Hemiparesis - case presentation.pptx

Hemiparesis is a condition characterized by weakness or paralysis on one side of the body, typically resulting from damage to the brain or spinal cord. In a case presentation, it is essential to provide a comprehensive overview of the patient's history, including any relevant medical conditions or events such as stroke, traumatic brain injury, or tumor. Additionally, outlining the physical examination findings, such as decreased strength, altered reflexes, and possible sensory deficits on the affected side, aids in diagnosing and assessing the severity of hemiparesis. Diagnostic tests like brain imaging studies (CT or MRI) and electrophysiological evaluations may also be included to confirm the underlying cause and guide treatment strategies, which often involve a multidisciplinary approach focusing on rehabilitation, medication, and supportive care to improve functionality and quality of life for the patient.

1. Hemiparesis Case presentation By : Jemini parmar Final year BPT

2. Subjective examination Demographic data : Name : Bharatbhai madhubhai rakholiya Age : 50 Years Gender : male Occupation : Watchman Address : surat Dominance : Right side Date of admission : 25/01/2022 Date of assessment : 8/2/2022

3. Chief complain : He is complaining of difficulty in moving his right side of body ,pain in right hand during movement ,difficulty in walking ,stair climbing ,dressing and eating since last 3 months .

4. History of present illness : On a date of 16 th December ,2021 in early morning 05.00 am patient get up from the bed and that time he experienced right side body weakness , unable to speech ,right side difficulty in gripping ,difficulty in walking and swallowing .and he felt tingling ,numbness and heaviness on right side of the body . Then in ambulance at 06.40 am he admitted in p.p.savani heart institute & multispeciality in ICU under care of Dr.Urmika dholiya and Dr.Rakesh bhalodiya . After being admitted to p.p.savani hospital ,the patient did a Ctscan and MRI which showed that he had ischaemic stroke .On 18 th December he shifted in general ward .In general ward he took physiotherapy treatment two times in day .On 20 th December ,2021 at 07.15pm he was discharged from p.p.savani hospital and that time he was on wheelchair.On 24 th December ,2021 he admitted in Vaidya hospital & rural toxicology center , dungari in general ward under care of Dr.bhumin ramavat .he took treatment for 6 days and on 31 st December ,2021 he was discharged from hospital that time also he was on wheelchair.. Dr.bhumin ramavat suggests for physiotherapy .After discharge for 25 days he took physiotherapy treatment at home and on 25 th janyuary ,2022 he admitted at swami atmanand sarswati ayurved hospital .and he continue start the physiotherapy treatment .Now , patient can able to walk independently without support .

5. Past history: Not relavant past history personal history :diet – veg sleep – normal patient is a chronic smoker ,6 cigarettes\day, (from last 5 year) Family history : no similar family history found in family member Medical history : not relevant Surgical history : not relevant Socioeconomic history : upper middle ( kuppuswami scale) Drug history :baclofen (reduce spasm and tightness of muscle) panicitam Ananta (enhance immunity) ecosprin gold ( lower the raised level of cholesterol)

6. Objective examination on observation : Body built : mesomorphic Posture and attitude of the limb :Anterior view Ear lobes are at same level . Both shoulders are not at same level ,asymmetry in shoulder joint. Right elbow joint is in slightly flexed position . Right hip is externally rotated.

7. Facial asymmetry : no facial asymmetry Muscle wasting : not present Trophic changes : no changes Gait : Hemiplegic gait Involuntry movement : not present Patients attitude : cooperative External appliance : patient is not using any external appliances,

8. On palpation : Temperature : normal (generalised) Tenderness : not present Spasm : not present Swelling \oedema : not present Tone : hypertonia side : right limb : upper limb

9. On examination : VITAL SIGN: Heart rate : 88 bpm Respiratory rate : 16 bpm Blood pressure : 110/80 mm/Hg Temperature :

10. [A] Higher mental function : Level of consciousness : patient is fully and well oriented . Vision : Good Hearing : Good Memory : MMSE scale : 29/30 Attention : Orientation : patient is oriented to time , place and person .

11. [ B]Cranial nerve examination : 1)Olfactory: affected 2)Optic-: intact 3) Oculomotor, Trochlear, Abducent Nerves: eye ball movement possible in all direction :intact 4)Trigeminal: intact Sensory-Touch-present Pain-present Pressure sensation-present Motor- clenching of teeth- normal

12. 5)Facial: intact 6) Vestibulocochler : intact 7) Glossophargyngeal & Vagus Nerve: intact 8)Accessory Nerve : intact 9)Hypoglossal Nerve: intact

13. [C] Sensory examination :  Superficial a} touch : intact b}temperature: intact c}pain: intact d}pressure: intact

14.  Deep: a. Kinesthesia : intact B . Proprioception : intact C . Vibration : intact

15.  Combined Cortical Tactile localization: intact Two-Point Discrimination : intact Tactile discrimination : intact Stereognosis: intact Graphesthesia: intact Double Simultaneous Stimulation: intact Barognosis : intact

16. [D]Motor examination [1] ROM: RIGHT LEFT AROM PROM AROM PROM NORMAL ENDFEEL Shoulder flexion 180 160 180 0 - 180 Firm Shoulder extension 40 35 40 0 - 40 Firm Shoulder abduction 180 180 180 0 - 180 Firm Shoulder adduction 180-0 180-0 180-0 180 - 0 Firm Shoulder internalrotation 60 55 60 0 - 60 Firm Sholder externalrotation 90 80 90 0 - 90 Firm Elbow flexion 140 130 150 0 - 150 Firm

17. Elbow extension 140-0 130-0 150-0 150 - 0 Wrist flexion 80 65 80 0 - 80 Firm Wrist extension 70 60 70 0 - 70 Firm Hip flexion 80 120 110 120 0 - 120 Firm Hip extension 20 20 0 - 30 Firm Hip abduction 40 45 40 45 0 - 45 Firm Hip adduction 40 - 0 45 - 0 40 - 0 45 - 0 45 - 0 Firm Hip internal rotation 45 45 45 45 0 - 45 Firm

18. Hip external rotation 40 45 45 45 0 - 45 Firm Knee flexion 120 135 130 135 0 - 150 Soft Knee extension 150 - 0 Soft Ankle dorsiflexion O O 10 15 0 - 20 Firm Ankle planterflexion 20 30 25 30 0 - 30 Firm Interpretation : Upper limb : ROM is not taken in right side because of synergy pattern and patient having severe pain during movement . Lower limb : hip extension , hip flexion and ankle dorsiflexion (Right side ) decrease because of contracture .

19. [2]Tone : Tone : (upper limb) Grade :3+ (exaggerated response , hypertonia ) Side : Right Spasticity grade : 3 ( consirable increase in muscle tone ,passive movement is difficult ) Tone (Lower limb ): Grade : 2+ (normal response ) Side : right

20. Flexors : Extensors : Muscles interpretation Shoulder flexors 3+ Elbow flexors 3+ Wrist flexors 3+ Knee flexors 2+ Ankle dorsiflexors Muscles interpretation Elbow extensor 3+ Wrist extensor 3+ Knee extensor 2+ Ankle plantarflexors 2+

21. [3] Voluntry control: Right upper limb 2 Right lower limb 6 Left upper limb 6 Left lower limb 6

22. [4]Muscle strength examination : MMT is not taken due to muscle weakness in upper limb . MMT of lower limb muscles: Muscles Right Left Hip flexors 5 5 Hip extensors 2 2 Hip abductors 5 5 Hip adductors 5 5 Hip internal rotators 5 5 Hip external rotators 5 5 Knee flexors 5 5 Knee extensors 5 5 Ankle dorsiflexors 5 Ankle planterflexors 5 5

23. [5]Reflex : Interpretation of DTR: 2+ (normal response ) There is abnormality present in upper limb reflex and Babinski sign is positive ,which is abnormal reflex . DTR Right Left Biceps jerk +3 +2 Triceps jerk +3 +2 Brachioradialis jerk +2 Knee jerk +2 +2 Ankle jerk +2 +2 Babinski sign Positive Not present

24. Speech examination : normal Bowel bladder : normal Balance assessment : Berg balance scale (score):43 Interpretation : A person with a score in this range is considered independent and should be able to move around safely without assistance

25. Coordination : Non equilibrium test : cannot be assessed due to muscle weakness. Equlibrium test: standing in normal comfortable posture : 4 Standing with one foot exactly in front of the other in tendom : 1 Standing with feet together : 3 Standing on one foot (support with therapist hand):0

26. Gait examination : Hemiplegic gait Arm swing is absent . In patient Normal Base width 5 cm 8 to 10 cm Step length 42 cm 72 cm Stride length 84 cm 144 cm cadence 62/min 90 to 120 step /min Angle of toe out 30 degree

27. Functional assessment :FIM (functional independent measure ) Interpretation : 114 Patient should be able to live independently . Outcome measures : STREAM (stroke rehabilitation assessment of movement )

28. Investigation : Ctscan : date –(18/12/2021) Findings : patchy & confluent non haemorrhagic recent ischemic infarcts involving left corona radiata , left basal ganglia ,left insular cortex & external capsule and left anterior temporal lobe . MRI : date – (18/12/2021) Findings : patchy fairly small to medium sized discrete & confluent acute non haemorrhagic infarcts involving left capsulo – ganglionic region , corona radiata , insula and adjacent part of fronto -temporo-parieto-occipital cortex & subcortical white matter . Few small old ischemic areas involving bilateral fronto – parietal lobes. Mild cerebro -cerebellar atrophic changes .

29. Provisional diagnosis : Right side hemiplegia

30. Problem list : Tonal abnormalities Muscular weakness Functional disability Synergistic pattern Tightness & contracture Coordination Gait abnormalities Postural abnormalities

31. ICF Health condition (stroke) Body structure & function  structure : left anterior temporal lobe  Function : right hemiplegia Activity limitation difficulty in ADL activity and house hold activity ( eg .dressing ,walking ,eating ,bathing ) Participation restriction  Not fulfil a role in family .  Not attend a social function . Personal factors family support active life style willingness to recover Environmental factors use rail

32. Physiotherapy management : Short term goal : Educate patient s family / caregiver regarding health condition and prognosis . Decrease risk of secondary impairment . ( eg . Pressure sore ) Flexibility and joint integrity. Improve strength . Improve upper extremity function Manage spasticity. Improve balance. Improve coordination . Improve locomotion . Improve aerobic function . Functional training .

33. Long term goal : Maintain all short term goal. To make him independence with self care and home management . Resume work , community and leisure roles . Discharge planning .

34. Educate patient s family / caregiver regarding health condition and prognosis . Interventions: Give factual information , counsel family members about patents capabilities & limitations. Give psychological support . Rationale : This helps patient understand the status as well as cooperates which reduces his recovery time . Decrease risk of secondary impairment . ( eg . Pressure sore ) Interventions : Proper positioning . Relive pressure point by padding & cushion . Frequent turning & changing position . Rationale : pressure sores are painful and stagnate the recovery .

35. Flexibility and joint integrity. Interventions : PROM with terminal stretch . AROM when possible with terminal stretch . Effective positioning . ( maintaining soft tissue length ) Stretching : on the extended paretic UE with the wrist extended and fingers open and extended . Tricps , calf , hamstring , adductor , piriformis . Rationale : improved joint flexibility and integrity help gain function sooner .

36. Improve strength . Interventions : Progressive resistive exercise . Hip & knee joint ROM with 2 kg weightcuff . Stair climbing while the patient is wearing weighted cuff. Wall squats Qudriceps table Rationale : overload principal helps improve strength .

37. Improve upper extremity function : Constrait induced movement therapy : Picking up object and reaching activities . Rationale : CIMT has been shown to improve unilateral function in subacute and chronic stages of rehab .

38. Manage spasticity : Interventions : Early mobilization & daily stretching . Promote optimal positioning . PNF : Rhythmic rotation or rhythmic initiation . Side sitting on hemiparetic side provide sustained stretch to the spastic side flexors . Modalities : cold pack , massage , ES Functional electrical stimulation . Rationale : inhibiting the continuous firing of the AHC.

39. Improve balance : Interventions : Balance : Facilitate symmetrical weight bearing on both side . Postural perturbation can be induced in different positions . Reaching activities . Modified plantigrade position . Dual task training . Rationale : balance is important aspects that govern most of our ADL activities .

40. Modified plantigrade position

41. Improve locomotion : Interventions : Initial gait training between parallel bars. Walking forward , backward , sideward ,crossed step . Step-up and step-down . Tandem walking . Treadmil training : gradually increased speed as the patients walking ability is improved . Eg , start with 0.23 m/s and increase after improvement eg , 0.42 m/s. Functional electrical stimulation . Rationale : Gait is important aspects that govern most of our ADL activities .

42. To improve functional status : Bed mobility : rolling , bridging ,sitting , sit to stand , sit down standing Rationale : these activities are important aspects in our ADL activities .

43. Discharge planning : interventions : Family members should participate daily in the therapy session & learn exercises. Home visits should be made prior to discharge . Architectural modification should be ready before discharge . Identify community services & provide information to the patient . Rationale : to further help to recovery process even after discharge and regain as much function as possible .

44. Thank you