outcome of the entire process of rehabilitation.
Stroke is the sixth highest disease burden worldwide in terms of disability-
adjusted life years. The South Asian region, which includes Sri Lanka has a
high prevalence of stroke, especially in younger individuals, and short-term
mortality from stroke is found to be high. Hemiplegia is one of the most
common presentations after stroke and contributes significantly to motor
impairment. Any rehabilitation intervention which can expedite the recovery
and reduce long term disability could have a major impact on both the
individual and the social burden of the disease. Physiotherapy is an
established component of stroke rehabilitation which aims at promoting the
recovery of the affected side by helping patients to regain independence in
functional tasks. The underlying principle which forms the groundwork for all
physiotherapy approaches is the re-education of normal movement by
encouraging recovery of the hemiplegic side.

Acute Care
The aims of physiotherapy during the acute phase are early mobilization,
prevention of complications and the encouragement of resumption of self-
care activities. Commencing mobilization within hours or days of stroke onset
such as sitting out of bed, standing, and walking may help faster recovery.
Proper positioning post-stroke is also essential in order to promote optimal
recovery by modulating muscle tone, providing appropriate sensory
information, increasing spatial awareness, and preventing complications
such as pressure sores. It is more beneficial to the patient if his bed in the
ward or room makes him look across his affected side. The bed must have a
firm mattress, and adequate pillow support should be provided to maintain
correct alignment of the patient’s head, trunk, and limbs.

65
 Hemiplegic positioning on affected side

Rehabilitation Care
Generally, recovery of function is fastest up to three months following the
onset of stroke, with statistically significant recovery occurring up to six
months while some patients continue to recover function up to one year.
Therefore, physiotherapists treat stroke patients for varying lengths of time.
Physiotherapy in the rehabilitation of stroke patients is represented by
various approaches that can be broadly divided into techniques based on
either neurophysiological or motor learning principles.

Neurophysiological Techniques
During the application of these techniques, the physiotherapist supports
correct movement patterns of the patient, acting as the decision maker for
those movements so that the patient is a relatively passive recipient.

66
Proprioceptive Neuromuscular Facilitation (PNF) Technique
The PNF technique is based on diagonal patterns of movements through the
application of a variety of stimuli which may be visual, auditory, or
proprioceptive ot achieve normalized movements. These movements
increase the recruitment of additional motor units, maximizing the motor
response required. This technique is a very effective therapeutic exercise for
the improvement of muscle thickness, dynamic balance, gait, and physical
functioning of stroke patients. If the patient is able to follow the commands,
PNF should be implemented preferably from the first day after stroke. During
these exercises, the upper and lower extremities are allocated two diagonal
patterns each, namely D1 and D2, and they involve the movement
components of flexion-extension, abduction-adduction, and internal-
external rotation. Diagonal patterns produce greater adaptive plasticity as
the neural recruitment increases compared to single plane movements.

Proprioceptive Neuromuscular Facilitation (PNF) Technique

Bobath Technique
Bobath is a widely accepted treatment which aims at optimizing the functions
of the person after a stroke by facilitating selected movements and orienting
these towards activities of daily living. This concept hypothesizes a
relationship between spasticity and movement, considering that the muscle
weakness is due to the opposition of spastic antagonists. The Bobath
Technique attempts at inhibiting spasticity by passive mobilization associated
with tactile and proprioceptive stimuli, thereby eliminating abnormal
movements, and restoring the normal ones. This approach begins from the

67
trunk, followed by the scapula and pelvis and then progresses on to more
distal segments.

Motor Re-learning Techniques

Evidence indicates that physiotherapy with motor re-learning techniques is
preferable to physiotherapy with neurophysiological techniques in the
rehabilitation of acute stroke patients. Motor re-learning requires the
intention to perform a task, repetition of particular task through practice, and
feedback. In contrast to the passive role of patients implied in the
neurophysiological techniques, motor re-learning techniques approach
stress-active patient involvement.

Activities While Lying

Mobilizing The Arm
A stiff painful arm imparts remarkable hindrance as it disturbs the balance
and movement of the whole body, limits treatment and interferes with daily
living. Passive elevation of the arm is performed every day, while the patient
is taught to clasp the hands together, with the fingers interlaced, and to
actively lift the arms up to full elevation.

Self-assisted arm movements Elevation of arm

Moving The Leg

The hemiplegic leg is mobilized using self-assisted movements. To prevent
associated movements, the patient’s hands can be clasped in elevation and
is then placed over the side of the bed by extending the hip. The knee is kept
in flexion and the foot in full dorsiflexion.

68
 Hip and knee flexion over the side of the bed

Trunk Stabilization
Stabilization of the trunk is necessary for the stability of the spine and pelvis
when they are in a functional position. The principal trunk exercises include
pelvic tilt exercises, quadruped exercises, abdominal hollowing exercises,
and bridging exercises. These can be used as low intensity weight bearing
exercises (9). Bridging exercises are used therapeutically for lumbo-pelvic
stabilization as they reduce fear and the instability of weight bearing during
gait and allow exercise in a secure posture.

Bridging with rotation of the pelvis Bridging on the affected leg

Rolling
Correct rolling makes the patient aware of the affected side and facilitates
the release of spasticity between the shoulder girdle and the pelvis, while
aiding the active movements of the trunk and limbs.

69
 Rolling to the affected side

Activities While Sitting

The recovery of sitting balance is commonly assumed to be essential to
obtain independence in other vital functions such as reaching, rising to stand,
and sitting down. Hence the patient needs to be moved into a sitting position
as soon as possible even if he is not fully conscious, to stimulate the balance
reactions. While sitting, emphasis is given to obtaining symmetrical weight
distribution by transferring weight through the affected upper limb.

Self-assisted arm movement in sitting

Activities While Standing

It is well known that one of the commonest issues when it comes to standing
with balance following a stroke, is the inability to transfer body weight onto
the affected leg. Since walking essentially requires the bearing of the entire
body weight on the affected leg during the single limb support phase, it is
encouraged that weight-shifting to the affected leg is practiced during
rehabilitation.

70
 Gait Training
The primary goals of people with stroke include being able to walk
independently and to manage to perform day-to-day activities. Although the
majority of stroke patients achieve an independent gait, many do not reach
a level of walking that enables them to perform all their daily activities. Gait
re-training through different types of exercise is the most common approach
in improving the ability to walk. While performing these exercises, the
physiotherapist’s observation, and direct manipulation of the positioning of
the lower limb during gait over a regular surface, followed by assisted walking
practice over ground is essential. These gait training exercises need to be
initiated promptly after stroke to promote cortical reorganization and
achieve better functional benefits.

Despite the benefits obtained by stroke patients through overground gait

training, there are some who fail to achieve the expected outcomes, resulting
in the increased acceptance of robotic devices such as electromechanical gait
trainers. In the gait trainer, the patient is supported with a harness while the
feet are placed on motor-driven footplates and the amount of body-weight
support provided by the harness is chosen according to the patient’s
individual needs. This method has resulted in the successful recovery of
walking in patients with stroke.

Patient with acute stroke walking overground Patient with acute stroke walking on
with moderate assistance from two electromechanical Gait Trainer with minimal
physiotherapists, walking belt, knee orthosis, assistance from physio- therapist.
and elastic bandage.

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Repetitive Task Training
Repetitive practice of functional tasks such as walking, reaching for objects,
and manipulating them is a major component of rehabilitation after stroke.
Some interventions used in the promotion of repetitive practice include
treadmill walking with body-weight support and robotic devices. These
interventions are typically performed with emphasis on more repetitions and
no added resistance to movement.

Constraint-Induced Movement Therapy (CIMT)

The aim of CIMT is to induce the patient to use the more impaired upper
extremity for as many hours of the day as possible, and it involves restricting
the contralateral arm in a sling and training the affected one. Repetitive
training of the more affected arm is prioritized in CIMT, as the brain changes
itself when the affected extremity is involved intensively for various
activities.

Role of Physiotherapy in Stroke Rehabilitation

As part of a healthcare team, the physiotherapist plays a vital role in the
recovery of physical function in stroke survivors, so much so that early
mobilization and functional training provided by a physiotherapist is
considered the most important aspect of acute treatment in the stroke unit.
As recovery may continue for years after stroke, the benefits of continuous
long-term care from a physiotherapist should be emphasized. The time of a
physiotherapist is not only spent on patient care; a large proportion of it also
extends to educating, advising, and training relatives and other caregivers.
Hence it can be concluded that the role of a physiotherapist in stroke care
and in curing the patient is immeasurable and it encompasses a wide array
of responsibilities such as assessing, treating, advising, training, and
supporting not just the patient, but also their relatives and other caregivers.

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1. Katan M, Luft A, editors. Global burden of stroke. Seminars in neurology;
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Physiotherapy in stroke rehabilitation: bases for Australian
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muscle tone and muscle stiffness in chronic stroke patient. Journal of
physical therapy science. 2016;28(3):967-70.
7. Graham JV, Eustace C, Brock K, Swain E, Irwin-Carruthers S. The Bobath
concept in contemporary clinical practice. Topics in stroke rehabilitation.
2009;16(1):57-68.
8. Bobath B. Adult hemiplegia. 1990.
9. Tessem S, Hagstrøm N, Fallang B. Weight distribution in standing and
sitting positions, and weight transfer during reaching tasks, in seated
stroke subjects and healthy subjects. Physiotherapy Research
International. 2007;12(2):82-94.
10. Goldie P, Matyas T, Evans O, Galea M, Bach T. Maximum voluntary weight-
bearing by the affected and unaffected legs in standing following stroke.
Clinical Biomechanics. 1996;11(6):333-42.
11. Morris D, Taub E, Mark V. Constraint-induced movement therapy:
characterizing the intervention protocol. Europa medicophysica.
2006;42(3):257.

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Chapter 9: Occupational Therapy for Stroke
Rehabilitation
Mr Nandana Welage & Mr H G T Dilshan

It is known that stroke in general, can have devastating effects on its victims
as it essentially derails their lives by rendering them incapable of performing
even the most basic of day-to-day activities, to varying extents. Regaining
functional independence, however minute, is of paramount importance and
hence occupational therapy is designed in such a way that it focuses on
improving motor control of affected areas of the body including the upper
extremities and hand function, training strategies to improve sensory,
perceptual, and cognitive weaknesses associated with stroke and on
maximizing the ability of self-care, along with the preparation of home and
work environments to live independently. The aim of occupational therapy is
to facilitate the functions of the person with stroke through training activities
of daily living, teaching compensatory methods to overcome lost abilities,
and improving their performing skills. Therefore, it can be said that in
including all the relevant aspects in a cohesive manner, the occupational
therapist provides a holistic approach in supporting the person to regain
independence of activities of daily living, work, and leisure.

The starting point of the therapy is the identification of the impact of stroke
in motor function, sensation, perception, cognition, and executive function
that are important in managing activities of daily living, via an appropriate
assessment. Identifying the functional level of the person and the
environmental barriers in order to plan person-centered goal setting in
conjunction with the multidisciplinary team, is made possible through further
assessments.

Occupational Therapy Assessments:

A description of core areas of occupational therapy assessments based on
the International Classification of Functioning (ICF) terminology (World
Health Organization, 2001) is provided. in table I. Rehabilitation goals related
to activity and participation that are specific, measurable, attainable,

74
realistic, and timely to the person with stroke are set by the occupational
therapist on the basis of the findings yielded through these assessments.
Commonly used memory and cognitive assessments
Occupational Therapy Adult Perceptual Screening Test (OT-APST)(Cooke,
2005)
Rivermead Perceptual Assessment Battery (RPAB)(Jesshope, Clark, &
Smith, 1991)
Mini Mental State Examination (MMSE)(Kurlowicz & Wallace, 1999)
Cognitive Assessment of Minnesota (CAM)(Feliciano, Baker, Anderson,
LeBlanc, & Orchanian, 2011)
Loewenstein Occupational Therapy Cognitive Assessment (LOTCA)(Katz,
Itzkovich, Averbuch, & Elazar, 1989)

Visual Perception
In adapting to the environment and practicing activities of daily living, the
role of vision is substantial, which prompts the assessment to begin with an
analysis of basic visual skills such as visual acuity, visual fields, and visual
tracking. Assessment of visual perception follows, with the therapist
screening for impairments of visual perception such as agnosia (lack of
recognition of familiar objects), visuospatial relations problems (organization
of the body in relation to objects or spatial awareness), and visual
discrimination skills (ability to distinguish different types of forms).

Memory and Cognition

Detailed assessments in the areas of orientation (awareness of time, place,
and person), memory (ability to retain and recall previously experienced
sensations, impressions, information, and ideas), cognition (process of
knowing, perceiving, or remembering), and executive functioning (ability to
make plans and carry them out) are conducted to determine the impact of
impairment on the ability of the person to resume daily function.
Standardized assessments and systematic observations are employed by the
occupational therapist for the identification of impairment and the
subsequent devising of a treatment regimen

75
LOTCA, consisting of subtests to measure Visuo-motor reorganization (LOTCA) and 3-D
orientation, spatial perception, motor praxis, construction
visuomotor organization and thinking
operations, is a widely used assessment
available in occupational therapy units to assess
vision, perception, and cognition.

Sensory, Motor, and Upper Limb Functions

An in-detail assessment is undertaken by the occupational therapist for the
motor and sensory changes in the wake of the stroke event, with particular
attention to upper limb and hand functions, after which the therapist
proceeds to discover changes in motor power, muscle tone, motor planning,
praxis, fine motor coordination, hand function, and sensory loss, with the aim
of regaining upper limb control and function.

Assessment tools available in occupational therapy units

Hand dynamometers (Cadenas-Sanchez et al., 2016).
O’Connor finger dexterity test (Corlett, Salvendy, & Seymour, 1971).
Purdue Pegboard (Buddenberg & Davis, 2000).
Nine-hole peg test (Mathiowetz, Weber, Kashman, & Volland, 1985).
Jamar monofilament sensory testing (Anderson & Croft, 1999)

76
 O’Conner finger dexterity test Monofilament sensory test

In addition, a number of other forms of assessments are utilized to appraise

upper extremity and hand functions. These measurements are used to gauge
the impairments that affect the functions in the upper extremity.

Measurements used to gauge the impairments that affect the functions

in the upper extremity.
Action Research Arm Test (ARAT) (Yozbatiran, Der-Yeghiaian, & Cramer,
2008).
Jebson Taylor Hand Function Test (JTHFT)(Jebsen, Taylor, Trieschmann,
Trotter, & Howard, 1969)
Motor Activity Log (MAL)(Uswatte, Taub, Morris, Light, & Thompson, 2006)

Jebsen Taylor Hand function Test

77
Home Assessment
In the course of the rehabilitation stage and just prior to discharge, the
person’s capacity to complete basic activities of day-to-day living, their ability
to manage safely in the home setting, and the extent to which secure access
to the community can be had, are usually examined by the therapist. The
home, including the environmental barriers, risk of falls, and the needs of the
patient and family, is evaluated for the purpose of achieving home
integration. The home visit provides the opportunity to apply various
observational and standard assessments, such as, The Home Falls and
Accidents Screening Tool (HOME FAST).

Occupational Therapy Intervention after Stroke

Rehabilitation following stroke should be commenced at the very first
opportunity that presents itself immediately after the medical condition
stabilizes. The individual’s abilities and needs are taken into consideration
and a tailor-made occupational therapy treatment plan is contrived.
Therapeutic activities which are the main treatment media of occupational
therapy, form the foundation for a considerable portion of the treatment.
This consists of graded tasks and activities to retrain motor, sensory, visual,
perceptual, and cognitive skills, while minimizing secondary complications,
and providing education and guidance to the person with stroke and their
family or caregivers.

Initially, the therapist strives for restoration, if the affected person displays
impairment of perceptual, cognitive, or executive functions, and should this
fail, an adaptive approach is opted for as compensation for the loss of
abilities. To understand this further, consider the treatment of choice for the
following scenario in which a person presents with dressing apraxia, which is
the inability to dress due to disorder of body scheme.

78
Adaptive approach: focuses on compensation of loss of functions
The position of dressing practice is altered, for example the sitting or lying
position.

Clothes are arranged and labeled for easy identification by the patient.
Buttons are replaced with Velcro fastening.

The type of dress is changed, for example a shirt instead of a T-shirt.

Restorative approach: focuses on restoring the impaired function

A variety of two- and three-dimensional tabletop activities are practiced.
The therapist places his/her own hand over that of the patient, and guides
to practice activities such as buttoning of the shirt.

A neurodevelopmental approach, employing weight bearing, weight

shifting, and the use of the affected extremities is applied to enhance
movements for independent dressing.

The steps of dressing are aided by visual and verbal cues from the
therapist.

Dressing practice

79
Intervention through occupational therapy adheres to practice methods
backed by evidence with the goal of maintaining or improving the body
functions including the upper extremity.

Neurodevelopment Technique (NDT)

Some of the conventional techniques are based upon basic
neurophysiological theories and such techniques are widely practiced in
stroke rehabilitation globally. One such technique is the Neurodevelopment
Technique (NDT) which is built on a problem-solving approach used in the
evaluation and treatment of persons with movement and postural control
disturbances. NDT is incorporated into occupational therapy activities.

Weight bearing on affected upper extremity, while engaging in the diversional activity of reading.

Proprioceptive Neuromuscular Facilitation (PNF) technique

Another conventional rehabilitation technique is the Proprioceptive
Neuromuscular Facilitation technique, whose principles form the basis of
activities designed by occupational therapists to increase the range of motion
and performance.

Activity based on PNF technique, placing cones in a diagonal pattern

80
Motor Relearning Technique
Improving a specific component of movement as a result of repetitive
practice of an activity is the core principle of the Motor Relearning
Technique. Practice is undertaken with the supervision of the therapist and
the re-learned skill is integrated into the routine daily activities of living. The
following image depicts a purposeful activity, repeatedly practiced in order
to improve mobility of the upper extremity.

Repetitive task practice.

Constraint Induced Movement Therapy (CIMT)

The theory of learned non-use is put into practice in the Constraint Induced
Movement Therapy (CIMT), as the occupational therapist attempts to train
the stroke patient with basic finger and wrist movements, compelling the use
of the affected extremity for activities, while the unaffected hand remains
constrained with a mitt.

CIMT

81
Mirror Therapy
A technique that is more befitting of patients having no or limited
movements in the affected hand, is the Mirror Therapy which utilizes the
theory of mirror neuron system and involves the practice of simple hand
tasks by the patient, while the affected hand is kept hidden behind a mirror
box.

Mirror Therapy

Motor Imagery
Motor Imagery is a method of activating the motor cortex of the brain by
attempting to repetitively form a mental image of the task. The person with
stroke is asked to form in his mind, an image of a structural hand activity
while it is being carried out simultaneously.

The above are a few techniques that are currently in wide use in the
occupational therapy units of Sri Lanka. People with stroke are also
approached with compensatory techniques on a temporary or permanent
basis, depending on the severity of the lesion and regaining of function.

82
When a stroke patient is rendered incapable of using the affected upper
extremity due to impairment, assistive devices designed for a short period of
use can be utilized, and the device can be discarded once the extremity
regains its function. However, an assistive device will be provided for lifetime
if the disability proves to be permanent in nature.

Upper extremity adaptations (feeding, brushing, and shaving)

Current research findings are more supportive of the fact that hand splints
are indeed not helpful in improving function and anti-spastic splints are rarely
used in the reduction of severe hand spasticity as it may give way to the
development of contracture and deformity.

Occupational Therapy: Post-Discharge Intervention

In other parts of the world, occupational therapists often conduct a home
visit prior to the discharge of the patient from the hospital, in order to assess
the home environment to make necessary modifications to ensure safety,
functionality, and independence therein.

Areas in which modifications can be made in the environment

Ramps and railing at the front entrance.
Furniture arrangement of the home.
Remove the clutter and loose rugs.
Proper illumination of the house
Bathroom modification
Toilet modification
Modification to the utensils at the kitchen including one handed instrument.

83
 Home modifications

Workplace and Community Reintegration

It is the duty of an occupational therapist to survey the workplace of the
patient as early as the acute stage if they had been engaged in a permanent
employment before the onset of the stroke. Information regarding the
nature of the occupation, types of duties to be carried out, work hours, work
conditions, and work environment should be gathered through a thorough
job analysis. Such measures are taken to aid the therapist in designing
training programs at the therapy units which include simulations of the tasks
practiced at work. Sometimes the circumstances necessitate the use of
adapted pens and writing practice, or computer skills with an adapted
keyboard and mouse before the affected individual can return to work.

Writing practice and fine hand skills practice with nuts and bolts

84
During home transfer and work placements, it is required of the occupational
therapist to work in close association with a social service officer to ensure
the supply of necessary assistive devices. Assessments are carried out to
screen the need for light work or different employment at the same
workplace or self-employment for those who are unable to return to their
previous jobs. If a situation does arise, where the person with stroke is in
requirement of a new employment, they are linked to the social service
officer to receive the necessary funds to start a new business. The
occupational therapist, in addition to job placement, recommends assistive
devices and home modifications such as installing a new commode chair,
with financial support from the social service department.

Core areas of occupational therapy assessment

ICF Body function Activity Participation Environment
dimension and structure

Occupational Occupational Occupational Occupational Environments

Therapy Performance Performance Performance and Contexts
terminology components and roles
assessment
areas
Vision Upper limb Occupational Physical
function roles (home, work)
Visual Personal self- Community Social
perception care tasks integration

Memory Domestic or Cultural

instrumental
activities of
daily living
Cognition Leisure
activities
Executive Driving
function
Sensory and
motor
Psychosocial
adjustment

85
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1. Anderson, A., & Croft, R. (1999). Reliability of Semmes Weinstein
monofilament and ballpoint sensory testing, and voluntary muscle testing
in Bangladesh. Leprosy review, 70(3), 305-313.
2. Bobath, B. (1977). Treatment of adult hemiplegia. Physiotherapy, 63(10),
310-313.
3. Buddenberg, L. A., & Davis, C. (2000). Test–retest reliability of the Purdue
Pegboard Test. American Journal of Occupational Therapy, 54(5), 555-558.
4. Cadenas-Sanchez, C., Sanchez-Delgado, G., Martinez-Tellez, B., Mora-
Gonzalez, J., Löf, M., España-Romero, V., . . . Ortega, F. B. (2016). Reliability
and validity of different models of TKK hand dynamometers. American
Journal of Occupational Therapy, 70(4),
5. Carr, J. H., & Shepherd, R. B. (1982). A motor relearning programme for
stroke. London: William Heinemann.
6. Cooke, D. M. (2005). Occupational Therapy Adult Perceptual Screening Test
(OT-APST): Function For Life.
7. Corlett, E., Salvendy, G., & Seymour, W. (1971). Selecting operators for fine
manual tasks: A study of the O'Connor Finger Dexterity Test and the
Purdue Pegboard. Occupational Psychology.
8. Edmans, J. (2010). Occupational therapy and stroke: Wiley Online Library.
9. Feliciano, L., Baker, J. C., Anderson, S. L., LeBlanc, L. A., & Orchanian, D. M.
(2011). Concurrent validity of the cognitive assessment of minnesota in
older adults with and without depressive symptoms. Journal of aging
research, 2011.
10. Jeannerod, M. (2001). Neural simulation of action: a unifying mechanism
for motor cognition. NeuroImage, 14(1), S103-S109.
11. Jebsen, R. H., Taylor, N., Trieschmann, R., Trotter, M. J., & Howard, L. A.
(1969). An objective and standardized test of hand function. Archives of
Physical Medicine and Rehabilitation, 50(6), 311-319.
12. Jesshope, H. J., Clark, M. S., & Smith, D. S. (1991). The Rivermead
Perceptual Assessment Battery: its application to stroke patients and
relationship with function. Clinical Rehabilitation, 5(2), 115-122.
13. Katz, N., Itzkovich, M., Averbuch, S., & Elazar, B. (1989). Loewenstein
Occupational Therapy Cognitive Assessment (LOTCA) battery for brain-
injured patients: reliability and validity. American Journal of Occupational
Therapy, 43(3), 184-192.
14. Kurlowicz, L., & Wallace, M. (1999). The mini-mental state examination
(MMSE): SLACK Incorporated Thorofare, NJ.

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15. Mackenzie, L., Byles, J., & Higginbotham, N. (2000). Designing the home
falls and accidents screening tool (HOME FAST): selecting the items. British
Journal of Occupational Therapy, 63(6), 260-269.
16. Mathiowetz, V., Weber, K., Kashman, N., & Volland, G. (1985). Adult norms
for the nine hole peg test of finger dexterity. OTJR: Occupation,
Participation and Health, 5(1), 24-38.
17. Ramachandran, V. S. (2005). Plasticity and functional recovery in
neurology. Clinical1 Medicine, Journal of the Royal College of Physicians of
London, 5(4), 368-373.
18. Rowland, T. J., Cooke, D. M., & Gustafsson, L. A. (2008). Role of
occupational therapy after stroke. Annals of Indian Academy of Neurology,
11(5), 99.
19. Taub, E., Uswatte, G., & Pidikiti, R. (1999). Constraint-Induced Movement
Therapy: a new family of techniques with broad application to physical
rehabilitation-a clinical review. Journal of Rehabilitation Research and
Development, 36(3), 237.
20. Turner-Stokes, L., Pick, A., Nair, A., Disler Peter, B., & Wade Derick, T.
(2015). Multi-disciplinary rehabilitation for acquired brain injury in adults
of working age. Cochrane Database of Systematic Reviews, (12). Retrieved
from
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004170.pub3/ab
stract doi:10.1002/14651858.CD004170.pub3
21. Uswatte, G., Taub, E., Morris, D., Light, K., & Thompson, P. (2006). The
Motor Activity Log-28 assessing daily use of the hemiparetic arm after
stroke. Neurology, 67(7), 1189-1194.
22. Voss, D. E. (1967). Proprioceptive neuromuscular facilitation. American
Journal of Physical Medicine & Rehabilitation, 46(1), 838-898.
23. World Health Organization. (2001). International classification of
functioning, disability and health : ICF. Retrieved from
https://apps.who.int/iris/handle/10665/42407
24. Yozbatiran, N., Der-Yeghiaian, L., & Cramer, S. C. (2008). A standardized
approach to performing the action research arm test. Neurorehabilitation
and neural repair, 22(1), 78-90.

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Chapter 10: Person-centered Dysphagia and
Communica on Support at the Stroke Unit
Dr Shyamani Hettiarachchi, Dr S P Rathnayake & Ms K P Dineshika

Introduction
If there is one client group where multi-disciplinary team collaboration is
imperative and its importance unmistakable, it would be in stroke care. In
our clinical work with stroke survivors, we are confronted by the centrality of
eating/drinking and communication to our lives; as it resonates with the very
core of our existence of ‘what makes us human’. At the heart of our work in
swallow therapy and communication therapy is unmistakably the most
important necessity of all needs of the stroke-survivor, the need for
individualized person-centered holistic care, and maintaining dignity and
quality of life. It is only through very close collaboration with all members of
the multi-disciplinary team that speech and language therapists are able to
offer the most optimal and timely care for the stroke survivor.

This requires, for instance, working directly with physiotherapy colleagues to

determine the most suitable postural management for safe swallowing,
which may also extend to positioning to enable access to a communication
system. With occupational therapy colleagues, a partnership is required to
decide on special seating and hand function for self-feeding and access to a
communication system, as required. Similarly, with psychologist and
counsellors, a close association is essential to enable client motivation and
readiness for speech therapy and in managing emotional lability; as well as a
working alliance with dietitians to provide adequate nutritional intake and
specialist nursing colleagues to establish swallow safety.

Within stroke care, speech and language therapists have a central role in the
identification and management of dysphagia and in establishing a
communication system for the stroke survivor immediately post-stroke. At
present, within the backdrop of Covid-19, speech and language therapists are
required to take particular precautions, given the aerosol generating

88
procedures connected to dysphagia management in particular, as well as to
communication therapy in general, due to the proximity of our interactions.

Scope of Practice
The Royal College of Speech & Language Therapists outline the key role
and scope of practice of a speech and language therapist within stroke
care.
Initial assessment of swallowing and communication difficulties post -
stroke
Training of other healthcare professionals to conduct screening
assessments.

Long-term intervention with the stroke survivor as a member of the core

multidisciplinary stroke rehabilitation team.

Training of carers and other professionals to aid communication

Supporting the medical team to assess capacity in instances where it is

difficult to gain consent from a stroke survivor

Devising a discharge plan for “seamless transition into the community”

with support mechanisms in place to enable continuous therapy

Establishing Swallow Safety

The Royal College of Speech & Language Therapists recommends an urgent
referral of the stroke survivor to the speech and language therapy service
within the first 24 hours following the stroke. A reported 40% – 78% of
stroke-survivors are said to present with some level of dysphagia
immediately post-stroke, with persistent difficulties seen in 76% who will
experience moderate to severe dysphagia, and 15% showing signs of
profound dysphagia.

89
Referral and care pathway

90
Covid-19 Considerations
The professional guidelines offered to speech and language therapists is to
minimise physical contact, limit face-to-face contact, avoid oro-motor
assessments including the testing of the reflexive and voluntary cough, and
suspend the use of specific instrumental assessments of dysphagia including
fibreoptic endoscopic evaluation of swallowing (FEES). As all these aspects of
assessment carry a risk of ‘aerosol generating procedures’, speech and
language therapists are acknowledged to be at an increased risk of exposure
to aerosol droplets. The Government Union of Speech and Language
Pathologists/Therapists have collated safety guidelines to be followed that
contain considerations of distance, protective PPE gear, hand hygiene,
disinfection and sterilisation, and individual care.

Assessment
Screening for dysphagia
As a working definition to our chapter, we will use Logemann’s perspective,
as a pioneer within the field of dysphagia. Logemann defines swallowing as
“the entire act of deglutition from placement of food in the mouth through
to the oral and pharyngeal stages of the swallow until the material enters the
oesophagus through the cricopharyngeal juncture”. The American Speech-
Language Hearing Association described dysphagia as “a swallowing disorder
involving the oral cavity, pharynx, oesophagus, or gastroesophageal
junction”.

The aims of a dysphagia service. (Royal College of Speech and Language

Therapists’ clinical guidelines by consensus for speech and language
therapists)
To provide a comprehensive and responsive service to clients presenting
with swallowing disorders within available resources

To facilitate intervention by the multi-disciplinary team and to refer or

recommend referral to other agencies where appropriate

To become engaged in the planning and provision of services to clients

presenting with swallowing disorders.

91
Within the Stroke Unit, the remit of swallow screening, assessment and
management lies with a speech and language therapist. In units where a
fulltime speech and language therapist is available, the initial screening is
undertaken by a speech and language therapist, and where unavailable, by
trained specialist medical or nursing staff. The pass/fail process of a swallow
screening will help identify the potential presence of dysphagia, strongly
suggesting a follow-up clinical swallow evaluation by a speech and language
therapist. The ‘water swallow test’, which is usually part of an initial
screening is conducted to determine the presence or absence of dysphagia.
Failure to successfully ‘pass’ the screening may lead the team to decide on
the temporary insertion of a naso-gastric tube to maintain nutrition and
hydration and for all oral medication. For a post-stroke adult with a
tracheostomy, a Modified Evans Blue Dye test to determine the safety of
introducing oral intake may be indicated when medically stable coupled with
analysing the data of oxygen saturation via pulse oximetry.

If the swallow screening is undertaken by specialist nursing staff, a referral to

speech and language therapy should be undertaken as a matter of routine,
irrespective of the outcome of the screening, in order to undertake a
comprehensive diagnostic assessment. Following the initial screening, a
speech and language therapist would undertake a comprehensive
assessment to ascertain the type and severity of dysphagia, immediate
strategies to be recommended and intervention to minimise the risk of
aspiration and support swallow safety, and to determine a suitable
individualised rehabilitation programme. Therefore, establishing a clear
screening protocol in consultation with the in-house speech and language
therapists would be essential.

Diagnostic assessment
In the assessment, intervention, and management of stroke survivors, speech
and language therapists use the World Health Organization’s ICF framework
as a guide.

92
 The ICF framework (Source reference 9)

Assessment and intervention target the impairment level, as well as its

impact on functional activities (e.g., eating and drinking skills and saliva
management) and on participation (e.g., meals with friends and family, going
to a restaurant for meals). The aim of the dysphagia and communication
assessment (as all assessments) is to determine the nature, severity and type
of disorder. The speech and language therapist’s diagnostic assessment of
swallowing would entail a detailed case history with information on the
medical history, current medical diagnosis and history of the swallowing
disorder, nutritional and respiratory status, together with a comprehensive
bedside clinical evaluation. The bedside assessment includes a structural
assessment, functional assessment, observation of posture, oral reflexes,
observation at rest and assessment of each phase of the swallow (pre-oral,
oral, pharyngeal and oesophageal stages) with food/liquid trials, and with the
adjunct use of cervical auscultation that relies on the therapist’s trained
observation skills and critical decision-making ability. The therapist will also
observe the level of alertness and the ability to follow instructions; key
factors in determining recommendations. A number of useful, locally
applicable assessments adapted from established global protocols have

93
emerged through mainly undergraduate research projects. This includes a
post-stroke dysphagia screening protocol by Elilnangai, the adapted “Nair
Hospital Bedside Swallowing Assessment” protocol for post-stroke adults by
Wijesekera enabling direct assessment by a speech and language therapist,
as well as the adapted and translated client-reported Eating Assessment
Screening Tool (EAT- 10) in Sinhala and in an accessible aphasia-friendly
format by Piyumali.

Bedside assessment of dysphagia

For the stroke-survivor experiencing difficulties with saliva control, the

speech and language therapist works in close partnership with the
physiotherapist on postural management to ensure safe drainage of saliva,
particularly during the night. Given the high risk of choking and aspiration of
secretions, this is a key area of multi-disciplinary collaboration involving
speech and language therapists. While the physiotherapist takes the lead in
advising on postural management for saliva control as well as on chest physio
to reduce build-up of phlegm, the speech and language therapist offers
advice on the stroke survivor’s ability to safely swallow their saliva. The
speech and language therapist will also seek support from the specialist
nursing team to ensure oral hygiene and suctioning of saliva, as required.

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Objective/instrumental assessments
Considered the ‘gold standard’ to determine the nature and extent of an
oropharyngeal swallowing dysfunction and the safest texture for the
individual, video fluoroscopy (or a Video Fluoroscopic Swallowing Study
(VFSS)) has emerged as standard practice in the Global North. To date, it
remains the most widely used objective assessment of oropharyngeal
swallowing. Globally, speech and language therapists are part of the core
team, together with a radiologist and radiology technician undertaking video
fluoroscopic swallow studies, which involve assessing a range of food/liquid
textures as well as diverse compensatory strategies, to ascertain the safety
of oral intake and the effectiveness of strategies. It captures information on
bolus transit times, motility issues, and aetiology of aspiration. That said, this
instrumental assessment is not currently widely available in local hospitals.
Although video fluoroscopy (VFSS), and fiberoptic endoscopic examination of
the swallow (FEES) are available in some hospitals in Sri Lanka, they are not
routinely used as yet, with arguably wider use of FEES, with the routine use
of pulse oximetry alongside FEES or a bedside assessment. Speech and
language therapists in Sri Lanka, similar to other therapists in the Global
South, are more reliant on the bedside assessment and cervical auscultation,
the latter used as an adjunct to direct clinical assessment, with a reliance on
extensive clinical experience.

Diagnostic assessment

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Intervention & Management
Interdisciplinary and multidisciplinary collaboration is paramount in
dysphagia management. The key objective during the acute phase is to
minimize the risk of aspiration and penetration of food, liquid and saliva by
facilitating swallow safety. To do so, following the bedside clinical
assessment, comprehensive diagnostic assessment and instrumental
assessments (if available and indicated), the speech and language therapist
would proceed to make clear individual recommendations to support
swallow safety and to enable maintenance of nutrition and hydration.
Consideration would be given to the confluence of general body posture,
tone and swallowing, cognitive factors, psycho-social concerns, and
emotional state, which all influence swallow therapy, with efficacy and
effectiveness of intervention considered. The specific dysphagia
management recommendations would be based on the physiology of the
dysphagia, the ability of the individual to follow directions, the physical
limitations of the stroke-survivor (including posture, hemiplegia, fatigue
levels), prognosis, family support, and the aims of the intervention decided
on by the speech and language therapist and the stroke survivor. Therapy
aims to alter the physiology of the swallow, working at the level of
impairment, but with a view to addressing issues of activity limitation and
restrictions to participation.

Overall, speech and language therapists situate their practice using the ICF
framework, with more emphasis placed in the last 20 years on addressing
issues of participation. Given the significance of hospitality and food in our
culture, this includes the reintegration of the stroke survivor into shared
mealtime experiences with family, friends, and the wider community, be it a
cultural-religious celebration of avurudu, Christmas, Eid, an almsgiving or
dane, dansal at Wesak, Thai Pongal or family gatherings at birthdays,
weddings or at funerals. It includes working directly with the stroke survivor,
as well as with members of the family, to implement a therapy programme.
This may entail training on the use of compensatory strategies, such as
modification of food/drink textures, and creating acceptance of these
potential changes, in order to offer a safe and non-judgmental
family/community mealtime experience.
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Compensatory strat egies
Broadly speaking, intervention involves deciding on oral vs enteral feeding
methods, and on direct vs indirect therapy of compensatory strategies and
therapeutic or rehabilitative techniques. Compensatory management aims
to overcome or ‘compensate’ for the swallowing difficulties, to eliminate the
stroke survivor’s symptoms. These client-specific strategies are usually short-
term and frequently monitored and modified, and involve using swallow
manoeuvres, postural changes and texture modification with regard to form,
volume, viscosity and temperature, or the use of oral prosthetics.

The aim within speech and language therapy management is to minimise

aspiration using a variety of methods such as modification of texture and
form of the food bolus, changes to body positions, maintenance of adequate
nutrition and hydration, and specific exercises for functional training. The
general guideline is to ensure that the stroke survivor is alert and in an
upright posture for all meals as well as when offered medication orally.
Specific body positions found to minimise aspiration are head rotation, side
inclination, chin tuck, reclining position, recumbent position or combining
several of these strategies. While the general guideline is of an upright
posture at 90o, it is important to note the evidence for using a reclining
position with stroke survivors. Whether the reclining position should be at
60o, 45o or 30o will depend on the thorough assessment of cognition, levels
of alertness, swallow safety and severity of dysphagia conducted by the
speech and language therapist in consultation with the physiotherapist and
occupational therapist. The speech and language therapist in conversation
with the physiotherapist may decide that a position assisted by the force of
gravity or a specific technique to steer food/drink to the non-paralysed side
may benefit an individual. Additionally, it is important to consider the seating
position of the caregiver, if the stroke survivor requires assistance during
meals. It would be supportive to the stroke survivor to maintain his/her head
and trunk position if the caregiver adopts a position at the same level or
slightly below their eye level. As there is no ‘one solution fits all’ within
dysphagia management whether body position or strategy for functional
training, Kagaya and colleagues encourage therapists to assess and confirm

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the effectiveness of body positions and strategies prior to use with individual
stroke survivors.

Body positions during mealtimes

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A stroke survivor who does not pass the swallow screen/water test, may be
kept nil-orally (NPO) with a short-term NG-tube inserted. The comprehensive
assessment by the speech and language therapist will determine whether the
individual is safe for any food/drink orally, and if so, which texture poses the
least risk of penetration/aspiration. Also, the comprehensive assessment will
offer information to make recommendations on the body posture or postural
technique to be used, any changes to the food texture or diet modification,
whether the bolus size needs to be decreased or increased, the amount of
food/liquid per spoonful, pace of feeding and any specific feeding or cueing
strategies to be utilized by the stroke survivor and/or caregiver, if needed. If
oral intake for food and liquid (including medication) is contra-indicated and
non-oral feeding is to continue, body positioning/postural techniques will still
be a consideration to minimize the risk of aspiration and/or reflux.

Therapy intervention
The specific dysphagia management recommendations would be based on
the physiology of the dysphagia, the ability of the individual to follow
directives, the physical limitations of the stroke survivors (including posture,
hemiplegia, fatigue levels), prognosis, family support, and the aims of
intervention/management decided collaboratively by the speech and
language therapist and the stroke survivor. The long-term holistic goals
include working closely with other team members to offer therapy
intervention to help the stroke survivor to return to (or near to) their pre-
onset level of skill. That said, as the American Speech-Language Hearing
Association propose, intervention can be “restorative”, aiming to ‘restore’
lost or impaired function, and/or compensatory, where retraining may not
be an option, at least, in the present or in the short-term. In the most recent
systematic review of swallowing therapy for dysphagia in acute and subacute
stroke, Bath and colleagues found a benefit of ‘behavioral interventions’ such
as oral motor swallowing exercises, environmental modifications, dietary
modification, expiratory muscle strengthening exercises, and
counselling/educating. The ‘restorative’ or therapy strategies that are widely
used by speech and language therapists depending on their applicability to

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the individual stroke survivor include exercises to develop range of motion,
safe swallow practice and thermal stimulation.

Standardizing texture descriptors

To ensure better understanding and compliance with texture modification,
the stroke unit could adopt the International Dysphagia Diet Standardization
Initiative (IDDSI) framework, specifically developed to ensure a global
standard. This could minimize potential intra- and inter-professional
confusion across speech and language therapists within a team or across
hospitals as well as across the multi-disciplinary team. In a local research
study, Devagiri formulated a resource tool with an exemplar food list for each
IDDSI level in consultation with stroke survivors, speech and language
therapists, dietitians, and occupational therapists that may be a useful
starting point. Within the global context, there have been policy-level
changes in hospitals where the IDDSI framework has been adopted as a basis
to label all hospital food using a clear colour-coding system.

International Dysphagia Diet Standardization Initiative (IDDSI) framework (Source 18)

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General Recommendations
While the recommendations that would be made to ensure swallow safety
would be individual to the stroke survivor, the following general guidelines
can be adopted by the members of the stroke unit.

Summary of General Recommendations:

Ensure that all oral feeding is offered when the stroke survivor is awake
and alert.

The general postural recommendation is to keep the head and trunk

upright. This would entail nursing staff in consultation with physiotherapy
colleagues, adjusting the ICU bed to an appropriate angle.
Inform the stroke survivor that it is a mealtime using the communication
system introduced by the speech and language therapist.

Take care to offer all food and drink given orally according to the texture
or consistency recommended by the speech and language therapist for the
individual stroke survivor.

If the speech and language therapist recommend thickening all drinks, the
team would need to ensure it is followed at all times to minimize the risk
of aspiration, as thin fluids are usually a challenge for many stroke
survivors.

Initially, if the stroke survivor has difficulties with chewing their food,
softer mashed food or pureed food may be recommended by the speech
and language therapist following assessment. It is important for the team
to follow texture recommendations during all mealtimes.

For some stroke survivors, eating small amounts at a time throughout the
day may be better than having three large meals, particularly if the stroke
survivor is experiencing difficulties with alertness, concentration and
motivation or gets tired easily.

It is best to offer small amounts per spoonful at a time and make sure the
food/drink has been swallowed and cleared prior to offering the next.

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 Stroke survivors may benefit from reminders to take small bites of food
and small sips of water. Taking one sip of water or liquid at a time may help
minimize the risk of aspiration.

Not mixing textures, such as food and liquid together (e.g. soup with
chunks of vegetables), but offering one texture at a time might help the
stroke survivor time their swallow better; again, minimizing the risk of
liquid trickling down to the lungs.

Avoid asking questions and engaging in conversation while the stroke

survivor is swallowing food/drink to minimize the risk of aspiration.
Communication is important but best done at the start of the mealtime
and after the stroke survivor has swallowed a spoonful of food/drink.

Offering prompts to swallow or to use specific techniques recommended

by the speech and language therapist may be useful.

Aim to make mealtimes as relaxed as possible by reducing distractions.

Display the texture and mealtime strategies to be used in a simple clear
chart at the bedside, particularly for stroke survivors who are NPO/NBM,
as this is a useful MDT strategy within a busy stroke unit.

Document any potential signs of aspiration or difficulty during mealtimes.

Implement a consistent daily oral care programme to manage oral hygiene
needs in consultation with the nursing staff, including clearance of any
food residue after meals.

It is important to keep the stroke survivor’s mouth and lips moist. If the
stroke survivor is not safe to take fluids orally, a saliva spray or special gel
may be recommended. Lip balm could be used to keep the lips from
cracking. The nursing staff could incorporate this as part of the oral hygiene
programme.

It must be emphasized that the above generic guidelines alone may not
suffice. In fact, a note of caution is required as these general guidelines may
not be beneficial to all stroke survivors and may even be contra-indicated in
many cases.

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Enabling Communication

“Only through communication can human life hold meaning.”

Paulo Freire

A prompt referral of the stroke survivor to the speech and language therapy
service is recommended to enable access to a suitable individual
communication system in the days immediately post-stroke. The right to
communicate is a central tenet within speech and language therapy, as
enshrined within the United Nations Convention on the Rights of Persons
with Disabilities, and to do so using any means available. Up to an estimated
third of all stroke survivors are said to experience a communication difficulty,
though the nature and severity levels vary.

A stroke resulting in aphasia affecting receptive and expressive spoken

language and/or reading and writing skills and dysarthria or dyspraxia
affecting clarity of speech is arguably a life-altering experience. As per the ICF
framework and its emphasis on participation, from the multitude of ‘roles’
played by the individual as a parent, grandparent, uncle or aunt, brother or
sister, friend, neighbour, and co-worker, even heading an organization as the
CEO of a company or Head of an organization, the stroke-survivor is suddenly
and rudely confronted by the challenge of not being able to recall words or
produce speech with clarity, affecting everyday simple communicative
exchanges, resulting in a lack of autonomy.

Assessment
During the person’s stay in the stroke unit, the effect of the stroke on
communication may be observed in difficulties experienced in understanding
the questions or instructions posed (including instructions within any clinical
examination), in formulating responses to questions and/or in initiating
conversation, including making requests or refusing intervention, as well as
in the intelligibility of speech, even to members of the family; all of which
challenge autonomy, a sense of self; and could have a psycho-social impact
on the individual. A screening tool based on the Sheffield screening

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assessment developed by colleagues at the National Hospital of Sri Lanka
(NHSL), and a relatively new Tamil Language Screening Test (LAST) validated
for use post-stroke by Saleem, Shadden, and Wickramasinghe are used
widely by speech and language therapists to aid the assessment process. The
screening assessment undertaken would gain information on hearing and
vision, and directly assess oro-motor skills, speech production,
comprehension and production of spoken language, cognition for
communication, and comprehension and use of written language.

Having established whether further assessment is warranted following the

screening assessment, a comprehensive assessment mainly targeting speech,
language, and cognitive communication are undertaken. The comprehensive
diagnostic assessment conducted by the speech and language therapist aims
to differentially diagnose between dysarthria and dyspraxia and to determine
the type of aphasia (i.e., Broca’s aphasia, transcortical aphasia etc.), the level
of severity, as well as the responsiveness to diverse cueing systems,
alternative and augmentative communication and/or multi-modal
communication. In bilingual or multilingual individuals, age of acquisition of
each and premorbid use and competence of each language should be
determined, and all languages assessed to determine the influence of the
stroke on everyday communication.

Within the comprehensive assessment, speech and language therapists aim

to gather information relevant to each component of the International
Classification of Functioning, Disability and Health (ICF) framework. This
includes gaining information on the impact of the stroke on communication
skills and interpersonal interactions that limit activity and participation in
performing usual social roles and life participation in the community, as well
as on the individual’s overall quality of life. Based on the principles of well-
established assessments of English such as the Boston Diagnostic Aphasia
Examination, Western Aphasia Battery, and Psycholinguistic Assessments of
Language Processing in Aphasia, local speech and language therapists and
researchers have developed Sinhala-language assessments for aphasia, such

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as, Rathnayake’s Sinhala Language Aphasia Assessment (SLAA), with
culturally-sensitive and linguistically-applicable test materials.

Comprehensive speech, language, and communication assessments

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Within the process of differential diagnosis, with a view to reaching a
communication diagnosis, speech and language therapists may employ a
classification system to denote the type of aphasia. One such commonly used
classification is the categorisation of aphasia as nonfluent or fluent, reflecting
features of spoken language expression. The aphasia classification employed
may change over time reflecting improvement in communication skills. A
stroke survivor may also present with complicated concurrent speech and
language difficulties, with aphasia together with dysarthria and/or dyspraxia.
Apart from the more commonly identified factors influencing aphasia
recovery, such as lesion site and size and immediate aphasia severity post-
stroke, social networks and social isolation, and post-stroke depression have
been found to deter the recovery process. This reiterates the need for speech
and language therapists to work collaboratively with psychiatrists,
psychologists, counsellors, and family members, as well as to forge close links
with Disabled People’s Organisations and social-support networks in the
community. This could compliment the adoption of a life participation
approach to aphasia.

The impact of communication difficulties on quality of life (QOL) in

comparison to the stroke survivor’s social roles in the family and the
community is a key consideration. Overall, post-stroke QOL is an area within
assessment and intervention, measured using specific questionnaires.
Karunathilake’s translated and adapted stroke and aphasia quality of life
scale (SAQOL – 39) in Sinhala could be a very useful tool for the local context.

The assessment may also lead to a diagnosis of a motor speech disorder of

dysarthria or apraxia/dyspraxia. Dysarthria is defined by Duffy as a group of
neurogenic speech disorders associated with "abnormalities in the strength,
speed, range, steadiness, tone, or accuracy of movements required for
breathing, phonatory, resonatory, articulatory, or prosodic aspects of speech
production". Apraxia of speech (AOS) is defined by Duffy as a “neurologic
speech disorder that reflects an impaired capacity to plan or programme
sensorimotor commands necessary for directing movements that result in
phonetically and prosodically normal speech” . AOS, also known as dyspraxia,

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acquired apraxia of speech, or verbal apraxia is a motor speech disorder
affecting speech sound production. An individual experiencing dyspraxia may
have difficulties with imitating and producing speech sounds independently,
display inconsistencies in producing words correctly, show groping oro-
motor behaviour, and slow speech production. Volitional movements are
significantly affected (e.g., coping a movement or speech sounds) compared
to automatic movements (e.g., blowing or licking an ice-cream; reciting bana
or prayers memorised through rote learning as a child) in dyspraxia.

Right Hemisphere Disorder (RHD) or Right Cognitive Communication Disorder

(RCCD) is another common communication disorder observed post-stroke
due to poor processing of cognitive skills related to communication, which
includes symptoms such as semantic processing of words, discourse
processing, prosody and pragmatics. The individual may experience
difficulties with attention and listening, memory, orientation, social
communication or pragmatic difficulties, higher language functions of
problem solving, reasoning, and understanding abstract language and
emotions. Additionally, mood swings, anosognosia and visual neglect are
common comorbid features associated with RCCD that could affect
communication and spoken and written language. Prevalence of RCCD has
been reported as 42%-49% in several hospital-based studies. It is worth
remembering that RCCD is a condition that is often missed due to the varied
presentation of symptoms.

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Intervention & Management

No speech is not everybody cup of tea!

Old friends came to my home
but could not talk to them,
was horrondous1, enormous effect.
HARD WORK!
Doesn't see them too much,
they are busy with everything,
That is HARD WORK too!

The poem ‘HARD WORK’ by Chris Ireland

Following a screening assessment, and a comprehensive diagnostic

assessment where possible, the speech and language therapist needs to
establish an accessible communication system that enables the stroke
survivor to engage in communication and be as autonomous as possible. At
the stroke unit, the establishment of a communication system for the stroke
survivor might be a simple augmentative and alternative communication
(AAC) system such as a communication board, alphabet board, use of
gestures, drawing or writing (motor skills permitting), or even the use of a
communication app on a mobile phone or iPad, where accessible and
appropriate.

As communication is a two-way process, the individual stroke survivor’s

difficulties with receptive and expressive language and/or motor-speech
skills could result in communication breakdown, making carer training on
facilitating conversation between the stroke survivor and members of the
family imperative. Using the ICF framework as a guide, therapy aims to get
the stroke survivor back to or as close as possible to their premorbid level of
skill; to be as independent as possible in their everyday communicative roles
and participation.

1
The original poem by Chris Ireland, who lives with post-stroke aphasia is given above with
no changes made to the grammar or spelling.

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The ICF is a guide for assessment, intervention, and management of
communication disabilities, given the potential far-reaching sequelae,
including addressing challenges faced in returning to the work-place.
Therefore, therapy could focus on impairment, activity, and participation
levels as per the ICF framework, in consultation with the stroke survivor.
Using the stroke survivor’s strengths and their communication needs, the
speech and language therapist will aim to work directly on areas of difficulty
or train the individual and/or the caregivers/members of family to use
specific strategies during conversation. This could also include
recommendations on better access to healthcare information through
aphasia-friendly written materials and reasonable accommodations at the
workplace. Here too, our intervention can be restorative, aiming to repair or
improve the ‘impairment’, and/or compensatory, focused on using strategies
to mediate any loss in function. The therapy approaches for aphasia could
focus on stimulation of language functions, reorganization of language
functions and/or substitution of language functions.

Life Participation Approach to Aphasia (source 33)

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The intervention could also directly focus on activity and participation, or
cueing systems to support word recall. An augmentative and alternative
communication device may be introduced to a stroke survivor following
robust assessment by the speech and language therapist in collaboration
with the physiotherapist and occupational therapist to encourage
communicative participation as part of a multimodal approach. Therapists
could also train the stroke survivor and partners/family members in using a
range of verbal and nonverbal communication strategies to support
conversation and social interaction. Facilitating the establishment of stroke
groups or community aphasia groups by and for stroke survivors has the
potential to address issues of post-stroke isolation and any limitation in social
networks. Extending this to caregivers, and facilitating carer support groups
may offer a useful safe space for family members to share their lived
experiences and to learn from each other.

For a stroke survivor experiencing dysarthria, therapy will address the

underlying sub-system or systems affected. Therapy for dysarthria is aimed
at achieving better intelligibility, naturalness, and efficiency of speech using
restorative approaches to improve the function affected. It can also include
compensatory approaches of training the stroke survivor to use specific
communication strategies, introducing an AAC device (remember Prof.
Steven Hawking’s high-tech AAC device), working with communication
partners to develop communication-partner strategies and modifying the
communication environment.

Similarly, the aim of therapy for an individual experiencing dyspraxia is to

enable the stroke survivor to reach the highest level of communicative
independence in everyday participation. Person-centered therapy focusing
on function includes retraining to produce speech sounds in isolation and in
words. It also encourages the speaker to use strategies for repairing
breakdowns in communication. When primary speech communication is not
an option, the speech and language therapist would consider a relevant and
accessible augmentative and alternative communication system including
gestures, writing, a communication wallet or a context-specific

110
communication board, a communication app or a specialist electronic voice-
output high-tech communication device. For a stroke survivor with a
diagnosis of RCCD, early intervention that includes strategies to reorganize
communicative functions into a logical sequence with use of appropriate
pragmatic and prosodic skills could increase effective communication,
reducing the significant impact of social isolation.

General Recommendations
While we do not wish to assume that the stroke survivor cannot understand
our questions or instructions, and while the communication method/system
put in place at the Stroke Unit for each stroke survivor is individual, the
following strategies may support communication.
Keep questions and instructions short and simple.
Initially, a slower pace of speech as well as pausing between
sentences might give the stroke survivor extra time to process what
is being said.
Model or offer examples of what you expect, where appropriate.
Point to relevant objects (e.g., tablets, NG tube) or pictures (e.g.,
pictures in a communication chart, communication app, or on an
iPad) to indicate the topic or key word within a discussion to aid
understanding.
Repeat instructions and simplify instructions or rephrase sentences if
not understood, incorporating gestures, facial expression and
pointing to target items, where necessary.
Give extra time to the stroke survivor to understand what is being said
and to formulate a response.
Use the communication method/system set-up by the speech and
language therapist when communicating with the stroke survivor
enabling a ‘voice’ in the decision-making process and in their care.
Write down instructions and recommendations in simple language,
highlighting the target words, adding additional picture support,
where necessary and appropriate.

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For a stroke survivor experiencing particular difficulties with finding
the right words, prompting using the first speech sound of the
presumed response may be useful.
For a stroke survivor experiencing significant difficulties with clarity
of speech or in formulating a response, opportunities to answer
yes/no questions using the communication method/system set-up by
the speech and language therapist (e.g., thumbs up/thumbs down,
eye blinking, eye gaze to point at a yes/no chart) may be easier,
enabling inclusion into conversations about their care.
The stroke survivor may get frustrated if repeated attempts at
speaking are not understood. They may need encouragement,
particularly initially, to use alternative ways of communication such
as writing down a message, writing and then reading it aloud, drawing
a picture, pointing to an alphabet board, word, letter, photograph,
picture on a chart or an object, using gestures or describing the word
when unable to recall the exact word.
Offer a pen and paper to write or draw to enable communication,
where appropriate.
It would be useful to minimise distractions during conversations
within the stroke unit, to encourage the stroke-survivor to listen to
the communication partner.
Limiting the number of communication partners at a time initially may
be useful, to help the stroke survivor to follow the thread of a
conversation.
If the stroke survivor uses a hearing aid and/or spectacles, ensure that
they have access to it and that the hearing aids are working during
conversations.

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 Facilitating communication at the stroke unit

Discharge Plan
The multi-disciplinary team discharge plan for the stroke-survivor
necessitates the training of family members/caregivers to maintain the
client’s NG tube. It also necessitates the stroke survivor and/or
caregiver/family member understanding the compensatory strategies and
therapy strategies recommended as part of the rehabilitation programme.
Additionally, the stroke survivor and/or family member/caregiver would be
offered clear communication strategies to use to minimise communication
breakdown, as well as recommendations on any specific therapy activities to
be conducted at home.

Telepractice Services
Within the backdrop of Covid-19, speech and language therapists have
considered innovative service delivery models of telepractice to ensure a
continued ‘duty of care’. The American Speech-Language-Hearing
Association defines telepractice as “the application of telecommunications
technology to the delivery of speech language pathology and audiology
professional services at a distance by linking clinician to client or clinician to
clinician for assessment, intervention, and/or consultation”. The main
telepractice types of synchronous, asynchronous, and hybrid have been
trialed by local speech and language therapists, with a local evidence-base
evolving. Given the heavy reliance on technology for the effectiveness of this
service delivery model, speech and language therapists continue to critically
reflect on possible issues of equality/equity of access in Sri Lanka, while
exploring a range of service delivery models in order to reach hard-to-access
communities.

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https://bmjopen.bmj.com/content/7/10/e017944.citation-tools [Accessed
12 June 2021].
23. Saleem S, Shadden B, & Wickramasinghe R. Validation of a new Language
Screening Test (LAST) for post-stroke Tamil speaking patients in Sri Lanka.
Poster presented at the Asia Pacific Conference on Speech, Language and
Hearing, September 2017, Narita, Japan.
24. Goodglass H. & Kaplan E. Boston Diagnostic Aphasia Examination (BDAE).
Philadelphia: Lea & Febiger; 1972.
25. Kertesz A. Western Aphasia Battery (WAB). San Antonio, TX: The
Psychological Corporation; 1982.
26. Kay J. Coltheart M. & Lesser R. Psycholinguistic Assessments of Language
Processing in Aphasia (PALPA). Psychology Press; 1992.
27. Rathnayake S. Developing and Validating a Language Assessment Tool to
Diagnose Aphasia in a Sri Lankan Sinhala Speaking Context. [PhD
dissertation]. University of Colombo, Sri Lanka, 2018.
28. Davis GA. Aphasiology: Disorders and clinical practice. 2nd ed. Needham
Heights, MA: Allyn & Bacon; 2007.
29. Saadi A, Okeng'o K, Biseko MR, Shayo AF, Mmbando TN, Grundy SJ, Xu A,
Parker RA, Wibecan L, Iyer G, Onesmo PM, Kapina BN, Regenhardt RW,
Mateen FJ. Post-stroke social networks, depressive symptoms, and
disability in Tanzania: A prospective study. Int J Stroke. 2018 Oct;13(8):840-
848. doi: 10.1177/1747493018772788. [Accessed 6th July 2021]
30. Khedr EM, Abdelrahman AA, Desoky T, Zaki AF, Gamea A. Post-stroke
depression: frequency, risk factors, and impact on quality of life among
103 stroke patients—hospital-based study. Egypt J Neurol Psychiatry
Neurosurg 2020; 56:66. Available from: https://doi.org/10.1186/s41983-
020-00199-8 [Accessed 6th July 2021].
31. Karunathilake KMMGSL. The adaptation and validation of stroke and
aphasia quality of life scale (SAQOL – 39) for the Sri Lankan context [BSc
dissertation]. University of Kelaniya, Sri Lanka, 2014.
32. Duffy, JF. Motor Speech Disorders: Substrates, Differential Diagnosis, and
Management. 4th Ed. Elsevier. 2021.

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33. Portegies M, Selwaness M, Hofman A, Koudstaal P, Vernooij M, Ikram M.
Left sided strokes are more often recognized than right-sided strokes: The
Rotterdam study. Stroke, 2015: 46, 252–254.
34. Aphasia Institute. Available from:
https://www.aphasia.ca/shop/swallowing/ [Accessed 8th July 2021].
35. Blake, ML. Clinical relevance of discourse characteristics after right
hemisphere brain damage. American Journal of Speech-Language
Pathology, 2006: 15,255–267.

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Chapter 11: Nutritional Management in Stroke
Dr Renuka Jayatissa & Dr Wasana Marasinghe

Half to two third of patients were found to have lost weight from week
one to six months post-stroke.

Nearly one fifth were undernourished at six months post-stroke.

Weight loss post-stroke is a major risk factor for poor clinical outcomes.

Failing to identify and treat dysphagia, malnutrition, sarcopaenia and

pressure injuries hampers recovery and rehabilitation, which adversely
affects quality of life.

Nutritional care should be initiated in a timely manner and monitored

regularly from the day of acute admission on through rehabilitation and
into the community.

Individualist dietary advice, fortified texture modified diets and medical

nutrition therapy play a key role across the continuum of post-stroke care.

Multi-disciplinary teamwork is essential throughout the journey of the

stroke patient.

The burden of stroke in Sri Lanka is alarming. Studies have revealed that
malnutrition is common in stroke patients at the time of admission (8% to
28%) and worsens during their hospital stay. According to the APPLE
(Algorithm for Post-stroke Patients to improve oral intake Level) study, 93.2%
of convalescent stroke patients above 65 years faced the risk of malnutrition.
In Sri Lanka, it was reported in 2011, that 75.9% of neurological patients had
inadequate calories in their diet. Global evidence has shown the necessity of
multi-disciplinary rehabilitation services including medical nutrition therapy.
Although nutrition could affect recovery from acute stroke, it is often
overlooked in Sri Lanka may be due to the lack of local evidence which

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influence local feeding policies and guidelines. Moreover, the lack of
consistent data about the benefits and risks of feeding regimens adds further
uncertainty to decision making. This article will focus on evidence-based
nutritional optimization strategies in stroke in view of motivating the health
care workers who struggle to meet the nutritional needs of their patients in
busy health care settings in Sri Lanka.

Risk factors for malnutrition following a stroke

Dysphagia
Consciousness / cognitive function
Visual disturbances
Speech
Facial, arm and hand weakness
Depression
Olfactory changes / loss of appetite
Fatigue
Dehydration
Environment

Impact of Sub-optimal Nutrition Intake.

Stroke related sarcopenia

Sarcopenia, characterized by loss of muscle mass and strength can develop
rapidly after a stroke, and has a reported prevalence of around 42%.
Sarcopaenia after stroke is a multifactorial systemic inflammatory response
caused by both catabolism and degradation of fat-free body mass. It is
further compounded by immobility, bed rest, and insulin resistance
associated with diabetes.

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Pressure injury
A failure in achieving nutritional goals is independently associated with the
development of pressure injuries.

Nutrition Screening and Assessment

All stroke patients should be screened. Screening should be followed by
detailed assessment of malnutrition for those “at-risk” within 48 hours of
hospital admission.

Patients deemed “at risk” for malnutrition should be referred to the medical
nutrition team for nutrition assessment, grading of malnutrition (mild,
moderate, severe) and for individualized medical nutrition therapy.

The following screening tools can be used

Nutrition Risk Screening 2002 (NRS 2002) is the most suitable screening
tool during the acute stage.
Malnutrition Universal Screening Tool (MUST),
Mini Nutrition Assessment for elderly patients (MNA),
Subjective Global Assessment (SGA).

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Medical Nutrition Therapy (MNT)
Points to be considered when implementing nutritional support for
stroke patients
Increased energy demand is usual in subarachnoid haemorrhage but is
not the same in patients following cerebral infarction.

Concomitant infectious complications may increase resting energy

expenditure.

Generally, stroke patients will receive energy and proteins based on their
maintenance requirement. (Energy - 20-30 kcal/kg/day and proteins -
1g/kg/day).

An early enteral feeding does have several advantages to improve gut

motility, gut immunity, and preventing translocation of gut bacteria into
the systemic blood flow.

Evidence has proven that medical nutrition therapy reduces the incidence
of infections in stroke.

In essence, adhere to the nutrition algorithm provided with a series of

step-by-step instructions, which will help health care workers to
overcome nutritional challenges of their patients.

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122
MNT for dysphagia in stroke patients
Due to its prognostic importance, early detection of oropharyngeal dysphagia
among post-stroke survivors would be a cornerstone in lessening the
occurrence of malnutrition, dehydration, and aspiration pneumonia. Up to
27% to 64% of stroke patients suffer from dysphagia and more than half of
them recovered spontaneously from dysphagia after 2 weeks. However, the
patients who remained with dysphagia are more prone to malnutrition
because of divergent eating speed, anxiety, and other reasons.

Evaluation of dysphagia:
Dysphagia should be screened for in all stroke patients within 2 hours of
admission to stroke unit using clinical bedside approach.

Water swallowing test (WST)

It is a non-specific test recommended for use in daily routine where the
patient is administered 50 to 90 ml of water and observed for signs of
aspiration such as cough and examined for double swallow.

Multi-consistency test/Viscosity swallow test (VST)

In this test, dysphagia is graded into four categories as severe, moderate,
mild or no dysphagia, and under each severity code, a detailed dietary
recommendation can be implemented.

If dysphagia is identified, tests should be performed by a speech and

language therapist or following instrumental testing should be performed.

Instrumental testing methods

Videofluoroscopic swallowing study (VFSS) -
It can reveal the cause for aspiration.
Fiberoptic endoscopic evaluation of swallowing (FEES)
It helps to check the anatomy and physiology of swallowing.

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Steps of MNT:
1. Use nutrition assessment tools to determine the level nutritional
requirement and method of delivery.
2. If there is a risk of aspiration or severe dysphagia, initiate tube
feeding.
3. If oral feeding is possible, consider starting texture-modified diet
either visually, textually via customization, through meal fortification
or providing oral nutrition supplements (ONS).
4. Monitor the nutrition requirements and intake throughout the
recovery

Suitable dietary methods when oral feeding is possible.

Through tube feeding
Using pre-thickening ONS
Using manual thickening powders
Using tailored food and drink preparation guidance

Texture modified diet

The nutritional intake of patients with dysphagia may be achieved by texture
modified diet after grading dysphagia. In 2016 International Dysphagia Diet
Standardization Initiative (IDDSI) was introduced. Texture modified feeds are
recommended in patients with chronic dysphagia to enhance nutritional
status.

Methods of texture modified feeding.

If thickened diets cannot optimize fluid intake in these patients, proper
monitoring is needed to prevent dehydration in acute or chronic
dysphagia.

Texture modified feeds can reduce aspiration pneumonia incidence in

patients suffering from acute dysphagia.

For the sake of reducing aspiration pneumonia in patients with chronic

dysphagia, the “Chin down” procedure and thin fluids should be the first
choice rather than thickened fluids.

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MNT for malnutrition in stroke patients
Screen all patients within 48 hours of admission, irrespective of dysphagia
status, and weekly during the acute stage.

Rescreen and monitor nutrition intake throughout the recovery and when
the patient is shifted from one unit to another (e.g., ICU to ward, ward to
home).

Adjust nutrition care plan from one method to another suitable method
(e.g. oral to tube, tube to oral)

MNT for sarcopaenia in stroke patients

Evaluate muscle strength, muscle mass, and physical performance using
tools appropriate for stroke patients.

Start nutrition intervention with adequate high-quality protein (1-2 g/kg

body weight, depending on the individual needs) together with physical
rehabilitation programme.

If one sided weakness is present, in addition to general physical exercises,

encourage strength training to unaffected side.

MNT for pressure injuries in stroke patients

Screen and assess for risk and presence.

Provide adequate calories, protein, and micronutrients for optimum

healing.

Monitor throughout recovery.

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General Nutrition Care Plan For Stroke Patients
Patients with prolonged severe dysphagia anticipated to last for more
than 7 days should receive tube feeding within 72 hours.

Critically ill stroke patients with a diminished conscious level requiring

mechanical ventilation should obtain early tube feeding support.

Theoretically, in dysphagic stroke patients, with a high risk of aspiration,

continuous feeding is more recommended, preferably with a feeding
pump rather than by a gravity-driven feeding bag. As this may cause
gastric overload and regurgitation with subsequent aspiration. Available
evidence shows no significant difference in nutritional outcome in
intermittent over continuous NG tube feeding in acute stroke patients.

When deciding the type of tube feeding, during the acute phase of stroke,
nasogastric (NG) feeding is preferred. A small gauge NG tube (8 French)
is favored to lower the risk of internal pressure sores. Due to the risk of
displacement, the correct position should be confirmed before each NG
feed and a local standard for the assessment of the correct NG position
should be established in every hospice.

If tube feeding support is anticipated to be more than one month a

percutaneous endoscopic gastrostomy (PEG) feeding shall be considered
in sub-acute stroke patients. Mechanically ventilated acute or sub-acute
stroke patients should receive a PEG at an early stage, usually within 1
week. Evidence has shown that PEG feeding was superior to NG feeding
in mechanically ventilated stroke patients in viewpoint of lowering the
risk of ventilator-associated pneumonia. In a Cochrane review (1966 to
2011) on “Interventions for dysphagia and MNT in acute and subacute
stroke” the expert committee stated that, reduced treatment failures,
reduced gastrointestinal bleeding, higher albumin concentrations, and
had higher feed delivery were noted in the PEG group compared to the
NG fed group.

FOOD (Feed or Ordinary Diet) trial, which was the study of the biggest
sample size (859 acute stroke patients) evaluating the timing of feeding
in stroke patients has not shown any superiority between PEG feeding
and NG feeding considering the endpoint of “mortality after six months”.
The study has revealed an increased prevalence of pressure sores in the

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 PEG group in contrast to the NG group. Reflecting all, decision of PEG-
tube or an NG tube in acute stroke patients, should be decided by the
attending physician jointly with multi-disciplinary discussion. If an NG
tube is well-tolerated, PEG-insertion should not be a rehabilitation plan
in a palliative care patient with an uncertain prognosis. Moreover, there
is an assumption that strategies to overcome dysphagia might not be
possible with an NG tube in situ. This hypothesis is contradicted by shreds
of evidence; NG tube in situ did not trigger any negative impact on
swallowing function and was not an obstacle to dysphagia rehabilitation.

Dysphagia therapy should start in a timely manner, in tube-fed as well as

non-tube-fed patients. Conscious stroke patients with tube feeding
should be offered additional texture modified oral feeds, assumed by
dysphagia grading.

If an NG tube is repeatedly removed inadvertently by the patient and if

tube feeding will be compulsory for more than 14 days, a nasal loop
(bridle) may be applied to anchor the NG tube. If it is not feasible or not
tolerated early positioning of a PEG should be considered.

Usually, the body produces more than 500ml of saliva daily with or without
oral feeds which is contaminated by bacteria and attributed to aspiration
pneumonia. Therefore, strict oral hygiene and oral decontamination has
been recommended in the prevention of ventilator-associated pneumonia.

It is important to enhance the awareness among non-nutrition experts that

nutrition is a modifiable factor in stroke patients, and it will improve the
outcome. In order to provide a holistic care, facilitation and integration of
nutritional screening and dysphagia assessment should be in cooperated into
routine stroke rehabilitation. Nutrition care as an integral component of
post-stroke management cannot be further emphasized.

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References
1. Andersen UT, Beck AM, Kjaersgaard A, Hansen T, Poulsen I. Systematic
review and evidence-based recommendations on texture modified foods
and thickened fluids for adults (≥ 18 years) with oropharyngeal dysphagia.
ESPEN Journal. 2013 Aug 1;8(4):e127-34.
2. Bischoff SC, Austin P, Boeykens K, Chourdakis M, Cuerda C, Jonkers-
Schuitema C, Lichota M, Nyulasi I, Schneider SM, Stanga Z, Pironi L. ESPEN
guideline on home enteral nutrition. Clinical nutrition. 2020 Jan 1;39(1):5-
22.
3. Burgos R, Bretón I, Cereda E, Desport JC, Dziewas R, Genton L, Gomes F,
Jésus P, Leischker A, Muscaritoli M, Poulia KA. ESPEN guideline clinical
nutrition in neurology. Clinical Nutrition. 2018 Feb 1;37(1):354-96.
4. Di Paolo G, Twomlow E, Hanna F, Farmer A, Lancaster J, Sim J, Roffe C.
Continuous or intermittent? Which regiment of enteral nutrition is better
for acute stroke patients? A systematic review and meta-analysis. Online
Journal of Neurology and Brain Disorders. 2019 Nov 7;3(3):247-55.
5. Geeganage C, Beavan J, Ellender S, Bath PM. Interventions for dysphagia
and nutritional support in acute and subacute stroke. Cochrane Database
of Systematic Reviews. 2012(10).
6. Gomes Jr CA, Andriolo RB, Bennett C, Lustosa SA, Matos D, Waisberg DR,
Waisberg J. Percutaneous endoscopic gastrostomy versus nasogastric tube
feeding for adults with swallowing disturbances. Cochrane database of
systematic reviews. 2015(5).
7. Indoor morbidity, mortality reports 2004 to 2010; Ministry of Health Sri
Lanka; www. health gov.lk
8. International Dysphagia Diet Standardisation Initiative. Complete IDDSI
framework: Detailed definitions.
9. J.Hamsananthy, V.Kumarapeli, S.Jeevatharan,R.Gamage. Unmet needs of
care and associated factors among stroke survivors followed up at the
neurological clinics, National Hospital Sri Lanka. https://jccpsl.sljol.info
10. Nishioka S, Okamoto T, Takayama M, Urushihara M, Watanabe M, Kiriya Y,
Shintani K, Nakagomi H, Kageyama N. Malnutrition risk predicts recovery
of full oral intake among older adult stroke patients undergoing enteral
nutrition: secondary analysis of a multicentre survey (the APPLE study).
Clinical nutrition. 2017 Aug 1;36(4):1089-96.
11. Ranawaka UK, Venketasubramanian N. Stroke in Sri Lanka: How Can We
Minimise the Burden? Cerebrovascular Diseases Extra. 2021;11(1):46-8.
12. Sakai K, Kinoshita S, Tsuboi M, Fukui R, Momosaki R, Wakabayashi H.
Effects of nutrition therapy in older stroke patients undergoing

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 rehabilitation: A systematic review and meta-analysis. The journal of
nutrition, health & ageing. 2019 Jan 1;23(1):21-6.
13. Wijesundara W.R.U.A.S, Weeratunga L.L, Wijetunga W.M.U.A, Tilakaratne
T.A.D, Subasinghe S, Katulanda P, 2012. Risk factors and prevalence of
non-fatal stroke in Sri Lanka, a community-based study, annual research
symposium 2012, University of Colombo (p260)
14. Wirth R, Smoliner C, Jäger M, Warnecke T, Leischker AH, Dziewas R.
Guideline clinical nutrition in patients with stroke. Experimental &
translational stroke medicine. 2013 Dec;5(1):1-1.
15. World Health Organization. The global burden of disease 2019:
https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-
death

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Chapter 12: Intervention of the Department of Social
Services for Patients’ Welfare Services.
Mr Chandana Ranaweera Arachchi
The gradual and steady on-going progress of interventions being carried out
by the social services department in the health sector in the recent past is
leading the way to provide optimal medical support for the patients.

In stroke rehabilitation, social interventions begin in the acute phase and

continue throughout the process of rehabilitation. As the medical
interventions gradually decrease, the social interventions increase
appropriately to offer maximal social support to the family and the stroke
survivor. Health care professionals have no reservations in acknowledging
the fact that social care services and interventions play a pivotal and vital role
in helping stroke survivors to reintegrate into the society and also support
the family of the stroke survivor by providing financial aid, vocational
training, and job opportunities to enhance their ability to cope and support
the patient. This is even so very important in the stroke survivor if he or she
is the sole bread winner, or the socio-economic state of the family so
deserves additions support and benefits.

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With a view of providing the optimal possible social support, an officer from
the social services department explores the patient's mental status,
medications and therapeutic interventions needed, the family's economic
state, and other basic social problems. Currently the social services
department provides assistance for renovation of the home to suit the needs
of the stroke survivor, basic support equipment, access facilities, and many
other services as deemed necessary by the assessing officer. These services
are commenced and provided continuously through the duration of in-
patient care, out-patient care, and community care. The services of a
dedicated social service officer have been available to stroke survivors from
2000 at the stroke unit of the National Hospital of Sri Lanka. Access to social
services is available to all stroke survivors in the island via the regional offices.

Social Services Officers provide patients’ welfare services in two phases.

Social services for the welfare of in-ward patients.
Providing solutions for the problems and needs of a patient that are
brought up during multi-disciplinary meetings or daily ward rounds
conducted by the rehabilitation team. For example, if a stroke survivor
needs an air mattress, the coordination to provide the equipment to the
patient is conducted by the social services officer of the rehabilitation team
with the assistance of government agencies or donors.

On discharge from hospital the social services officer coordinates the

required assistance to the family such as providing commode toilet
facilities, wheelchair, access facilities, as well as assisting in improving the
socio-economic status of the family via assisting in educational facilities,
vocational training, and securing employment to mention a few examples.
The facilities provided are individualized to the requirements of the family
of each stroke survivor. The officer may also coordinate other related
services.

An information report is prepared for the patient for use in future

rehabilitation plans.

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Engagement of social services officers in the following matters are also
very effective
Providing vocational training facilities for target groups.
Providing career opportunities.
Counseling.
Intervening in issues occurring with employers.
Making contacts with the Department of Labour.
Coordinating on providing compensation.
Making family members and the community aware about disabilities.
Referring for Legal Aid Services.
Maintaining and strengthening organizations for the persons with
disabilities.
Providing housing and other facilities for the stroke survivor and family.
Bringing the problems of the persons with disabilities to the national level.
Bringing the sports capabilities of the persons with disabilities to the
national level.
Bringing the artistic and cultural abilities of the persons with disabilities to
a national level.
Making health staff aware of social service activities.
Supporting the establishment of organizations for patients (e.g The
National Stroke Association of Sri Lanka).
Introducing music therapy programmes.
Making public officers aware of social service activities.
Participating in national and international conferences.
Inter-agency coordination.
Providing knowledge on disability prevention programmes and first aid to
target groups.

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 Coordination of welfare services and social services officers of the
relevant Divisional Secretariats on discharge from hospital.
The social services officer of the relevant hospital coordinates with the
relevant persons, institutions, and organizations to ensure that the
required equipment is delivered to the patient's home and the required
social services are arranged on or before the discharge of the patient from
the hospital.

They also coordinate to assist the patient to obtain financial assistance for
traveling expenses required to attend hospital clinics from remote areas
and assist in obtaining the necessary medications and other medical
requirements.

The above welfare cycle provides a clear outline of the functioning of services
provided by the social services department where persons with disabilities
and patients including the stroke survivors are at the forefront. Of special

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concern are adults who do not have carers and need significant assistance
form social service officers.

The stroke survivor, their carers, and families benefit the most when the
social services officer is also a member of the multi-disciplinary team that
conducts regular meetings and sets goals and targets in rehabilitation whilst
the patient is in the ward or a stroke unit.

The teams with which the social services officers have to coordinate
Stroke survivor.
Hospital staff.
Stroke survivor’s family members, caregivers, friends, rural community
groups, and organizations.
Field officers of the Divisional Secretariat (e.g. -Technical officers,
Samurdhi Development Officers, Agrarian Development Officers, Relevant
Officers in the Office of the Director of Health Services (MOH) )
Grama Niladhari of the area
Organizations, donors, and societies (rural development societies, sports
clubs, children's clubs, “Swashkthi” groups for the persons with disabilities,
and senior citizens' organizations to name a few).
Other Government Agencies
National Secretariat for Persons with Disabilities
Relevant Pradeshiya Sabha, Provincial Council
Ministry of Education
Office of the Director of Regional Health Services
Department of Labour
Relevant Provincial Councils

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Challenges faced by social services officers.

Lack of financial or other resources required in carrying out emergency

patient needs.
Breakdown of inter-agency and inter-personal relationships.
Failure to establish an appropriate centralized system to provide proper
services (related to patient wellbeing).
Problems with updating of knowledge.
Lack of proper awareness of some hospital authorities on patient welfare
services provided by the social services officers.
Lack of basic facilities for social service officers in certain hospitals.
Methodological development issues.

Strategies used by social services officers to overcome the challenges.

The vast majority of officers are university graduates.

Long-term experience and work experience in the field of social work.
Being creative.
Sympathy for the entire target group, especially the stroke survivor and
the family.
Possess communication skills.

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The primary duty of the social services officers both in the hospital and the
community are directed towards the wellbeing of the stroke survivor. The
Social Services Department serves the differently abled, the injured, and the
stroke survivors through the "National Programme for the Rehabilitation of
Persons with Disabilities” or “CBR Programme" established in the
Department of Social Services. Majority of the disability welfare services in
the community, especially to those discharged from hospital and for those
currently in the society with disabilities are carried out using the annual
allocation of LKR 10 million to the Social Services Department. A database on
persons with disabilities is being maintained through the CBR programme
since 2017.

The Department of Social Services performs a national mission to raise the

living standards of the disadvantaged and marginalized communities in the
society and provides a great opportunity to make welfare services more
effective by adopting modern methodologies to further formalize this duty,
as an institution under the Ministry of Health.

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