REHABILITATION OF PATIENT WITH LEFT HEMIPARESIS DUE TO INFARCTION STROKE SUBACUT PHASE WITH MOBILIZATION DISTURBANCE AND ADL DISTURBANCE

REHABILITATION OF PATIENT WITH LEFT HEMIPARESIS DUE TO INFARCTION STROKE SUBACUT PHASE WITH MOBILIZATION DISTURBANCE AND ADL DISTURBANCE

1st CASE PRESENTATION Tuesday, 14 July 2015

Presented By:Ardhita Resiani, dr.

Supervised by :Novitri, dr., Sp.KFRMarietta Shanti, dr., Sp.KFRINTRODUCTION2DEFINITIONlocal or global cerebral function disorder which occurs abruptly and rapidly, for more than 24 hours or up to death due to disorder of brain circulatory system.

Based on WHO, definition for stroke is...3BRAIN BLOOD SUPPLY

The principal blood supply for the brain comes from two arterial systems :the anterior circulation, fed by the internal carotid arteries, and the posterior circulation, which receives blood from the vertebral arteries. The vertebral arteries join at the junction of the medulla and pons (or pontomedullary junction) to form the basilar artery, which lies unpaired along the midline. The anterior circulation is also called the carotid circulation, and the posterior circulation, the vertebral-basilar circulation. 5

The circle of WillisThe anterior and posterior arterial systems connect at several locations, by the communicating arteries. The posterior communicating artery allows blood to flow between the middle and posterior cerebral arteries, and the anterior communicating artery allows blood to flow between the anterior cerebral arteries on both sides of the cerebral hemispheres.5

The anterior cerebral artery supplies the dorsal and medial portions of the frontal and parietal lobes. The middle cerebral artery supplies blood to the lateral convexity of the cortex. The posterior cerebral artery supplies the occipital lobe and portions of the medial and inferior temporal lobes.4CLASSIFICATIONBased on clinical features and temporal profile:Improving Stroke ( RIND = Reversible Ischemic Neurologic DeficitWorsening Stroke ( SIE = Stroke in Evolution )Stable Stroke ( Completed Stroke)1. Improving Stroke ( RIND = Reversible Ischemic Neurologic Deficit), i.e., when the neurologic deficit is totally cured in the period of 24 hours to 3 weeks.2. Worsening Stroke ( SIE = Stroke in Evolution ), i.e., when the neurologic deficit becomes progressive severe, both quantitatively and qualitatively, and both from anamnesis and follow up. 3. Stable Stroke ( Completed Stroke ), when neurological deficit goes on completely with a very small changes in a given period.

5And classification based on intracranial 6

RISK FACTORSModifiable HypertensionHistory of TIA/strokeHeart diseaseDiabetesCigarette smokingHyperlipidemia NonmodifiableAgeSex ( male > female)Race ( African Americans 2 > whites > Asians)Family history of stroke

CLINICAL SYNDROMESMotor Control and StrengthMotor Coordination and balanceSpasticity

Motor Control and StrengthStroke hemiplegia; Synergy patterns.Motor Coordination and balanceTrunk control and stability, coordination of movement patterns, and balance all involve complex extrapyramidal systemsSpasticitySpasticity is a velocity-dependent increase in resistance to muscle stretch that develops after an upper motor neuron injury within the central nervous system. Loss of upper motor neuron control causes disinhibited alpha and gamma motor neuron activity and heightened sensitivity to class 1a and 2 muscle spindle afferents. Consequently, monosynaptic and multisynaptic spinal reflexes become hyperactive.Often, as voluntary motor activity returns, a reduction in tone and reflex response is noted, but if recovery is incomplete, spasticity usually remains9TIME COURSE OF THE DISEASEAcute Phase (several days to two weeks post stroke).Subacute Phase (Recovery Phase) : (2 weeks to 6 months)Chronic Phase (Advanced Phase): (>6 months).

Acute Phase: characterized with hemodynamic and neurologic conditions that have not been stabile (several days to two weeks post stroke).Subacute Phase (Recovery Phase) : characterized with recovery and reorganization of nerve system (2 weeks to 6 months), important to recover functionally.Chronic Phase (Advanced Phase): characterized with accomplishment of nerve system reorganization. The next recovery that is still possible to continue is a functional recovery process based on adaptation and compensation against the existing disability (>6 months).

10REHABILITATION OF STROKEBrunnstrom Stages of Motor RecoveryStageCharacteristicsStage 1No activation of the limbStage 2Spasticity appears, and weak basic flexor and extensor synergies are presentStage 3Spasticity is prominent; the patient voluntarily moves the limb, but muscle activation is all within the synergy patternsStage 4The patient begins to activate muscles selectively outside the flexor and extensor synergiesStage 5Spasticity decreases; most muscle activation is selective and independent from the limb synergiesStage 6Isolated movements are performed in a smooth, phasic, well-coordinated mannerbasic strengthening, range of motion exercises, balance training, and postural control.Pattern of motor recovery after stroke: at onset, the arm is more involved than the leg but motor recovery in the arm is less than the leg. The prognosis for return of useful hand function is poor when there is complete arm paralysis at onset or no measurable grasp strength by 4 weeks.Motor recovery evaluation including an evaluation of tone, strength, coordination and balance.Stage I day 2-3 in patient of stroke from infarct (day-14 in hemorrhage.) The main goal of rehabilitation program nowadays is to prevent the complicated immobilization and prolonged bed rest. PROM AAROM. Bed mobilization.Stage II main problem : spasticity. Intensive mobilization, hand function exercise in order able to do daily activitiesStage III- IV Synergic pattern is broken into more coordinated movement as wished or orderedStage V VI the exercise activities are more focused on skill exercises and maintaining self-care11Spasticitydaily stretching, especially of the shoulder, wrist, fingers, hip, and ankles.Shoulder Painsubluxation, contractures, complex regional pain syndrome (CRPS), rotator cuff injury, and spastic muscle imbalance of the glenohumeral jointShoulder pain & paresis shoulder immobilization neurogenic heterotropic ossification limited A&PROM frozen shoulder.Subscapularis.m in hemiplegic shoulder synergy syndrome shoulder adducted internally rotated position pain& tenderrness over deltoid insertion area in upper outer humerus pain on palpation biceps tendon limited A&PROM.Th/frozen shoulder : spontaneous recoveryROM excPain relief : local ice, heat, ultrasound application, TENS, NSAID/analgesicManipulationSurgery 12PROGNOSISPrognosis ad vitam: depends on stroke type, site and size brain lesion, risk factor, comorbid disease or condition and complication.Prognosis ad sanationam: The probability of stroke recurrence is highest in the post acute stroke period. Risk factors for initial stroke also increase the risk of recurrence.

13Prognosis ad functionam, depends on:Onset post-strokeMost improvement is noted in the first 6 months, although as many as 5% of patients show continued measurable improvement to 12 months post-onset. Site and size of neuroanatomical lesion.Comorbid diseases or conditions.ComplicationsThe motivation and support of the patients family.The available facilities and professional labours of rehabilitation. CASE REPORTANAMNESIS (10 April 2015)Mr S, 53 years old, right handed, married, moslem, lives in Cicendo, Bandung. He was consulted from Neurology Department of Hasan Sadikin Hospital during his hospitalization on 27 March 2015 - 5 April 2015 with diagnosis stroke ec infark atherotrombotic right carotid system risk factor hypertension, hypertension stage II, dyslipidemia.

Chief Complain: Weakness of his right limbs

History of Present IllnessMr. S felt sudden weakness of his right limbs upon go home from his work. He couldnt raise nor move his right arm and leg at all. He felt that his right arm is as weak as his right leg. He felt difficult speech and mouth deviation to the left. He also felt numbness on his right leg. He didnt complain about vomiting, dizziness, double vision, choking, tinnitus, seizure, nor blackout. He didnt lose consciousness, but his family said that he looked confused and didnt recognize his family for a while. His family brought him to Emergency Room of KebonJati Hospital. His blood pressure was 170/110. He was referred to HasanSadikin Hospital

On the 4rd day of his hospitalization, he was consulted to PMR department. He was only able to move his right limbs on his hip and knee on full range of motion, although still cannot go against gravity. Defecation and urination disturbances were denied. The program given was proper bed positioning, turning/ 2 hour, passive range of motion exercise for his right limbs and active range of motion exercise for his left limbs.During hospitalization, he felt some progresses. After 9 days of hospitalization, he was allowed to go home. His rehabilitation program was to stand by his bed with support and then walk around the house with support as he can. Passive range of motion exercise for his right limbs and active range of motion exercise for his left limbs are still continued 3 times/ day. He got some medications that need to be continued: Acetosal 1x 80mg, Amlodipin 1x5mg, Simvastatin 1x10mg.One week after discharge, his speech was still slurred but people can still understand him better. He could already walk by walker around the house and to his neighborhood as far as +- 300 meters with a couple resting time, but he had not been able to climb and down stairs. He didnt feel numbness anymore on his right leg. He could brush his teeth, ate, & drank independently. His wife still helped him bathing by picking up the dipper and washed him. Grooming, toileting, and dressing still helped his wife and his son and daughter.He regularly exercises his limbs with his wife 3 times/ day. No complains of pain on limbs movement.

History of past illnessHistory of hypertension (+), known since 7 months ago with the highest blood pressure 160/100. He did routinely control or take regular medication at klinik near his home. History of dyslipidemia (+), known since 7 months ago. History of diabetes mellitus (+) known since 7 months agoHistory of prior stroke was deniedHistory of Familial DiseasesHistory of familial hypertension, diabetes mellitus, and heart disease is deniedHistory of HabitsSmoking (+) 6 packs/ day since 1985, stopped after strokeEating fatty food (+)Doing sport or exercise (-)

History of education :He graduated from junior high school

Psychosocial and Economic HistoryHe is married to his wife and has 3 children (2 sons & 1 daughter). He lives in his house with his wife, his 2childs, his 1 grandchild . The house has 2 floors, sized 3x6 meters, 2 bedrooms, and filled with 5 persons. He uses squatting toilet and doesnt find difficulty in using it. His house has enough lighting, but less ventilation. It is 5 meters away from toilet. There are stairs in the house, but he doesn't need to go upstairs. After the sickness, he often feels sad because he didnt work and activity again. He gets angry easily. He has good relationship with his families and neighbors. His family always gives him support.His monthly budget for daily living until date is covered by his savings. He made 1 million a month on average before his sickness. His wife does not work. He uses BPJS PBI for medical insurance.History of Vocational and AvocationalBefore the illness, he works as a entrepreneur since 5 years ago. He have small shop in front of alleys home.He often works overnight and often stay up. The other job, he also work as a taxi driver, but he was already stop since 1 years ago. After the illness, he has not work ever since. He hopes that he can work again soon. He can pray 5 times/day, but he prays in sitting position because he has not been able to endure rukuh and sujud position. He can rise from sitting to standing without help.

PHYSICAL EXAMINATIONFUNCTIONAL ASSESSMENTCognitive : MMSE = 22 (considered normal cognitive)Communication :Naming: goodRepetition: goodFluency: goodComprehensive: goodActivity of Daily Living :Barthel Index = 11 (moderate disability)

Laboratory findings on March 28, 2015

Laboratory on March 30, 2015

Supporting Examination

Head CT Scan (8 March 2014)Infark serebri di subcortical lobus parietalis kiriTidak tampak perdarahani ntraserebri

Chest X-Ray (8 March 2014)Kardiomegali tanpa bendungan paruDIAGNOSISClinical DiagnosisInfarction Stroke due to Partial Anterior Circulation Syndromes Left Carotid System Subacute Phase (G.46.1)with mobilization disturbance (Z 74.0), ADL disturbance (Z 74.1) due to left hemiparesis - Hypertension grade I (I.11)- Diabetes Mellitus type II (E.12)- Dyslipidemia (E.78.0)Etiological DiagnosisCerebral infarction , with risk factor hypertension, diabetes mellitus, Dyslipidemia, smokingLocation DiagnosisNeuromuscular system, musculoskeletal system, metabolic systemFunctional DiagnosisImpairmentRight hemiparesisRight central VII & XII nerve paresisDisabilityADL & IADLMobilizationHandicapVocational &Avocational

PROGNOSISQuo ad vitam: ad bonamQuo ad sanationam: dubia ad bonamQuo ad functionam: dubia ad bonam

PROBLEMM1: StrokeM2: HypertensionM3: DyslipidemiaR1: MobilizationR2: ADL and IADLR3: Vocational &Avocational

REHABILITATION GOALShort term :Maintain ROM to maintain flexibilityImprove muscle strength of right side hemiparesisImprove balanceADL independentlyLong term :Prevent recurrent stroke by controlling hypertension, dyslipidemia, stop smokingImprove cardiopulmonary enduranceRegain optimal gait patternBack to work

PROGRAM1. StrokeS : Right side limbs weakness O : Right side upper and lower limb weakness Spasticity (MAS) grade 1 for right upper& lower limb Right central VII & XII nerve paresis Head CT scan: Infarkcerebri in subcortical sinistra parietalis lobe Low risk of fallMMSE = 22/30 (mild impairment cognitive function) -> impaired in attention & calculation, recall, languageG : Prevent recurrent stroke Improve functional capabilityP : Educate the patient and family about stroke, risk factors, time course, and recovery of stroke Assess psychological status in the next meeting

2. Hypertension S : History of hypertensionO : Blood pressure 170/110 mmHg on Amlodipin 1x5mgG : Control regularly and reduce risk factorP : Educate the patient to control to Neurology Department and take the medicine regularly (Amlodipin 1x5mg) Consult to nutrisionist for low salt diet

3. DyslipidemiaS: History of dyslipidemia known since hospitalizedO :Total Cholesterol: 231 mg/dL HDL Cholesterol: 41 mg/dL LDL Cholesterol : 160 mg/dL Trigliseride: 270 mg/dlG: Control regularly and reduce risk factorP : Educate the patient to control to Neurology Department and take the medicine regularly (Simvastatin 1x10mg) Consult to nutrisionist for low fat diet

4. MobilizationS: Patient walks with abnormal gait and tires easilyO: Weakness of right lower limb(MMT 2543) Proprioceptive: impaired for right lower limb Hemiparetic gaitG: Short term : Maintain ROM to maintain flexibility Improve muscle strength of right side hemiparesis Improve balance Long term : Improve cardiopulmonary endurance Regain optimal gait patternP : Short term : Active Assistive ROM exercise for lower limbs Exercise testing with ergocycle Ergocycle for endurance & strengthening exercise Long term : gait training5. Activities of Daily LivingS :Patient cant brushes his teeth, eating, & drinking using his left hand, still needs help to pick up the dipper and wash himself while bathing, cant climb & down stairs, grooming, toileting, and dressing can be done independently if the patient mainly uses his left handO :Barthel Index = 11/20 (moderate disability) -> impaired in feeding, bathing, grooming, dressing, toileting, climbing stairs (see attachment 6) Weakness of the right upper limb (MMT 4444) Trunk weakness (MMT: flexion = 4, extension = 4, rotation = 4) Weakness of right lower limb(MMT 2543) Hemiparetic gaitG :Independence in activities of daily livingP : Active Assistive ROM exercise for upper limbs Passive ROM exercise for lower limbs

6. Vocational &AvocationalS : patient hopes to be able to get back to workO : Weakness of the right upper limb (MMT 4444) Impaired right hand prehension and dexterity Trunk weakness (MMT: flexion = 4, extension = 4, rotation = 4) Weakness of right lower limb(MMT 2543) Proprioceptive: impaired for right lower limb Hemiparetic gaitG : Assign patient for workP : Active Assistive ROM exercise for upper limbs Passive ROM exercise for lower limbs

DISCUSSIONAnamnesis: felt sudden weakness of his right limbs upon go home from his work. He couldnt raise nor move his right arm and leg at all. His blood pressure at Emergency Room was 170/110. Physical examination: right hemiparesis and right central paresis of VII & XII nerve, increase of physiologic reflex, presence of pathologic reflex and spasticity The anamnesis & physical examination stroke infarction. This patient has contralateral hemiparesis and contralateral cranial nerve paralysis, but no hemianopia or aphasia so subtypes of cerebral infarction is partial anterior circulation (PACS). The risk factor : smoking, hypertension, and dyslipidemia. The time course of this case is 3 months.It is a subacute phase stroke. Impairment : hemiparese, right central VII &XII nerve paralysis disable in ambulation, and ADL & IADL. He feels sad because of his sickness. He also becomes easier to be angryRehabilitation program is emphasized on optimalizing neurological recovery while preventing complications so that his recovery progress is facilitated well to achieve optimal functional capability possiblePrognosis ad vitam : ad bonam because the vital signs are stable and the risk factors has already been controlledPrognosis sanationam : dubia adbonam, because the patients compliance in control to neurologist for his hypertension & dyslipidemia, consume the medications regularly, and diet modificationis questionablePrognosis ad functionam : ad bonam he has good motivation to do exercisesCASE ANALYSIS

Hb12,8

Ht40

Leukosit12.400

Trombosit406.000

Na140

Kalium4,1

Ureum36

Kreatinin0,78

GDS160

Kolesterol total231

HDL41

LDL160

Trigliserida270

HbA1c6,5

GDP89

AsamUrat4,5

GD2PP103