A neuro-physiotherapy Case study - Review and analysis

Let take a look at this case study and have a brief review and breakdown on Rehabilitation process

A case of a 70 y/o man being managed for acute right hemispheric ischaemic stroke likely cardio-embolic

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He was apparently healthy until about 7 days ago when he woke up from sleep around 5.45 Am in the morning to take his breakfast from fasting, he fell asleep again and woke up around 6.30 am in the morning and immediately noticed he could not use his Left upperlimb and Lower limb.

No History of trauma to the head and limbs, no Hx of Loss of Consciousness and headaches prior to the symptoms. No Hx of vomitting and convulsion. No Hx of polyuria, polydipsia and polyphagia. No Hx of chest pain, palpitation dyspnoea and PND. No Hx of joint pain and skin rash. No Hx of stroke or TIA.

He is a known cardiology unit patient being managed for Congestive Cardiac Failure (CCF) 2° to Hypertension heart disease about a month ago. He has been on anti- failure regimen. He has however been diagnosed of Hypertension about a year ago and poor drug compliance.
Since onset of symptoms, He presented at the hospital, where a brain CT scan was done and has been on further management.
He has then placed on neurophysiotherapy management

PMHx: He has an history of congestive heart failure which he his being managed for by the cardiopulmonary team.

He is not sickle celled, asthmatic, diabetic or epileptic

PSHx: Nil

PDHx: Digoxin, Clopidogrel, Telmisartan, Amlodipine, Cetirizine, Pregabalin, Furosemide, Vasoprin.

DHx: Amlodipine, Aspirin, Clexane, Atrovastatin

The drugs he is on is also very important, we will get into that in subsequent posts.

F&SHx: He is a 75year old farmer. He is married in a polygamous setting and has 16 children. There is no known history of stroke in the family.He does not drink alcohol or smoke.

Observation and Examination: He was met in supine position in bed, afebrile, acyanosed and not in any obvious respiratory distress.

Vitals
Bp: 145/80milimeter of mercury
RR: 20count/min
PR: 60beat/min
SpO2: 95%
Pcv: 41%

GCS
Eo- 4
VR- 5
Mr- 6. 15/15

Segmental Examination
HEAD AND NECK

• Active and passive range of motion is full and pain-free at the neck region

Thorax and Abdomen

• no chest deformity
• poor trunk control
  -Abdomen is flat and move with respiration

Upperlimbs:

Muscle bulk; preserved bilaterally
Muscle tone; RT normal, Lt hypotonia
Sensation: intact bilaterally
AROM: RT: full and pain-free, Lt: could not initiate movement
PROM: Full and pain-free bil
Spasticity: absent
GMP: RT 4 and Lt 0
GRIP STRENGTH: RT: Good, Lt: poor
OEDEMA: absent bilaterally
CREPITATIONS: absent
DEFORMITY: Nil

LLs:
Muscle bulk; preserved bil
Muscle tone; RT: hypertonia (MAS: 1), Lt: hypotonia
Sensation: intact bilaterally
AROM: RT: full and pain-free, Lt: could not initiate movement
TA tightness: RT: absent Lt: present
PROM: Full and pain-free bil
GMP: 4 for RT and 0 for Lt
OEDEMA: Absent bilaterally
CREPITATIONS: absent
DEFORMITY: Nil
Spasticity: present at the Rightt, absent at the Left
Clonicity: absent

Functional Assessment

• He cannot sit, stand or walk independently
  FIM score
• Motor sub score- 52/91
• Cognitive subscore- 35/35
• Total: 87/126 (minimal assistance)

Analysis of findings

• pt is hypertensive due to heart disease
• poor grip strength at the Lt and good at the RT
• Pt is hemiplegic at the Lt ULs and LLs
• Poor trunk control
• presence of TA tightness
• Hypotonia at Lt ULs and LLs
• Hypertonia present at the RT LLs (MAS- 1)

Radiological Investigation
Cranial CT scan shows RT hemispheric lacunar infarct (film not available)

Impression: Lt hemiplegia 2° to RT hemispheric ischaemic stroke likely cardioembolic

The focus of this case study is the plan, what exactly should our intervention be like as neurophysiotherpists?

Ok our plan on intervention should should go like this, but not limited to all stated here, anything less will most likely be inadequate :

Plan
We want to:

• preserve physiological properties of the unaffected musculature
• prevent pressure sores.
• Functionally rehabilitate him as his condition improves
• Improve trunk control
• Educate him where necessary
• Ambulate him out of bed as he improves
  -improve function at left ULs and LL

Means of proposed intervention

• passive mobilisation to Lt ULs and LLs
• passive stretching to the RT LLs
  -Autoassisted Exercises to the left ULs and LLs
• Tactile stimulation to the Lt ULs and LLs
• Trunk exercises
  -Therapeutuc positioning
  -EMS to the left LLs and ULs

Caution: while doing all this, dont forget that he has a still present cardiopulmonary compromise, so his vitals should be closely monitored.

Acronyms and abbreviation used :
Lt- Left
Rt- Right
Hx- history
UL- upperlimbs
LL- lowerlimbs
PMHx- past medical history
PSHx- Past surgeical history
PDHx- past drug History
DHx- Drug history
MAS- Modified asworth scale
FIM - Functional Independent Measure

References