Stroke Rehabilitation

Dr. CHOW Chi Ping, Alex

Director, Department of Physical Medicine and Rehabilitation

Director, Rehabilitation Centre

Honorary Consultant in Rehabilitation Medicine

Specialist in Rehabilitation

Acute stroke is the cause of a wide spectrum of neural deficits and functional losses, including, hemiplegia, loss of sensation, aphasia, and cognitive impairment. The severity depends on the extent and location of damaged tissues

Supported by multiple disciplines, stroke rehabilitation can help minimise the adverse impact of stroke and improve quality of life with holistic assessments and treatments.

Stroke rehabilitation focuses on the prevention and treatment of common complications and side effects of stroke. It helps reduce functional loss, maximise self-care abilities and return patients to their normal lives.

Common Complications and Side Effects of Stroke

Delirium

• Important to keep the patient’s airway patent.

Swallowing Difficulty

• Crucial to prevent pneumonia caused by food entering the lungs.

Malnutrition

• Control reduced calorie uptake and deterioration due to swallowing difficulties, dependence on feeding by others/ tube feeding or depression
• Monitor intake of water, protein and calories.

Pressure Sores

• Common in immobile and bedridden patients
• Essential to relieve pressure with specially designed mattresses and heel protectors, turn the patient routinely, check and clean the patient’s skin every day, and ensure good nutrition, etc.

Spasticity

• Improve with stretching, orthotic treatment and/or prescription of anti-spasticity medications.

Deep Vein Thrombosis

• In early stage, perform passive exercises when stable; engage in active and intensive exercises if allowed to reduce the risk of deep vein thrombosis as well as for physical and psychological relief.

Reduced Mobility

• Can help patients with body movements, such as turning in bed, sitting in bed, transferring to wheelchair, standing, walking and other day-to-day care, e.g. combing and washing hair, eating, putting on clothes.

Shoulder Subluxation and Upper Limb Pain

• Avoid pulling the affected arm when moving
• Improve with regular stretching and application of functional electrical stimulation.

Language and Communication Difficulties

• Problems with listening, speaking, reading and writing, and impact on pronunciation and voice.
• Show significant improvement with intensive training.

Depression

• Can improve with prescription of antidepressants after assessment.

Under the guidance of a multidisciplinary rehabilitation team, the duration of stroke rehabilitation varies from patient to patient. Generally speaking, the longer and more intensive the training, the better the clinical outcome. 

Multidisciplinary Rehabilitation

Specialist in Rehabilitation

Consultation usually begins with a preliminary assessment of functional loss and its extent, e.g. limb power, swallowing, communication, self-care ability, excretion, bladder control, etc.

Based on further assessments of neural condition and ability to relearn cognitive skills, patients are given achievable goals along the way to promote maximum rehabilitation.

Rehabilitation Nurse and Community Nurse

On top of guidance to patients on day-to-day care, e.g. bathing, specially trained nurses can help ensure good medication compliance in patients and keep track of their skin condition.  

Upon referral, patients can receive holistic and continuous care, treatment and guidance at home from a community nurse.

Physiotherapist

Based on the assessment of one’s physical impairment and function, a specially designed physiotherapy treatment program me can be provided at different stages of recovery. Physiotherapy includes motor learning, electrical stimulation, Constraint-Induced Movement Therapy (CIMT), core muscle training with Pilates exercises, balance training, robotic gait training, etc.

• Motor Learning: Repetitive training of core and limb muscles can enhance joint stability, movement speed, muscle endurance, coordination of muscle control, body posture and overall balance.

• Functional Electrical Stimulation (FES): Electrical stimulation that synchronises with the patient’s movement retrains and enhances motor functions of the affected limbs. 
• Constraint-Induced Movement Therapy (CIMT): With the unaffected arm restrained, the affected limb would undergo specific, intensive and progressive functional training to improve its function in daily living.

• Pilates Exercises: Train the strength and agility of weakened muscles, and enhance the coordination among different muscle groups to perform more precise movements.
• Balance Training: Under the guidance of physiotherapists, balance training and fall prevention can be achieved. For patients with higher fall risks, the suspension system can provide adequate support and protection during training. Gym balls, balance board and trampoline are used in more advanced balance training.
• Robotic Gait Training: For patients who need assistance with walking, robotic gait training with virtual reality engagement can improve their gait patterns and walking tolerance.

Occupational Therapist

Occupational therapists can help stroke patients return to normal family lives, careers and society as well as regain independence with wide-ranging treatments: 

• Upper limb assessment and training, e.g. temperature sensation test, tactile sensation test, hand function assessment and training, recommendations on and customisation of eating utensils.
• Cognitive function assessment and training improves patients’ focus, memory and arithmetic ability.
• Daily living assessment and training
• Home assessment and customisation, training of carers
• Wheelchair assessment and recommendation ensures proper support to patients’ limbs and reduce pain, dislocation and pressure sore.
• Assistive device assessment and training help enhance quality of life and safety with reduced burden on carers.

Speech Therapist

Speech therapists are professionals in assessing and treating communication problems of stroke patients. They conduct swallowing assessments to identify unusual symptoms during eating, e.g. coughing, change in voice quality, swallowing difficulties, etc. Videofluoroscopic Swallowing Study (VFSS) and Fibreoptic Endoscopic Examination of Swallowing (FEES) are also performed to assess swallowing problems as indicated, followed by wide-ranging measures to improve communication and swallowing, which may include:

• Oral and pharyngeal muscle strengthening and coordination exercise
• Language (speaking, comprehension, reading and writing) and articulation training
• Voice training
• Modification of food texture and consistency in meals
• Recommendations on feeding postures and techniques
• Stimulation training, e.g. electrical stimulation, reflex stimulation.

Prosthetist-orthotist

Prosthetist-orthotists design tailored orthoses and other devices to stabilise, support and protect the affected limbs, with the added benefits of minimal contracture, reduced pressure sores and improved gait. 

Case Sharing

1. Mrs. CHOW (48 years old)

Mrs. CHOW suffered a left-sided stroke in 2018 and stayed in a public hospital for several months. Her husband Mr. CHOW decided to opt for private rehabilitation services for his wife after discharge.

While Mr. CHOW had no idea as to what her wife might need for treatment, he knew that a comprehensive rehabilitation plan was crucial to her recovery. As he could not care for Mrs. CHOW 24/7, after comparing different service providers, Mr. CHOW finally chose HKSH for its wide-ranging services and professional teams. 

Mrs. CHOW remained bedridden when transferred to HKSH. Her self-care ability and comprehension was also limited. Mr. CHOW had consulted the rehabilitation specialist at HKSH before transfer, and admission went smoothly with the cooperation of the public hospital. After comprehensive assessments, the HKSH rehabilitation team came up with a tailored treatment plan for Mrs. CHOW. Everyone knew that the rehabilitation would take time, and despite all the ups and downs, gradual improvement was witnessed in the patient throughout the process.

Mrs. CHOW was discharged from HKSH after 7 months, and she continues to visit HKSH for physiotherapy, occupational therapy, speech therapy, etc. every day. While the left-sided stroke has made a great impact on Mrs. CHOW’s speech ability, she can now move freely at home and does show improvement in communication.

In addition to receiving treatment at the Hospital, installation of home rehabilitation equipment is usually recommended if space allows. On top of the rehabilitation exercise at HKSH, Mrs. CHOW can also practise at home with a wall bar, a stretch board, a sandbag and loadings. Medical professionals were consulted beforehand to ensure that Mrs. CHOW can exercise safely at home and at an appropriate difficultly level.

A visit to HKSH has now become a part of Mrs. CHOW’s daily routine, thanks to her trust in the HKSH rehabilitation team.  And with the mutual support from other patients, Mrs. CHOW is ready to overcome any challenge with optimism and resilience.

2. Mr. WONG (61 years old)

In 2015, Mr. WONG was airlifted back to Hong Kong for emergency treatment after suffering right brain stem stroke in the Mainland. His chance of recovery was considered so low that he would probably die afterwards. As he was unable to talk, eat and walk after stroke, Mr. WONG was discharged from the public hospital after 4 months and infirmary care was recommended.

Traditional Chinese manipulation and acupuncture were arranged when his fingers were found to be curled and weak, but to no avail. A history of tonsillar cancer (diagnosed in 2001) and the resulting muscle weakness further aggravated his condition, making him susceptible to infection. Mr. WONG’s family finally chose HKSH for safe treatment in a hospital setting. Mr. WONG was admitted to HKSH, and was given prescriptions by the HKSH rehabilitation specialist along with comprehensive treatment from a multidisciplinary team. Significant improvement was seen within a short period of time.

Recalling his rehabilitation journey, Mr. WONG felt most encouraged when he could stand up on a tilt table during physiotherapy. He then began to learn to sit up after further treatment. Now he is able to stand up on his own, and walk with the assistance of two helpers. He can also practise at home with a monkey pole.  

Under guidance at HKSH, Mr. WONG also tried to speak with the artificial airway for the first time after tracheotomy at the public hospital. With weakened lungs and excess sputum, much time was spent on mucus suction and rest when he first tried to put the speaking valve in place. After training for 1.5 years, Mr. WONG can now communicate with others using the speaking valve. He also took the advice of the doctor and is now learning to use the Cough Assist for sputum clearance at home. According to his family members, Mr. WONG never thought that he could ever speak again when he was discharged from the public hospital. Everything became possible only after consultation with the speech therapists at HKSH. After much effort and practice, he can now speak his mind again with the speaking valve.

Cakes made by helper under Mr. WONG’s instructions.

Ms. YUEN is Mr. WONG’s girlfriend, who has been staying by Mr. WONG’s side throughout the years. “The medical team at HKSH does care about patients. They truly understand how chronic patients feel and what they need,” said Ms. YUEN. “Also they are accommodative towards patients and good at encouragement and persuasion. It helps overcome patients’ initial resistance towards treatment.”