UMFC4026 Clinical Neurology Posting
Case Presentation 1
Cerebrovascular Accident (CVA)
Name: Tan Song Yi
Student ID: 17UMB03983
1
Cerebrovascular accident (CVA)
• The sudden death of some brain cells due to lack of oxygen when the
blood flow to the brain is impaired by blockage or rupture of an artery
to the brain.
Type of CVA
• Ischemic stroke (85%)
• Caused by interruption of blood flow to a certain area of the brain
• Hemorrhagic stroke (15%)
• Caused by a blood vessel that breaks and bleed into the brain
• Transient ischemic attack (TIA)
• Blood supply to the brain is blocked for a short time
(Tadi & Lui, 2020)
2
Risk Factors
• Hypertension
• Diabetes mellitus
• Heart disease
• Hypercholesterolemia
• Obese
• Smoking
• Chronic alcoholism
(Sharma & Gaillard, 2020)
3
Signs and Symptoms
• Numbness/weakness on one side of body
• Lack of coordination and balance
• Difficulty speaking/understanding words spoken by people
• Rigid/weak muscle that limit movement
• A loss of symmetry in smile
• Difficulty swallowing
• Tremors
(Sharma & Gaillard, 2020)
4
Investigations
• CT scan
• MRI
• ECG
• Angiogram
Medical Management
• Antiplatelet agent
• Anticoagulants
• Thrombolytic medication
• Carotid endarterectomy
• Angioplasty and stents
• Craniotomy with open surgery
(Muir, 2001)
5
Physiotherapy Management
• Positioning
• Early mobilization
• Strengthening exercise
• Bed mobility
• Balance training
• Trunk control exercise
• Gait training
(Sharma & Gaillard, 2020)
6
Case Study
7
Demographic Data
Name
Mr. L
Age
48 y/o
Gender
Male
Race
Chinese
Occupation
Hardware shop worker
Handedness
Right side
Date of Ax
1/6/2021
Doctor Dx
Right basal ganglia bleed
Doctor Mx
Operative management and refer to physiotherapy for rehabilitation
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SUBJECTIVE ASSESSMENT
Chief Complaint
Patient c/o muscle weakness in left hand and leg as well as unable to walk.
Present Hx
On 12th April 2021, patient was fainted suddenly during his work at night.
However, his father noticed this situation on next day morning. Pt was admitted at
Pantai Hospital on 13th April 2021 and had done a craniotomy. His skull was stored
at his left lower part of abdominal (left lumbar region). The skull will be replaced
on September 2021.
Past Hx
NIL
Surgical Hx
Craniotomy was done
Medical Hx
 Hypertension for 3 years
 Diabetes for 2 years
Medication Hx





Metformin HCL 500mg
Prazosin 2mg
Amlodipine 10mg
Metoprolol Tartrate 100mg
All take twice per day
9
Family Hx
Mother have hypertension
Fall Hx
NIL
Personal Hx




Quit smoking (previously 10 cigarettes/day)
Non-alcoholic
Hobby: Playing snooker
Pt felt stressful during work
Socioeconomic Hx


Marital status: Single
Live with parents
Environmental Hx



Live in double storey house
Room at ground floor
Commode
Investigation Hx
 CT scan on 13th April 2021
 Finding: Rt. basal ganglia bleed
Pre-morbid status
Independent
Post-morbid status
Partially dependent
10
Vital sign
Temperature
35.7 °C
Blood Pressure
114/72 mm Hg
Heart Rate
77 beats/min
Respiratory Rate
18 breaths/min
Interpretation: Vital sign is stable
11
OBJECTIVE ASSESSMENT
1. On Observation
Attitude of limb
Presence of flexion synergy on Lt UL
Built
Mesomorph
Surgical Incision
 Right top of head 23cm
 Left abdominal area 8.5cm
Posture
In Sitting
 Forward head
 Slightly kyphosis and rounded shoulder
External Appliances
Wheelchair
Edema
NIL
Muscle Wasting
NIL
Deformity
NIL
Skin
Dry skin
12
2. On Palpation
Subluxation
NIL
Warmth
NIL
Tenderness
NIL
Swelling
NIL
Capillary refill
< 3sec
13
3. On Examination
Higher Mental Function
Level of Consciousness
Conscious, alert and obey to command
Orientation
Person: Good
Place: Good
Time: Good
Vision and Hearing
Able to see and hear clearly
Communication
Able to express and communicate well
Attention
Good
Memory
Immediate: Good
Recent: Good
Remote: Good
Cognition
Good
Emotional Status
Normal
Interpretation:
Pt had no cognitive
impairment
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Cranial Nerve
Nerves
Comments
I- Olfactory
Interpretation:
II- Optic
III- Oculomotor
IV- Trochlear
NAD
V- Trigeminal
VI- Abducent
VII- Facial
Pt has impaired facial
nerve and hypoglossal
nerve due to upper
motor neuron lesion
Drooping corner of mouth
VIII- Vestibulocochlear
IX- Glossopharyngeal
X- Vagus
NAD
XI- Accessory
XII- Hypoglossal
Tongue deviates towards left
side
15
Sensation
Sensation
Superficial
Deep
Combined
cortical
Light touch
Pain
Proprioception
Graphesthesia
Stereognosis
UL
Rt.
Intact
LL
Lt.
Impaired
Impaired
Intact
Impaired
Impaired
Rt.
Lt.
Intact
Impaired
Interpretation:
• Pt has impaired superficial and cortical sensation on Lt UL d/t neurological
deficits.
• Pt has impaired superficial, deep and cortical sensation on left lower limb
due to neurological deficits.
16
Range of motion
Joint
Shoulder
Elbow
Forearm
Wrist
Hand and
Finger
Hip
Knee
Ankle and
Foot
Rt.
AROM
AFROM
Lt.
PROM
AROM
PROM
Spastic
Spastic
AFROM
AFROM
Interpretation:
 Lt UL ROM unable to assess d/t
spasticity.
 Pt has full active and passive
ROM at both lower limb and
right upper limb.
APROM
18
Muscle Tone
Joints
Shoulder
Elbow
Forearm
Wrist
Muscles
Flexors
Extensors
Abductors
Adductors
Internal Rotators
External Rotators
Flexors
Extensors
Supinators
Pronators
Flexors
Extensors
Ulnar Deviation
Radial Deviation
Rt.
Lt.
0
3
0
3
0
3
0
3
19
Joints
Hand & Finger
Hip
Knee
Ankle
Muscles
Flexors
Extensors
Flexors
Extensors
Abductors
Adductors
Internal Rotators
External Rotators
Flexors
Extensors
Dorsiflexors
Plantarflexors
Rt.
Lt
0
3
0
0
0
0
0
0
Interpretation:
 Increases muscle tone over Lt UL d/t spasticity.
 Normal muscle tone for right side upper limb and lower limb
20
Muscle Power
Joints
Shoulder
Elbow
Forearm
Wrist
Muscles
Flexors
Extensors
Abductors
Adductors
Internal Rotators
External Rotators
Flexors
Extensors
Supinators
Pronators
Flexors
Extensors
Ulnar Deviation
Radial Deviation
Rt.
5/5
5/5
Lt.
Spastic
Spastic
5/5
Spastic
5/5
Spastic
21
Joints
Hand & Finger
Hip
Muscles
Flexors
Extensors
Flexors
5/5
Spastic
3/5
3+/5
Abductors
3/5
5/5
3/5
Internal Rotators
3/5
External Rotators
3/5
Flexors
3/5
Extensors
Ankle
Lt
Extensors
Adductors
Knee
Rt.
Dorsiflexors
Plantarflexors
5/5
5/5
3/5
3/5
3/5
Interpretation:
 Unable to assess Lt. UL muscle tone d/t spasticity of upper limb.
 Pt has reduced muscle strength on Lt. LL d/t immobile.
22
Reflexes
Reflexes
Rt.
Lt.
2+
0
Superficial
Plantar
Deep
Biceps
3+
Brachioradialis
3+
Triceps
2+
2+
Knee
3+
Ankle
0
Interpretation:
 Left superficial reflex and ankle reflex absent d/t neurological deficits.
 Hyper-reflex on left biceps, brachioradialis and knee reflex d/t upper motor
neuron lesion.
 Pt has normal response for right deep tendon reflexes.
23
Coordination
Coordination Test
Non-equilibrium
Equilibrium
Grade
Rt.
Lt.
Finger to nose
4
0
Heel to shin
4
2
Standing with normal
posture
KIV
Standing with eye
close
KIV
Interpretation:
• Poor coordination of Lt LL d/t muscle weakness.
• Left upper limb coordination unable to perform due to spasticity..
24
Balance
Static
Dynamic
Sitting
Sitting with eyes open- Good
Sitting with perturbation- Good
Forward reaching- Good
Standing
Standing with eyes open- Poor
(need maximal assistance)
KIV
Interpretation:
 Pt has poor static standing balance d/t Lt. LL weakness
 Pt has good static and dynamic sitting balance.
25
Outcome Measure
Motor Assessment Scale
Component
Scoring
Supine to side-lying onto intact side
2
Supine to sitting over side of bed
4
Balance sitting
4
Sitting to Standing
2
Walking
0
Upper Arm Function
0
Hand Movements
0
Advanced Hand Activities
0
General Tonus
3
Total
Interpretation:
Low UL functioning compare to
LL functioning over the Lt. side.
15/54
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Barthel Index
Component
Scoring
Feeding
5
Bathing
0
Grooming
5
Dressing
5
Bowels
10
Bladder
10
Toilet use
5
Transfer
5
Mobility
5
Stairs
0
Total
Interpretation:
Pt is partially dependent d/t
spasticity over right upper limb
and muscle weakness on left
lower limb.
50/100
27
Health condition
CVA with Right Basal Ganglia Hemorrhage
ICF Classification
Body impairment
Activity limitation
- Impairment of facial and hypoglossal
nerve
- Sensation impaired over Lt. UL and LL
- Spastic over Lt. UL.
- Reduce muscle strength over Lt. LL.
- Hyperreflex on Lt. UL and LL
- Poor coordination over Lt UL and LL
- Poor standing balance
- Poor bed mobility
-
Participation restriction
Difficulty in standing
Unable to walk and climb stair
Unable to drive car
Difficulty in performing ADL
-
Personal Factors
Unable to work
Unable to participate in snooker
game
Unable to do social interaction
with friends
Environment Factors
+ve
-ve
• Cooperative
• Quit smoking, non-alcoholic
• Financial stable
• Hypertension
• Diabetes
• Stressful while working
+ve
• Supportive family
• Living with family
• Room at ground floor
-ve
• No handrail at toilet
• Double storey house
28
Physiotherapy Impression
• Impairment of facial and hypoglossal nerve d/t upper motor neuron
lesion.
• Sensory impaired over Lt. UL and LL d/t neurological deficit.
• Increase muscle tone over Lt. UL d/t spasticity.
• Reduce muscle strength over Lt. LL d/t immobile.
• Hyper-reflex over Lt. UL and LL d/t upper motor neuron lesion.
• Poor coordination over Lt. UL and LL d/t spasticity over Lt. UL and muscle
weakness over Lt. LL.
• Poor standing balance d/t Lt. LL muscle weakness
• Poor bed mobility skill d/t muscle weakness.
29
Goals Settings
Short Term Goals
•
•
•
•
•
To reduce muscle tone of Lt. UL within 3/52.
To increase ROM of Lt. UL within 3/52.
To improve muscle strength of Lt. LL from 3/5 to 4/5 within 3/52.
To improve bed mobility within 2/52.
To improve standing balance to fair within 3/52.
Long term Goals
•
•
•
•
Able to perform ADL task independently within 4/12
Able to ambulate independently and safely within 3/12
Able to work and drive
To prevent complication such as foot drop and muscle atrophy
30
Treatment Plan
1.
2.
3.
4.
5.
6.
PROM with stretching exercise
Approximation
AROM exercise
Strengthening exercise
Patient education
Home exercise program
31
Intervention
32
PROM with passive stretching exercise
• Position: Supine lying
• Action: Therapist passively move the pt’s Lt. UL of shoulder, elbow
and wrist in flexion, extension, shoulder abduction and adduction,
forearm supination and pronation with stretching
• Repetition: 10 times for each movement
(Sands, et33al., 2013)
Approximation
• Position: Sitting
• Action:
• Pt extend the both elbow and place behind/beside the body
• Pt shift the body weight towards left side
• Therapist supports pt’s elbow to prevent buckle
• Repetition: Hold 5mins
34
AROM Exercise
Suspension Exercise
• Position: Sitting
• Action: Pt move the Lt. UL in horizontal abduction and adduction
• Repetition: 3 mins
(Jung & Choi, 2019)
35
Strengthening Exercise
Short arcs quads exercise
• Position: Supine lying with rolled towel placed under the knee
• Action: Pt press the knee toward the towel
• Repetition: Hold 10sec, 10 times
Hip adductor exercise
• Position: Crook lying with pillow placed between the knee
• Action: Pt squeeze the pillow
• Repetition: Hold 10sec, 10 times
36
Bridging
• Position: Crook lying
• Action: Pt lift the pelvic up from the bed
• Repetition: Hold 10sec, 10 times
Straight leg raises in 2 planes
• Position: Supine/side lying
• Action: Pt raise up the leg away from the bed without knee
bending
• Repetition: Hold 10sec, 10 times for each movement
37
Bed mobility training
Supine to side lying
• Procedure
• Rotate the head and upper trunk
toward Lt. side
• Bend the Rt. LL
• Roll towards the Lt. side by rotating
the whole body with the help of Rt.
upper
Side lying to sitting
• Procedure
• Use the Rt. leg t move the Lt. leg
down and off the bed
• Use the Rt. hand to support the body
and get up from side lying to sitting
38
Patient Education
• Posture correction
• Advise patient to wear hand splint to reduce flexion synergy
• Advise patient to wear foot drop splint to avoid foot drop
Home Exercise Programme
• Perform approximation for Lt. UL for 5mins daily
• Perform strengthening exercise that taught 2 set with 10 repetition
daily
39
Evaluation
• Vital sign is stable
• Blood pressure: 118/75mm Hg
• Heart rate: 73 beats/min
• Pt able to perform exercises without any complaint
40
Review
• ROM
• MMT
• Muscle Tone
• Coordination
• Balance
• Barthel Index
• Motor Assessment Scale
• Exercise taught
41
Follow Up (10/6/2021)
•S
• Patient does not have any complaint.
•O
• ROM
• Same as 1/6
• MMT
• Hip flexor and extensor muscle improve from 3/5 to 4/5
• Muscle Tone
• Same as 1/6
• Coordination
• Lt. UL improve from 0 to 2.
• Balance
• Fair static standing.
• Poor dynamic standing balance.
42
Outcome Measure
Motor Assessment Scale
Component
Scoring
Supine to side-lying onto intact side
3
Supine to sitting over side of bed
5
Balance sitting
4
Sitting to Standing
2
Walking
0
Upper Arm Function
1
Hand Movements
0
Advanced Hand Activities
0
General Tonus
3
Total
Interpretation:
Pt has improve from 15/54 to
18/54.
18/54
43
Barthel Index
Component
Scoring
Feeding
5
Bathing
0
Grooming
5
Dressing
10
Bowels
10
Bladder
10
Toilet use
5
Transfer
15
Mobility
5
Stairs
0
Total
Interpretation: Pt is minimal dependent.
65/100
44
• A-same as 1/6, add on with
• Fair static and poor dynamic standing balance due to muscle weakness
• P- same as 1/6, add on with
• Strengthening exercise of Lt. UL
45
• I- same as 1/6, add on with
• Active assisted ROM
• Grasping the hand together then perform shoulder flexion and extension
• Repetition: 10 times each exercise
• Isometric exercise for UL
• Position: Supine lying
• Action: Pt resist the force that applied in different direction
• Repetition: Hold 10sec, 10 times each movement
• Sit to stand (Sousa, et al., 2019)
• Position: Sitting on a chair with back support and hand support
• Equipment: Walker
• Procedure:
1. Pt sit at the edge of chair.
2. Pt perform sit to stand by hand grasping the walker for support.
• Repetition: 10 times
46
•E
• Patient does not have any complaint after exercises
• Vital sign stable
•R
•
•
•
•
•
•
•
•
ROM
MMT
Muscle tone
Coordination
Balance
Barthel Index
Motor Assessment Scale
Exercise taught
47
Reference
Jung, K. M., & Choi, J. D. (2019). The Effects of Active Shoulder Exercise with a Sling Suspension System on Shoulder
Subluxation, Proprioception, and Upper Extremity Function in Patients with Acute Stroke. Medical Science
Monitor, 25, 4849-4855. doi:10.12659/MSM.915277
Muir, K. W. (2001). Medical management of stroke. Journal of Neurology, Neurosurgery, and Psychiatry, 70, 12-16.
doi:http://dx.doi.org/10.1136/jnnp.70.suppl_1.i12
Sands, W. A., McNeal, J. R., Murray, S. R., Ramsey, M. W., Sato, K., Mizuguchi, S., & Stone, M. H. (2013). Stretching and Its
Effects on Recovery: A Review. 35(5), 30-36. doi:10.1519/SSC.000000000000000
Sharma, R., & Gaillard, F. (2020). Basal Ganglia Haemorrhage. Retrieved from Radiopaedia:
https://radiopaedia.org/articles/basal-ganglia-haemorrhage-2
Sousa, D. G., Harvey, L., Dorsch, S., Varettas, B., Jamieson, S., Murphy, A., & Giaccari, S. (2019). Two weeks of intensive sitto-stand training in addition to usual care improves sit-to-stand ability in people who are unable to stand up
independently after stroke: a randomised trial. Journal of Physiotherapy, 65(3), 152158.doi:10.1016/j.jphys.2019.05.007
Tadi, P., & Lui, F. (2020). Acute Stroke . Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK535369/
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THANK YOU
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