1st CASE PRESENTATION

Tuesday, 14 July 2015

REHABILITATION OF PATIENT WITH LEFT

HEMIPARESIS DUE TO INFARCTION STROKE
SUBACUT PHASE WITH MOBILIZATION
DISTURBANCE AND ADL DISTURBANCE

Presented By:
Ardhita Resiani, dr.
Supervised by :
Novitri, dr., Sp.KFR
Marietta Shanti, dr., Sp.KFR

INTRODUCTION

Better risk
factor
reduction &
medical
management

long term
stroke
survival

Rehabilitatio
n
intervention
to maximize
patient QOL

DEFINITION
local 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.

BRAIN BLOOD
SUPPLY

CLASSIFICATION
Based on clinical features and temporal
profile:
1. Improving Stroke ( RIND = Reversible
Ischemic Neurologic Deficit
2. Worsening Stroke ( SIE = Stroke in
Evolution )
3. Stable Stroke ( Completed Stroke)

Thrombotic

Ischemic
intracrania
l
pathologic
al

Embolic

Lacunar

Haemorrhag
ic

Intracerebra
l
Subarachnoi
d

RISK FACTORS
Modifiable
Hypertension
History of TIA/stroke
Heart disease
Diabetes
Cigarette smoking
Hyperlipidemia

Nonmodifiable
Age
Sex ( male > female)
Race ( African
Americans 2 > whites
> Asians)
Family history of stroke

CLINICAL SYNDROMES
Motor Control and Strength
Motor Coordination and balance
Spasticity

TIME COURSE OF THE DISEASE

Acute Phase (several days to two weeks post

stroke).
Subacute Phase (Recovery Phase) : (2 weeks
to 6 months)
Chronic Phase (Advanced Phase): (>6
months).

REHABILITATION OF
STROKE

Brunnstrom Stages of Motor

Recovery

Stag

Characteristics

e
Stag No activation of the limb
e1
Stag Spasticity appears, and weak basic flexor and extensor
e 2 synergies are present
Stag Spasticity is prominent; the patient voluntarily moves the
e 3 limb, but muscle activation is all within the synergy patterns
Stag The patient begins to activate muscles selectively outside
e 4 the flexor and extensor synergies
Stag Spasticity decreases; most muscle activation is selective
e 5 and independent from the limb synergies
Stag Isolated movements are performed in a smooth, phasic,
e6

well-coordinated manner

Spasticity
daily stretching, especially of the shoulder,
wrist, fingers, hip, and ankles.
Shoulder Pain
subluxation, contractures, complex regional
pain syndrome (CRPS), rotator cuff injury, and
spastic muscle imbalance of the glenohumeral
joint

PROGNOSIS
Prognosis 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.

Prognosis ad functionam, depends on:

Onset post-stroke
Most 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.
Complications
The motivation and support of the patients family.
The available facilities and professional labours of
rehabilitation.

CASE REPORT

ANAMNESIS (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
Illness
Mr. 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 illness

History 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 ago
History of prior stroke was denied

History of Familial Diseases

History of familial hypertension, diabetes mellitus,

and heart disease is denied

History of Habits
Smoking (+) 6 packs/ day since 1985,

stopped after stroke

Eating fatty food (+)
Doing sport or exercise (-)

History of education :
He graduated from junior high school

Psychosocial and Economic

History
He 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

Avocational
Before 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
EXAMINATION

FUNCTIONAL ASSESSMENT
1. Cognitive : MMSE = 22 (considered normal

cognitive)
2. Communication :
Naming
Repetition
Fluency

: good
: good
: good

Comprehensive

: good

3. Activity of Daily Living :

Barthel Index = 11 (moderate disability)

Laboratory findings
March 28, 2015

on

Laboratory

on March 30, 2015

Supporting Examination
Head CT Scan (8 March 2014)
Infark serebri di subcortical
lobus parietalis kiri
Tidak
tampak
perdarahani
ntraserebri

Chest X-Ray (8 March 2014)

Kardiomegali tanpa bendungan paru

DIAGNOSIS
Clinical Diagnosis Infarction 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 Diagnosis Cerebral infarction , with risk factor hypertension,
diabetes mellitus, Dyslipidemia, smoking
Location Diagnosis Neuromuscular system, musculoskeletal system,
metabolic system
Functional Diagnosis Impairment
Right hemiparesis
Right central VII & XII nerve paresis
Disability
ADL & IADL
Mobilization
Handicap
Vocational &Avocational

PROGNOSIS
Quo ad vitam: ad bonam
Quo ad sanationam : dubia ad bonam
Quo ad functionam : dubia ad bonam

PROBLEM
M1
M2
M3
R1
R2
R3

:
:
:
:
:
:

Stroke
Hypertension
Dyslipidemia
Mobilization
ADL and IADL
Vocational &Avocational

REHABILITATION GOAL
Short term :
Maintain ROM to maintain flexibility
Improve muscle strength of right side hemiparesis
Improve balance
ADL independently
Long term :
Prevent recurrent stroke by controlling hypertension,
dyslipidemia, stop smoking
Improve cardiopulmonary endurance
Regain optimal gait pattern
Back to work

PROGRAM
1. Stroke
S : 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 fall
MMSE = 22/30 (mild impairment cognitive function) ->
impaired in attention & calculation, recall, language
G : Prevent recurrent stroke
Improve functional capability
P : 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 hypertension
O : Blood pressure 170/110 mmHg on Amlodipin 1x5mg
G : Control regularly and reduce risk factor
P : Educate the patient to control to Neurology Department and take the
medicine regularly (Amlodipin 1x5mg)
Consult to nutrisionist for low salt diet
3. Dyslipidemia
S : History of dyslipidemia known since hospitalized
O
:Total Cholesterol : 231 mg/dL
HDL Cholesterol : 41 mg/dL
LDL Cholesterol
: 160 mg/dL
Trigliseride
: 270 mg/dl

G : Control regularly and reduce risk factor

P
: Educate the patient to control to Neurology Department and
take the medicine regularly (Simvastatin 1x10mg)
Consult to nutrisionist for low fat diet

4. Mobilization
S : Patient walks with abnormal gait and tires easily
O : Weakness of right lower limb(MMT 2543)
Proprioceptive: impaired for right lower limb
Hemiparetic gait
G : Short term : Maintain ROM to maintain flexibility
Improve muscle strength of right side hemiparesis
Improve balance
Long term : Improve cardiopulmonary endurance
Regain optimal gait pattern
P
: Short term : Active Assistive ROM exercise for lower limbs
Exercise testing with ergocycle
Ergocycle for endurance & strengthening exercise
Long term : gait training

5. Activities of Daily Living

S :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 hand
O :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 gait
G :Independence in activities of daily living

6. Vocational &Avocational
S : patient hopes to be able to get back to work
O : 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 gait
G : Assign patient for work
P : Active Assistive ROM exercise for upper limbs
Passive ROM exercise for lower limbs

DISCUSSION
Anamnesis: 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 angry
Rehabilitation program is emphasized on optimalizing
neurological recovery while preventing complications so
that his recovery progress is facilitated well to achieve
optimal functional capability possible
Prognosis ad vitam : ad bonam because the vital signs
are stable and the risk factors has already been controlled
Prognosis sanationam : dubia adbonam, because the
patients compliance in control to neurologist for his
hypertension & dyslipidemia, consume the medications
regularly, and diet modificationis questionable
Prognosis ad functionam : ad bonam he has good
motivation to do exercises

CASE ANALYSIS