HEMIPARESIS CASE PRESENTATION

Case presentation on Hemiparesis

1. HEMIPARESIS DARSHAN PARMAR

2. DEMOGRAPHIC DATA Name : Bhavsangbhai Kyor Age : 75 years Gender : Male Address : Matru Ashish, street no.2, Rameshwar nagar , Jamnagar Occupation : Retired Dominance : Right Affected side : Right Socioeconomic condition : Good Height : 158cm Weight: 60kg BMI : 24 kg/m2

3. DEMOGRAPHIC DATA Provisional Diagnosis : CVA Rt. Hemiplegia (ischemic) Laboratory Reports : Hb : 14 grams/dL RBC count : 4.41 trillion cells/L HCT : 41.2 % WBC count : 14600 cells/L ↑ Platelet : 236000/mcL Random Blood Sugar : 170 mg/dL ↑ VLDL Cholesterol : 40 mg/dL ↑ 01/11/2021

4. VITALS Blood Pressure : 138/72mmHg Temperature : Normal Heart Rate : 88 pulse/min. Respiratory rate :22 breath/min.

5. CHIEF COMPLAIN On 04/11/2021 Unable to lift his right arm Unable to lift his right leg Unable to walk independently Unable to maintain Balance Tingling and Numbness on right Upper and Lower limb and Scalp. On 23/11/2021 Unable to maintain balance while walking Tingling and Numbness on right sole of foot and scalp area.

6. HISTORY Present History : On 30/10/2021 at 7:00 am patient fell down and was unable to lift his Right arms and leg . Patient had took bath with cold water in Cold environment before stroke at 5:00 am. Later the patient was taken to the local clinic at Haridwar, during that period patient was fully conscious and was able to communicate with his family, even he had asked his family member to take him to the clinic by giving address. (this interpret that during the time of stroke patient was fully conscious and his memory was intact). Doctor at local clinic had referred the patient to the Hospital . So the patient was taken to “Ramakrishna Mission Sevashrama , Kankhal ” in the Emergency ward at Haridwar(Uttarakhand) on same day. The attendant Doctor was Dr. Ashwani Chauhan over their. Patient was diagnosed with DM and HTN at that time. Their was No H/o DM and HTN before the stroke. On Examination patient was having Pulse: 100/min, BP: 190/100mmHg after 15 minutes it was reduced to 170/100mmHg, SpO2: 96% and RBS: 193mg/dl .

7. Patient had a complain of Rt hand and leg weakness and pain on both the leg (which could be probably post-stoke pain*) during admission. Treatment given was Inj. Pantop 40 mg IV (Acid reflux) Inj. Emeset 10mg IV (Nausea & Vomiting) Inj. Nitroglycerin 1ml/hr (Angina) Inj. Lasix 2ml IV (High BP) Tab. Telma 40 (High BP) Cap. Ecosprin 150 (Anticoagulant) Tab. Atorva 40 (Cholesterol) Inj. Strocit 10mg in 100NS (psychostimulant) Treatment for leg pain Tab. PCM 50mg (pain relief) Tab. Cyclopex (Antispasmodic) Tab. Betasone (Allergy) Tab. Ranitidine (Acid reflux) Tab Nimesolide (pain relief) Tab. Dexon (Anti-inflammatory) Tab. Cetrizine (Allergy) *Sullivan 6 th edition pg:669

8. Family members were asked to admit the patient for 20 days, but he was not admitted. Later he was taken to Jamnagar, where they consulted Dr. Amit Udani on 01/11/2021. Patient was advised for Brain MRI and ECG. By the reports of MRI Dr. Amit Udani sir had advised for Physiotherapy and the medication prescribed by him were Cap. Clopcare A 150 (Blood thinning) Cap. Atvast 40 (lower’s blood Cholesterol) Tab. Methron (for infection) Patient had started Physiotherapy from 02/11/2021 by a Visiting Physiotherapist. The treatment given by the Physiotherapist was Passive and Active-assisted Hip and knee ROM exercise, Ankle toe movement. On 04/11/2021 patient entered Neuro Department of GPTC on wheel chair with the complain of unable to lift his right arm and leg. Patient was assessed thoroughly, accordingly exercise for prescribed and he is taking treatment at GPTC till date. 10 days

9. Past History : Not Relevant Personal History : Smoking since 50 years Stopped consumption of Alcohol before 20 years (used to consume once a week) Family History : H/o DM – wife and son (Not Relevant) Surgical History : Removal of Kidney stone before 6 years through LASER. Medical History : DM and HTN since 30/10/2021, Type 1 LV Diastolic Dysfunction. 30/10/2021 – BP : 170/100 mmHg, RBS : 193mg/dl 01/10/2021 – RBS : 170mg/dl 06/11/2021 – BP : 150/90 mmHg 10/11/2021 – RBS : 174mg/dl

10. Current Drug History : Cap. Clopcare A (for blood thinning) Cap. Atvast 40 (lower’s blood Cholesterol) Tab. Elfolin Plus (Nutritional deficiency) Tab. Olmetime (for HTN) Tab. Glycomet (for DM) Rehabilitation History : Stretching to Tight Muscle Passive movement for Rt Shoulder Active – assisted for Rt elbow, wrist, hip, knee, ankle Sit to stand Bridging, Curls up, Plantigrade positioning Hamstring curls with support Shoulder elevation, depression, retraction, protraction with Biofeedback Weight bearing on Rt hand and Reachouts Reachout in standing with Pelvis supported Marching by holding Parallel bars Gait Training in Parallel bars

11. INVESTIGATION MRI BRAIN : (01/11/2021) Multiple small to medium sized acute non-haemorrhagic infarcts involving left high fronto -parietal region and small similar infarct involving right high parietal region. Old lacunar infarcts involving left basal ganglia and pons . Age related atrophic changes. Few small vessel ischaemic changes. Moderate atherosclerotic changes involving left extracranial ICA origin causing 10 to 20% narrowing. Moderate atherosclerotic 30 to 40 % narrowing involving left main stem MCA Mild atherosclerotic changes involving right carotid bulb and proximal ICA without significant narrowing.

12. Frontal Lobe injury : Impairment of recent memory, inability to concentrate, behavior disorders, difficulty in learning new information. Emotional lability, Contralateral plegia , paresis , Expressive/ Brocas /motor aphasia.* Parietal Lobe Injury : Inability to discriminate between sensory stimuli, Inability to locate and recognize parts of the body. Severe Injury: Inability to recognize self, Inability to write .* Lacunar Infarct : Dysarthria, Ataxic hemiparesis, Dystonia, Deficit in consciousness, language, or visual fields are not seen because higher cortical areas are preserved . A hypertensive haemorrhage affecting the thalamus can also produce central stroke pain .** Middle Cerebral Artery infarct : Contralateral Hemiparesis (UL>LL) , Contralateral sensory loss, Motor/sensory/global Aphasia, Ataxia, Pure motor hemiplegia (Lacunar stroke) ** Internal Carotid Artery infarct : ACA + MCA Anterior Cerebral Artery infarct : Contralateral Hemiparesis (UL<LL), Contralateral sensory loss, Urinary incontinence, problem in copying, absence of will power, slowness .** *Minnesota Brain Injury Alliance; About Brain Injury: A Guide to Brain Anatomy **Sullivan 6 th edition pg:650-653

13. INVESTIGATION ECG : (01/11/2021) Type 1 LV Diastolic Dysfunction.

14. ON OBSERVATION Built : Mesomorphic Posture : Anterior View Right shoulder depressed Bow legs Right leg external rotated

15. Posterior View : Right shoulder depressed Right leg external rotated

16. Lateral View : Forward head posture

17. Anterior View : Right shoulder depressed Posterior View : Right Shoulder depressed Scapular Dyskinesia

18. Forward head poster Right shoulder Protracted.

19. GAIT Anterior View : Right leg moves in External Rotation More weight bearing on sound leg Arm swing reduced Patient usually see downwards (due to loss of sensation on sole of foot due to DM) Lateral View : Arm swing reduced Uneven steps to maintain Balance

20. ON OBSERVATION Assistive device : Wheelchair (04/11/2021 to 10/11/2021) Walker (10/11/2021 to 15/11/2021) Swelling : Not Present Tropic changes : Not Present Involuntary Movement : Not Present Muscle wasting : Not Present Deformity : Not Present

21. ON PALPATION Tenderness : Anterior joint line of right shoulder Temperature : B/L symmetrical Spasm : Not Present Swelling : Not Present

22. ON EXAMINATION Higher Function Examination : Consciousness : Alert Orientation : Oriented to Time, Place and Person Memory : Immediate, Short term and Long term memory - all are intact Attention : Alternating attention (Normal) Behaviour : Cooperative Speech : NAD Reading : Non Fluent Writing : Impaired

23. Cranial Nerve Examination : Olfactory (S) : Intact Optic (S) : Intact Oculomotor (M) : Intact Trochlear (M) : Intact Trigeminal : Intact Abducent (M) : Intact Facial : Intact Vestibulocochlear (S) : Intact Glossopharyngeal : Intact Vagus : Intact Spinal Accessory (M) : Intact Hypoglossal (M) : Intact

24. SENSORY EXAMINATION Superficial Sensation : Fine Touch : Impaired on B/L sole of foot (300gm force) Crude Touch : intact Pin Prick : intact Pressure : intact Deep Sensation : Proprioception : intact Kinaesthesia : intact Vibration : intact (impaired on Planter surface of B/L Great Toe and Metatarsal joint) Cortical Sensation : Stereognosis : intact Tactile localization : intact Barognosis : intact Graphesthesia : intact * Predictor of Diabetic Foot Ulcers : Pin-Prick sensation, Vibration and 10g monofilament pressure sensation at sole of foot. Loss of 10g monofilament perception and reduced vibration perception predicts foot ulcer

25. PAIN ASSESSMENT Site : Right Shoulder Joint Onset : Gradual Tenderness : Anterior joint line of right shoulder Type : Dull aching Aggravating factor : Activity (Shoulder flexion, abduction) Relieving factor : Rest NPRS : Activity : 3/10 Rest : 0/10

26. TONE 04/11/2021 25/11/2021 Shoulder Extensor 1 Elbow (Flexor/Extensor) 0 (Normal) Wrist (Flexor/Extensor) 0 (Normal) Hip (Flexor/Extensor/Abductor) 0 (Normal) Knee (Flexor/Extensor) 0 (Normal) Ankle (DF/PF) 0 (Normal) Right Shoulder Flexor, Abductor, Extensor - Hypotone

27. VOLUNTARY CONTROL 04/11/2021 Shoulder 0/6 Elbow 3/6 Wrist 3/6 Hip 4/6 Knee 6/6 Ankle 5/6 24/11/2021 Shoulder 3/6 Elbow 4/6 Wrist 3/6 Hip 4/6 Knee 6/6 Ankle 5/6

28. MMT KNEE RIGHT LEFT FLEXOR 4/5 4/5 EXTENSOR 5/5 5/5

29. Reflex : Left Left Right 23/11/2021 04/11/2021 04/11/2021 23/11/2021 2+ 2+ Biceps 2+ 2+ 2+ 2+ Triceps 2+ 2+ 2+ 2+ Knee jerk 2+ 2+ 2+ 2+ Ankle jerk 2+ 2+ Synergy : Flexor Synergy in Right UL. Tightness : B/L Hamstrings, Adductors Extensor Response Babinski sign Extensor Response

30. LIMB LENGTH DISCREPANCY (LLD) Right Apparent length Left 95 cm Umbilicus to medial malleolus 95 cm Right True length Left 13 cm ASIS to GT 13 cm 39 cm GT to lateral Knee joint 39 cm 41 cm Medial knee joint to M.M. 41 cm

31. CO-ORDINATION TEST NON EQUILIBRIUM : Finger to finger test Finger to nose test Dysdiadochokinesia Knee to heel test EQUILIBRIUM : Tandem walking : Severe Impairment : Able only to initiate activity without completion. Walking sideways : Minimal Impairment : Able to accomplish activity, slightly less than normal speed. Single leg standing : Severe Impairment : Able only to initiate activity without completion. Minimal Impairment : Able to accomplish activity, slightly less than normal speed.

32. BALANCE TEST BERG BALANCE SCALE : 04/11/2021 : 32/56 Affected Component : Sit to stand – need assistance Standing unsupported – cannot maintain balance Standing unsupported with leg together – cannot maintain balance Reaching forward – cannot maintain balance Turn 360 – need supervision Alternate Step on stool/stepper, one leg standing, Tandem standing 25/11/2021 : 46/56 Affected Component : Sit to stand – need support of hand Turn 360 – slow One leg standing

33. GAIT EXAMINATION Step length (Rt) (Rt Toe  Lt Toe ) : 31cm Step length (Lt) (Lt Toe  Rt Toe ) : 34cm Stride length (Rt) (Rt Toe  Rt Toe ) : 63cm Stride length (Lt) (Lt Toe  Lt Toe ) : 66cm Cadence : 62 steps/min.

34. FUNCTIONAL ASSESSMENT Grooming : Independent Dressing : Need Assistance Bathing : Independent (need supervision) Toileting : Independent (need supervision) Transferring : Need Assistance Ambulation : Need Assistance (cane – due to fear of fall) Feeding : Independent (Modified – started to use Left hand to feed himself, before stroke he was using right hand)

35. FUGL-MEYER ASSESSMENT SCALE TOTAL UPPER LIMB SCORE : 48/66 (Affection : Flexor synergy, Coordination) TOTAL LOWER LIMB SCORE : 32/34 (Affection : Coordination) BALANCE TOTAL SCORE : 10/14 (Affection : one leg standing) SENSATION TOTAL SCORE : 23/24 (Affection : sole of foot) JOINT ROM TOTAL SCORE : 43/44 (Affection : Shoulder abduction) PAIN TOTAL SCORE : 40/44 (Affection : Shoulder flexion, abduction and knee flexion) TOTAL FUGL-MEYER SCORE : 196/226 (87%)

36. ICF* Body Functional & Structural Impairment : B/L loss of sensation on sole of foot, Tingling and numbness on Right foot and scalp, synergy in UL Composite Impairment : Balance and Gait deficits Activity Limitation : Dressing and walking independently Participation Restriction : unable to attain social functions Performance Qualifiers : moderate difficulty in locomotion  use of cane Facilitator : Good Family support Barriers : Fear of losing balance *Sullivan 6 th edition

37. CLINICAL DIAGNOSIS Right side Hemiparesis

38. PROBLEM LIST Impaired balance while walking Needs the support of hand for standing from sitting Needs assistance for Dressing Upper limb synergy Right Shoulder pain Lack of coordination in upper limb Tightness of B/L hamstrings and adductor

39. MANAGEMENT SHORT TERM GOALS : To improve Balance while Walking Transfer Activity (Assistance to Independent Transfer) Make Independent in ADLs Break Upper Limb Synergy Improve Co-ordination Pain Management

40. To improve walking balance : Strengthen Lower limb and core muscle  Improve Sitting Balance  Improve sit to stand  Improve standing balance  Improve dynamic balance.* 1) Strengthening of Lower Limb : Active – Assisted exercise  Active exercise  Resisted Exercise. Ballster kicking (forward, backward and side ward) also improves balance. Hamstring curls with support  without support 2) Strengthening of Core Muscle : Bridging  One leg Bridging  Bridging with SLR** Curls ups Alternate arm and leg raise in Quadripod position Pelvic PNF (Anterior elevation and Posterior depression)*** Trunk Rotation** *Steps to Follow – Patricia ** E.Ko et al; The Additive effects of core muscle strengthening and Trunk NMES on Trunk Balance in Stroke patients, Ann Rehabil Med. 2016 Feb; 40(1): 142-151 ***H. Patni; A Comparative study on the effects of Pelvic PNF exercise and Hip extensor strengthening exercises on Gait Parameters of Hemiplegic patients; Int J Physiother Res 2019 Vol 7(4): 3150-56

41. 3) Improve Dynamic Sitting Balance : Sitting on Vestibular ball  Perturbation while sitting on Vestibular ball. 4) Improve Sit to Stand : Wall squats  Squatting  Sit to Stand from low stool 5) Improve standing balance : Standing with wide base  narrow base  Tandem standing  Standing on one leg Catching ball in standing (Task specific training) Perturbation in standing Reaching with Lower limb in Standing 6) Improve Dynamic Balance (Walking) : Walking on foot prints Tandem walking Sidewards walking Obstacle walking LL-CIMT* *E Oliveria et al; Effects of Lower Extremities Constraint Induced Movement Therapy on Gait and Balance of Chronic Hemiparetic Patients after Stroke: Description of Study Protocol for RCT-Clinical Trial; Research square; July 19,2021

42. Transfer Activity (Assistance to Independent Transfer) : It gets improve by the previously mentioned exercise Initially when assistance is required  never lift the patient from Axilla Break Upper Limb Synergy : Plantigrade Position D2 flexion for UL Scapular PNF (also improves scapular alignment) Improve Co-ordination Finger to Finger Finger to Nose Finger to Therapist Finger Peg board activity in diagonal pattern Holding a glass of water and taking it towards mouth

43. Pain Management : Grade 1/2 Maitland Mobilisation Cryotherapy Table top polishing exercise* (reduces pain by improving shoulder integrity) To improve Shoulder Stability : Scapular Strengthening Exercise (also improves scapular alignment) Scapular PNF (also improves scapular alignment) Shoulder Strengthening Exercise (Active-assisted  Active  Resisted exercise ) To improve Flexibility : Stretching of Tight muscle To improve Cardio-Pulmonary function : Breathing Exercise (Diaphragmatic breathing, Segmental breathing, Spirometry) Marching Walking *Sullivan 6 th edition pg : 683

44. LONG TERM MANAGEMENT Improve Flexibility (Stretching) Improve Strength of Upper Limb ( Resisted Training : Therabands , dumbells , Theratubes ) Improve Cardiac endurance (Walking, Cycling)

45. HOME ADVICE Use of affected limb in daily activity. Avoid stepping out of house without Foot wares. Inspect the sole of foot regularly Moisturise the feet Walking (to improve circulation) Yoga , Meditation Focus on diet

46. THANK YOU