Stroke - Case presentation

Stroke Case Presentation

1. Case Presentation 1. Shubhankar Whaval

2. Question A 68 - year old male found in garden at home by his wife with the complaints of drowsy , uncommunicative & had vomited. In next three hours , patient was shifted to multi-speciality hospital. Their CT scan shows ( RT ) middle cerebral artery infarct. After few hours, patient developed ( LT ) sided weakness , reduced reflexes and fever. The patient history shows, he is an non-smoker and had undergoing treatment for atherosclerosis. Describe the Physiotherapy management for this patient.

3. Demographic Data Full Name : Mr. Mohan Age : 68 years Gender : Male Dominance : Right (Assumed) Ward : Intensive Care Unit Date of admission : 22/09/2020 Date of assessment : 22/09/2020

4. Chief complaints : Difficulty in moving the left side of his body (arm and face – assuming from MCA infarct) since a few hours. History of present illness: Patient has a history of atherosclerosis under going treatment. Patient was found by his wife in their garden in a drowsy and unresponsive state. Patient also had an episode of vomiting. Patient was then taken to a multispecialty hospital after 3 hours where a CT scan revealed an right MCA infarct. Few hours later the patient seemed to have developed weakness in his left side, reduced reflexes and developed fever as per the assessment done by the concerned personnel.

5. Past history : Past Medical - Atherosclerosis (under treatment) Past Surgical – None given Family history : not give n Personal history : Appetite – not given Sleep – not given Narcotic addiction - None Alcohol addiction - None Bowel – flaccid Bladder – flaccid (catheterized) Socioeconomic history : Kuppuswami Scale

6. Physical Examination General Examination : Blood pressure : 130/85 mmHg (Assuming based on atherosclerosis) Temperature : 99.2 F (Assuming based on complaint of fever) Pulse rate : 72 beats/min Respiratory rate : 19 breaths/mi Systemic Examination : On Observation Built : Endomorphic Nutrition : Mixed Pallor : Absent Icterus : Absent Oedema : Absent Attitude o f the Patient : Supine lying

7. On Observation : Posture and Gait : Cannot be assessed Any equipment attached Oxygen mask S phygmomanometer Pulse Ox ECG leads Intravenous line Foley Catheter On Palpation : Clubbing : Absent Cyanosis : Absent Oedema : Absent Tenderness : Absent

8. Nervous System Examination: Higher Mental Function Coordination : Cannot be assessed due to weakness

9. Cranial Nerve Assessment CN I - Sense of smell in each nostril CN II – Acuity of vision Field of vision Color vision CN III, IV, VI - External Ocular Movements CN V - Sensations over the face, Corneal, Conjunctival, Jaw Jerk ○ CN VII - Expressions CN VIII - Rinne’s test, Weber’s test CN IX, X – Uvula “Ah” , Gag reflex CN XI - Trapezius, Sternocleidomastoid CN XII - Protrude tongue Involuntary Movements - Absent

10. Motor System Examination: Range of Motion : Active Rom reduced on the left side Passive Rom Full Tone : Left side – 1+ Gradings 0 No response (flaccidity) 1+ Decreased response (hypotonia) 2+ Normal response 3+ Exaggerated response (mild to moderate hypertonia) 4+ Sustained response (severe hypertonia)

11. Power : MMT Muscle group Left Right Shoulder Flexors Extensors Abductors Adductors Internal Rotators External Rotators 2 / 2+ 4 Elbow Flexors Extensors Forearm Supinators Pronators Wrist Flexors Extensors Radial Deviators Ulnar Deviators Hip Flexors Extensors Abductors Adductors Internal Rotators External Rotators Knee Flexors Extensors Ankle Dorsiflexors Plantarflexors Invertors Evertors

12. Reflexes : Superficial Plantar - + Abdominal - + Hoffman’s Sign - Present Deep Biceps - + Triceps - + Supinator - + Finger flexion - + Knee - + Ankle - + Primitive - May or may not the present Sucking/Rooting Grasp Glabellar Tap Graded Absent (--) Depressed (+) Normal (++) Brisk (+++) Clonus (++++)

13. Sensory System Examination: Superficial Senses Touch - Diminished on the Left side Temperature - Diminished on the Left side Pain - Diminished on the Left side Deep Senses Position - Diminished on the Left side Joint sense - Diminished on the Left side Vibration - Diminished on the Left side Cortical Senses Tactile Localization - Diminished on the Left side Tactile Discrimination - Diminished on the Left side Stereognosis - Diminished on the Left side

14. Outcome Measures Fugl -Meyer Assessment of Motor Recovery after Stroke Motor functioning (in the upper and lower extremities) Sensory functioning (evaluates light touch on two surfaces of the arm and leg, and position sense for 8 joints) Balance (contains 7 tests, 3 seated and 4 standing) Joint range of motion (8 joints) Joint pain Scoring: Scoring is based on direct observation of performance. Scale items are scored on the basis of ability to complete the item using a 3-point ordinal scale where 0=cannot perform, 1=performs partially and 2=performs fully. The total possible scale score is 226. Classifications for impairment severity have been proposed based on FMA Total motor scores (out of 100 points): 0-35 = Very Severe 36-55 = Severe 56-79 = Moderate > 79 = Mild

15. Investigations CT scan shows ( RT ) middle cerebral artery infarct Diagnosis Medical Diagnosis – Right Middle Cerebral Artery Infarct Physiotherapy Diagnosis – Inability to use the left side of the body and weakness secondary to right MCA infarct.

16. Problem List Tonal abnormalities Muscular weakness Functional disability Possible Problems in Post Stroke Synergistic pattern Tightness & contracture Imbalance & incoordination Gait abnormalities Postural abnormalities Deconditioning

17. Goals Short Term(Acute Phase) To make the patient aware about the status of his condition Improve respiratory & circulatory function Prevention of secondary complications Prevent from deconditioning Long Te rm(Sub-Acute and Chronic Phase) Maintain all short term goals Improve sensory function Flexibility & joint integrity Improve strength Manage spasticity Improve motor control Improve upper extrimity function Improve balance Improve locomotion Improve aerobic function Improve feeding & swallowing Discharge planning

18. Short Term(Acute Phase)

19. G - To make the patient aware about the status of his condition Interventions Give factual information, counsel family members about patient’s capabilities & limitations Give information as much as Pt or family can assimilate Provide open discussion & communication Be supportive, sensitive & maintain a positive supporting nature Give psychological support Refer to help groups Rationale : This helps patient understand the status as well as cooperates which reduces his recovery time

20. G – To Improve respiratory & circulatory function Interventions Breathing exercise Chest expansion exercise Postural drainage Huffing & Coughing techniques Passive & active ankle & toe exercise (after careful & thorough examination of cardiopulmonary system) Rationale : These help prevent pulmonary and circulatory complications

21. G – To Prevent of pressure sores Interventions Proper positioning Relieve pressure points by padding & cushion Frequent turning & changing position Prevent from moisture Tight fitting cloth to be avoided Use of waterbed, air bed & foam mattress Rationale : Pressure sores are painful and stagnate the recovery. These interventions will help that and reduce hospital stay

22. G – To prevent from deconditioning Interventions Neuro-Developmental Technique Early mobilization in the bed (active turning, supine to sit, sit to supine, sitting, sit to stand) Pelvic bridging exercise Early propped up positioning, sitting & then later to standing Moving around the bed Facilitate movement of functioning limbs Rationale : Patient exercise capacity increases as well as disuse atrophy is prevented

23. Long term(Sub-Acute and Chronic Phase)

24. G – To Improve sensory function Interventions Positioning hemiplegic side towards door or main part of room Sensory Integration Therapy - Presentation of repeated sensory stimuli Stretching, stroking, superficial & deep pressure, iceing , vibration etc. Wt bearing ex & Joint approximation tech Stoking with different texture fabrics Pressure application Improve other senses like use of visual & auditory Rationale : The sooner the sensations return, the better it is for the patient to control his movement and do motor training.

25. G – To improve flexibility & joint integrity Interventions Soft tissue, joint mobilization & ROM exercise AROM & PROM with end range stretch Effective positioning & edema reduction Stretching program & splinting Rationale : Improved joint flexibility and integrity helps gain function sooner

26. G – To improve strength Interventions Strengthening of agonist & antagonistic muscle Graded ex program using free weights, therabands , sand bags & isokinetic devices For weak patients (<3/5), gravity-eliminated ex using powder boards, sling suspension, or aquatic ex is indicated Gravity-resisted active movts are indicated (>3/5 strength) Rationale : Overload principle helps improve strength

27. G – Manage spasticity Interventions Roods Approach Sustained stretch & slow iceing of spastic muscle Weight bearing exercise Prolonged & firm pressure application Slow rocking movement PNF – Rhythmic rotations Rhythmic initiation Rationale : Inhibiting the continuous firing of the AHC

28. G – Improve motor control Interventions Dissociation & selection of desired movt patterns Select postures that assist desired movements through optimal biomechanical stabilization & use of optimal point in range Start with assisted movt , followed by active & resisted movt Contemporary Task Oriented Approach Rationale : Motor control helps patient ambulate and perform ADLs

29. G – Improve upper extremity function Interventions Constraint Induced Movement Therapy Picking up objects, Reaching activities Lifting activities Manipulation of common objects Rationale : CIMT has been shown to improve unilateral function in sub acute and chronic stages of rehab using the principles of Neuroplasticity

30. G – Improve balance and locomotion Interventions Balance Facilitate symmetrical wt bearing on both side Postural perturbations can be induced in different positions Sit or stand on movable surface to increase challenge Reaching activities Locomotion Initial gait training between parallel bars Proceed outside bars with aids & then without aids Rationale : Balance and Gait are important aspects that govern most of our ADLs. Vestibular stimuli from these exercises will help improve function

31. G – Improve feeding & swallowing Interventions Proper head position in chin down position Movements of lips, tongue, cheeks, & jaw Refer to Speech Language Pathologist Rationale : Helps patient eat solid food

32. G – Discharge planning Interventions Family member should participate daily in the therapy session & learn exercises Home visits should be made prior to discharge Architectural modifications, assistive devices or orthotics should be ready before discharge Identify community service & provide information to the patient Rationale : To further help the recovery process even after discharge and regain as much function as possible

33. Thank You