CASEANALYSIS
REPORT
24(103), May - June, 2020
ARTICLE
Medical Science
ISSN
2321–7359
EISSN
2321–7367
Regaining activities of daily living in patient with
middle cerebral artery stroke- A case report
Simran Mishra, Palak Darda, Waqar M. Naqvi, Arti Sahu
Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
Authors contact information
Simran A. Mishra - mishrasimran2998@gmail.com; ORCID ID- https://orcid.org/0000-0002-0221-9423
Palak P. Darda - dardapalak@gmail.com; Orcid ID- https://orcid.org/0000-0003-1617-3486
Waqar M. Naqvi - waqar.naqvi@dmimsu.edu.in; Orcid ID - https://orcid.org/0000-0003-4484-8225
Corresponding author

Professor and Head of Department, Community Health Physiotherapy, Ravi Nair Physiotherapy College,
Wardha, Maharashtra, India;
Email: waqar.naqvi@dmimsu.edu.in
Article History
Received: 11 March 2020
Reviewed: 13/March/2020 to 19/April/2020
Accepted: 20 April 2020
E-publication: 28 April 2020
P-Publication: May - June 2020
Citation
Simran Mishra, Palak Darda, Waqar M. Naqvi, Arti Sahu. Regaining activities of daily living in patient with middle cerebral artery
stroke- A case report. Medical Science, 2020, 24(103), 1731-1737
Publication License
This work is licensed under a Creative Commons Attribution 4.0 International License.
General Note
Introduction: The World Health Organization (WHO) described stroke as: 'Rapidly developing clinical signs of focal (or global)
cerebral disruption, with symptoms lasting 24 hours or longer or leading to death, with no obvious cause other than vascular origin.
Physiotherapy has been found to be effective and rehabilitation is started as early as possible to minimize the patient potential to
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ABSTRACT
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Article is recommended to print as color digital version in recycled paper.
CASE REPORT
ARTICLE
functional recovery. Patient main concerns were inability to perform any activities including activities of daily living and inability use
right upper and lower extremity for any task also major complaint was communication. Main clinical findings were decreased range
of motion, minimal spasticity, and dependency of patient on others. Diagnosis Middle Cerebral Artery stroke was confirmed in MRI
brain. Shoulder subluxation was confirmed on x-ray. Therapeutic interventions are found to be effective to minimise the
complications and improve outcomes of patient. Physiotherapy intervention included Range of motion exercises (ROM),
strengthening exercise, Functional mobility exercises, trunk control exercises, weight shift exercise, weight bearing exercises and use
of electrical modalities. Motor assessment scales, Stroke Rehabilitation Assessment of Movement, Functional independent measure
scale were major outcome measure for the patient. Conclusion: The patient was able to achieve certain goals like able to
communicate through gestures, complete decline of spasticity, able to perform exercises and able to stand unsupported and
improve functional capacity after continuous 12 week intensive physiotherapy rehabilitation program.
Keywords: Middle Cerebral Artery, Stroke, Rehabilitation.
1. INTRODUCTION
The World Health Organization (WHO) described stroke as: 'Rapidly developing clinical signs of focal (or global) cerebral disruption,
with symptoms lasting 24 hours or longer or leading to death, with no obvious cause other than vascular origin (Truelsen et al.,
2006). It is evident that in India, stroke is the foremost cause of death and disability (Pandian and Sudhan, 2013). The goals of
physiotherapy rehabilitation include maintaining the range of motion (ROM) and preventing deformity. Furthermore, it is important
to create awareness, promote active movement, improve trunk control and postural balance, improve functional mobility, initiate self
care activities and improve overall functioning of patient (Susan, 2014). In this case, the patient initially denied to perform the
investigations for the purpose of diagnosis of stroke and within a span of few days, he suffered from stroke, which was medically
managed in an academic hospital. He was then referred by his physician to the physiotherapy department for rehabilitation.
2. PATIENT INFORMATION
A 56 year old, right hand dominant, male hospital attendant visited the physiotherapy OPD on wheelchair with his son presenting
with the complaints of inability to perform any activity from right side of his body (both extremities and trunk). He experienced
difficulty in performing ADLs, inability to talk, and inability to stand and walk post-stroke due to weakness. Patient suffered from CVE
(left hemiplegia) on 27-09-2019, wherein he had a headache which was sudden in onset, difficulty in talking and fall resulting from
loss of consciousness. He was immediately admitted in hospital by his son. MRI brain and colour Doppler of left upper-extremity
were done along with other blood investigations. On 28-09-2019, Intra-arterial Thrombolysis was done. For the next 15 days, patient
was on Inj. Mannitol, Inj. Strocit Phes IV, antiplatelets and anticoagulants. Patient also had a past history of Transient Ischemic attack
(TIA) 3 years back.
3. CLINICAL FINDINGS
On admission in physiotherapy OPD (Day 1), after taking proper informed consent complete evaluation was done. Initial
examination of mental status couldn’t be performed due to patient’s difficulty in communication. There was difficulty in
comprehension and impairment in receptive language. Sensory examination was also limited, being secondary to communication
inability.
Motor Assessment: Complete evaluation of spasticity, joint play and soft tissue compliance was done. Motor assessment scale was
utilised for assessment of motor function.
Spasticity assessment: By utilising Modified Ashworth scale, spasticity was assessed. Spasticity in shoulder flexors, elbow flexors, wrist
flexors and hip flexors were grade 1 and in knee flexors and ankle Plantarflexors, the grade was 1+. For extensor group of muscles,
spasticity was 0.
assistive device.
Functional assessment: Patient required maximum assistance in basic ADLs (eating, bathing, transferring and toileting) as well as
Instrumental ADLs (communication, transportation, and handling medication), as assessed using FIM.
Clinical Photograph- On 1st day of assessment patient was wearing shoulder sling for subluxation (Figure 1).
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Gait: Patient was unable to stand and walk. Prior to stroke, his gait level was functional in home and outdoor without the use of any
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Reflex: All deep tendon reflexes were normal i.e. 2+.
ARTICLE
CASE REPORT
Figure 1 Patient on 1st day of assessment.
Timeline
Date of previous episode (TIA)
10-12-2015
Annual Health Check-up (further
Investigation advised)
24-09-2019
Date of CVE (left hemiplegia)
27-09-2019
Date of operation (Intra-arterial
Thrombolysis)
28-09-2019
Physiotherapy OPD admission
15-10-2019
Diagnostic Methods
For the diagnosis of problems associated with patient’s day to day life including the activities of daily living and motor function,
Motor Assessment Scale was used. Basic mobility activities were assessed using STREAM, FIM, which further helped to design the
rehabilitation program and achieve the functional goals.
Motor assessment scale - On Motor assessment scale patient total score was 8 on 1st day.
FIM - On FIM scale patient total score was 18 on 1st day.
STREAM – on this scale patient scored minimal points on 1st day.
Diagnostic challenges
Patient’s lack of education of the condition and ignorance led to altered prognosis. Patient’s denial for the check-up and tests led to
stroke. Major challenge was communication with the patient, which was due to comprehension problem. Later, the patient started
responding through gestures. Shoulder subluxation was also a challenge as it delayed the recovery.
Therapeutic intervention
Patient was managed through a multidisciplinary approach, which included a team of doctors, nurses, physiotherapist, speech
therapist and occupational therapist to achieve good prognosis. Patient underwent physiotherapy session for the duration of 12
weeks, 6 days a week. Physiotherapy interventions were planned on the basis of functional goals, primary aim being prevention of
Description
Week 1
Patient was discharged from the hospital and was referred to physical therapy out-patient department for rehabilitation. His family
member was educated about the condition and was explained about complete rehabilitation program based on patient condition. In
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further complication and improvement of quality of life of the patient.
ARTICLE
CASE REPORT
the first week of rehabilitation, patient positioning was taught, passive movements on the affected side with all precaution due to
subluxation of shoulder was undertaken and active movements on sound side were incorporated. Exercise for normal limb included
ROM exercise with 10 repetitions twice a day. In the later half of first week of rehabilitation patient was asked to perform combined
ROM exercises for both extremities with the help of sound extremity. Stretching was integrated to reduce spasticity.
Week 2-4
In second week of rehabilitation, Progressive resisted exercises were administered for normal limb after the subluxation resolved and
the patient was promoted to use affected limb for activities. For reducing spasticity Roods approach was incorporated using Icing
technique and stretching. Static orthosis was advised. Patient was taught segmental rolling. For strengthening upper extremity,
Electrical muscle stimulation was given to the patient with following parameters- Stimulus pulse: Symmetric Biphasic, Amplitude: 060mA, Pulse width: 300µsec, Frequency: 25 to 50 Hz, Duty cycle: 10 sec off 10 sec on. In later half of 3rd week functional electrical
stimulation was used for shoulder subluxation, wherein 2 electrodes were placed: one over supraspinatus and one over posterior
deltoid. The frequency used for stimulation was set to 36 Hz in order to obtain tetanized muscle contraction. The intensity of FES
was adjusted such that humerus elevation together with some abduction and flexion was produced to withdraw the head of
humerus into the glenoid cavity. The ratio of contraction and relaxation was gradually changed from 10/2s to 30/2s for the FES
sessions. It was applied for 5 days a week for 8 consecutive weeks depending on degree of subluxation.
Week 5-8
In this phase of rehabilitation, spasticity was at maximum. Minimal active contraction of affected extremity was observed; hence
repetitions of ROM exercise were increased. Exercises like knee to chest, straight leg raising, hip abduction, and adduction were
incorporated in supine lying position. PNF was incorporated for both extremities. EMS and FES were continued. In sitting position,
dexterity activities were continued. Since patient’s hand functions were poor, so activities like holding a glass, pen, etc were initiated.
Functional task oriented activities were progressed.
Week 9-12
In this phase of rehabilitation, spasticity grade was 1 on MAS. Mass movements were observed in both upper and lower limbs.
Strength training was continued and functional task oriented exercises were promoted. Functional reach activities in sitting and
standing were challenged in multi-direction approach .Transfers from bed to chair was progressed. Transitions of movement were
advanced. Mirror therapy was useful in treating the patient as he was able to correct abnormal pattern. In all these phase of
rehabilitation speech therapy was continued with regular physician follow ups.
Follow up and outcomes
Patient was assessed on day 1, at 4th week, 8th week and 12th week of intervention.
Spasticity – Spasticity changes were grade 1 on day 1, grade 1+ & 2 in the 4th week, 1 in 8th week and 0 in 12th week.
Reflex- Reflexes were 2+ on day 1, 3+ in 4th week, 2+ & 3+ (TA & Knee jerk) in 8th week and 2+ in 12th week.
Motor Assessment Scale- Scores were 8, 14, 20 and 27 in respective weeks.
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FIM score- Scores were 18, 31, 41 and 47 in respective weeks.
Figure 2 Shoulder subluxation resolved, Synergy pattern was also reduced.
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STREAM
Initially patient was scored the least in performing voluntary movements of limb and basic mobility, which progressed to gross
independence in various domains after 12 weeks of rehabilitation. Clinical Photographs of patient progression in Figure 2, 3, 4 and 5
during 2nd, 6th, 10th and 12th week of assessment respectively.
Figure 3 Spasticity was reduced and Patient was able to raise affected hand and used it for picking objects. Sitting unsupported
achieved.
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Figure 4 Patient was able to stand with walker unsupported.
Figure 5 Patient performing reaches out activity in standing.
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Limitation
Patient denial for checkup landed him with deadly disease. Shoulder subluxation following stroke was also challenging. Different
types of stroke present with different impairments. Here patient’s dominant hemisphere was involved that lead to communication
problem that became biggest challenge during treatment. This treatment protocol is specific and varies among patients with
different outcome measures.
4. DISCUSSION
In this case patient visited physiotherapy department with complains of inability to perform any activities using the right side of
body including right upper limb and right lower limb, difficulty in performing ADLs, inability to talk, and inability to stand and walk
due to weakness after stroke. Multiple treatment approaches were planned, such as Roods approach icing (cryotherapy) over spastic
muscle, which was found to clinically diminish resistance of spastic muscle to rapid stretching and decrease or inhibit Clonus
(Monaghan et al., 2017). Electrical muscle stimulation was used for strengthening or activating the weak muscle and enhanced the
motor re-learning process following damage to central nervous system (Popović et al., 2009). Functional electrical stimulation was
found effective in managing shoulder subluxation, wherein FES was applied on the Supraspinatus and Posterior Deltoid muscles
along with giving conventional treatment. This was found to be more beneficial than conventional treatment alone (Koyuncu et al.,
2010).
Conventional therapy involves exercise regimen which include active exercises, resisted exercises and stretching. It plays as a key
element of rehab that prevents atrophy of muscles. Stretching is integrated to preserve or increasing joint mobility by influencing
the soft tissue extensibility of the joints (Wu et al., 2006). Proprioceptive neuromuscular facilitation exercises are very successful and
were provided in the first week of stroke to generate voluntary control and improve everyday functional activities. The intervention
should be started first from scapula to boost arm function. Because of the irradiation effect, tone and power are generated and
improved at the upper extremity (Chaturvedi Poonam et al., 2016). Strength training was given for the sound extremities and later
along with ROM exercise progressively resisted exercise were initiated for hemiplegic limbs. It is evident that strength training
enhances the upper limb’s strength and function without causing an increase in tone or pain in people with strokes (Harris and Eng,
2010).
5. CONCLUSION
This article is not much frequently publishing model regards “regaining activities of patients with middle cerebral artery stroke”. This
case report demonstrated that the patient achieved maximum goal. This case report provided a comprehensive weekly rehabilitation
protocol for a patient to gain basic ADLs. Outcome measures were markedly improved with regular exercise and rehab protocol.
List of Abbreviations
WHO-
World Health Organisation
ROM-
Range of motion
OPD-
Out-Patient Department
ADLs-
Activities of Daily living
CVE-
Cerebrovascular Event
TIA-
Transient Ischaemic Attack
MAS-
Modified Ashworth Scale
FIM-
Functional Independent Measure Scale
STREAM- Stroke Rehabilitation Assessment of Movement
Author’s contribution
All author made best contribution for the concept, assessment and evaluation, data acquisition and analysis and interpretation of
1736
the data.
Funding:
Page
This research received no external funding.
Conflicts of Interest:
The authors declare no conflict of interest.
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CASE REPORT
Patient consent
Proper consent was taken from patient for writing case report.
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