Physical Therapy approach to Left hemispheric ischaemic cerebrovascular accident- A concise case study

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Oohkay!!! Let take a look at case of a 71 year old woman with left hemispheric Ischaemic Cerebrovascular accident

Now these are the complaints: Inability to use the right upper and lower limbs for about a week now

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Background History

She was said to have been in her usual state of health until about 8 days ago when she developed sudden onset of slurred speech while she was at home. There was associated deviation of the mouth and facial asymmetry.

About an hour later, She developed sudden onset of weakness of the right extremities which was reported to have progressively got worse. No history of preceding headache, seizure, dysphagia, diplopia, dizziness, fall or trauma to the head. She is a known hypertensive patient diagnosed about 1 year ago with poor medication compliant.

Following the onset of symptoms, She was initially taken to the hospital. The following day, she presented at the Accident and Emergency unit about 5 days ago

On account of the above she has been placed on physiotherapy management.

Past Medical History
She is not sickle-celled
She is a known hypertensive
She is not asthmatic
She is not diabetic
She is not epileptic

No History of epilpsy, seizure or convulsion

There was a known history of cerebrovascular accident in the family (older sibling).

Drug history
Vasopressin, Amlodipine, Rosavastatin

Past surgrical history
None

Family and social history
She is 71 year old, left handed, livestock feed trader. She is married in a monogamous setting and blessed with 3 children. She neither smokes nor takes alcohol.

Observation and Examination
She was met in lying position with the head of bed inclined to about 45°, she is conscious and alert, oriented in time place and person, afebrile, acyanosed, aniteric and not in any obvious respiratory distress.

Vital Signs:
PR- 76bpm
SPO2: 98%
RR- 24cpm
BP- 152/83 mmhg

PCV - 41%

GCS: 15/15:
EO-4
BVR-5
BMR-6

SEGMENTAL EXAMINATION:

Head and Neck

-Facial assymmetry, mouth deviation to the the left
-reduced crease on right side of the face
-Active range of motion was full and painfree
-Passive range of motion was full and painfree
-Slurred speech

Thorax and Abdomen

Good chest excursion
Abdomen was full and painfree
Abdomen moved with respiration
Sensation was intact
Normal back alignment

Upperlimbs

-Muscle bulk: Preserved bilaterally
-Muscle Tone: Normotonia bilaterally
-Sensation: Intact bilaterally
-Spasticity: Absent bilaterally
-Gross Muscle Power:
Right upperlimb- 0/5
Left upper limbs-4/5

If you have been following my previous post, you should know the meaning of the above grading of muscle power

Active Range of Motion:
Left upperlimb- Full and pain free
Right upperlimbs- Could not initiate (this actually confirms that the muscle power is 0)

Passive Range of Motion
Left upperlimb- Full and pain free
Right upperlimbs- Full but painful in all joints

Grip strength
Left upperlimb- Good
Right upperlimb- could not initiate

Edema
Left upperlimb- Absent
Right upperlimb- Present (dorsum of the hand)

Deformity: Right wrist drop

Tremor:Absent bilaterally
Crepitation: Absent bilaterally
Pain: Present at all the joints in the Rt UL

Lowerlimbs

-Muscle bulk: Preserved bilaterally
-Muscle Tone: Normotonia
-Sensation: Intact bilaterally
-Spasticity: Absent bilaterally

Gross Muscle power
Left lowerlimb- 4
Right lowerlimb- 0

Active Range of Motion:
Left- Full and painfree
Right- Could not initiate

Passive Range of Motion:
Left: Full and pain free
Right- Full but painful

-Edema:
Right pedal edema (Resolving)

-TA Tightness: Absent bilaterally
-Clonicity: Absent bilaterally
-Deformity: Absent bilaterally
-Crepitation: Absent bilaterally
-Patella: Mobile bilaterally
-Pain: Present at the Rt ankle and toes
-Skin: No discoloration or rashes

Functional assessment:
-She can sit in bed with support.
-She cannot feed or bath himself.
-She is dependent on caregiver in ADL

Functional Independence Measure Score:

Motor sub-score; 13/91
Cognitive sub-score; 35/35
Total Functional independence Measure score- 48/126

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Analysis of findings:

Facial asymmetry
Slurred speech
Pain in the Right Upperlimbs(joints) and Left ankle and toes
Swelling at the dorsa of the Right hand and foot
Poor grip strength in the Right Upperlimb
Gross Muscle Power:
Right upperlimb-0
Left upperlimb- 4
Right lowerlimb-0
Left lowerlimb -4
She can sit with support but cannot stand or walk

Clinical diagnosis: Right sided hemiplegia 2° to Left hemispheric Ischaemic Cerebrovascular accident

So now lets draft a plan for intervention for her 👇

Plan of intervention

She has pain, so first thing first, we want to reduce pain to the bearest minimum

Improve her facial symmetry

Invite the speech therapist as she currently has slurred speech

Reduce swelling at the dorsum of right hand and foot by improving venous return

Improve grip strength at the right upperlimb.

Strengthen weak muscle group to improve the gross Muscle power especially at the right uppelimb and lower limb

Improve her general functional ability thereby improving independence in activities of daily living

Preserve the physiologcal properties of the musculatures

Prevent other complications that may arise such as shoulder subluxation, for this, there would be need for a shoulder support

Now this plan will definitely be reviewed as the she improves.

The mean of intervention

Soft tissue mobilization with analgesic ointment

Tactile stimulation to the right upperlimb and lowerlimb

Facial massage ( for this case, it is best to rub the face with face power before performing this)
Note : don't use a methylated powder

Facial exercises

Passive mobilization to the right upperlimb and lowerlimb

Weightbearing on right upperlimb and lowerlimb with appropriate support

Electrical muscle stimulation to the right upperlimb and lowerlimb

Assisted exercises to the right upperlimb and lower limb

Auto assisted exercises to the right upperlimb and lower limb

Active exercises as power in right upperlimb and lowerlimb improves

Resisted exercises as power in right upperlimb abd lowerlimb improves

Grip strengthen exercises as she regains hand functions. Note: there would be a need to improve power in the right upperlimb especially the hand, before grip strengthening exercise can take place.

So that will be all for this case study, don't forget that intervention plans and treatment mean are not rigid, they are and can be modified based on new observations.