PATIENT CATEGORY REPORT Stroke – Cerebral Vascular Accident

MARTIN CLEMENT CLINICAL INTERNSHIP 1 HOPITAL GERONTOLOGIQUE & MEDICO SOCIAL - PLAISIR GRIGNON APRIL 13TH – JUNE 19TH 2015

DATE: CLASS: CI: CS:

29/05/15 LP14-21 MRS. FREDERIQUE PADEL DRS JOSEFINA HERMANS

Introduction   Description  of  the  medical  diagnosis   A   stroke,   or   CVA   (Cerebral   vascular   Accident)   is   defined   as   an   accident   with   “rapidly   developing   clinical  signs  of  focal  or  global  disturbance  of  cerebral  function”.  Symptoms  last  24  hours  or  longer  or   may   lead   to   death.   The   cause   is   from   vascular   origin,   which   is   typically   characterized   by   a   sensory-­‐ motor   impairment   of   the   contralateral   side   of   the   body.   This   can   lead   to   cognitive   as   well   as   emotional  disturbances.  [1]   We  find  two  main  categories  of  stroke,  Ischaemic  and  Haemorrhagic.   In   an   ischaemic   stroke,   blood   supply   to   a   certain   area   of   the   brain   is   decreased,   which   causes   dysfunction   of   the   area   supplied   by   the   blood   vessel.   A   haemoragic   stroke   can   be   intracerebral   or   intracranial   where   in   both   case   building   up   a   haematoma   (in   the   brain   or   within   the   skull   in   general).   [1]   Symptoms   mainly   find   in   Strokes   are   headaches,   weakness   and/or   numbness   of   the   face,   leg   or   arm.   Loss   of   coordination,   balance   as   well   as   lack   of   control   of   the   bladder   or   bowels   does   occur   within   different  range  of  severity.  Communication  impairments  and  Apraxia  may  be  seen  regarding  the  area   affected   by   the   CVA   as   well   as   emotional   and   personality   changes.   Decreased   vision   and   neglect   may   happen  following  a  stroke.  [2]  [3]    

Epidemiological  Data   Stroke   is   the   third   leading   cause   of   death   in   the   United   States   (US)   and   a   leading   cause   of   serious,   long-­‐term  disability.  (American  Heart  Association.  2001)  [4]   Stroke   kills   almost  130,000  Americans   each   year,   which   represents   1   out   of   every   20   deaths.   (CDC   WONDER  Online  Database)  [5]   On   average,   one   American   dies   from   stroke   every  4   minutes   and   every   year,   more   than  795,000   people  in  the  United  States  have  a  stroke.  About  87%  of  all  strokes  are  ischemic  strokes.  Stroke  costs   the   United   States   an   estimated  $34   billion  each   year.   This   total   includes   the   cost   of   health   care   services,  medications  to  treat  stroke,  and  missed  days  of  work.  [6]   Prevalence:   Strokes   tend   not   to   be   immediately   fatal.   The   thirty-­‐day   mortality   rate   for   ischemic   strokes  is  7.6%  compared  to  37.5%  of  hemorrhagic  strokes.  [7]  Of  those  individuals  who  survive  the   first  30  days,  20%  require  some  sort  of  institutionalized  care.  [8]  While  there  are  few  sources  of  data,   it  is  estimated  the  prevalence  of  stroke  among  Americans  age  20  and  older  is  11/1,000  persons.  The   prevalence   of   stroke   among   Americans   age   65   and   older   is   40/1,000   persons,   and   one   in   10   Americans  over  75  has  experienced  a  stroke  [9]   Risk  factors  for  stroke  have  been  well  studied.  Age  (older),  race  (black)  and  sex  (male)  are  all  strong   risk   factors.   People   with   atrial   fibrillation   have   a   very   high   risk   of   stroke   compared   to   the   general   population.  [10]  [11]   High  blood   pressure,  high   cholesterol,   and   smoking   are   major  risk   factors   for   stroke.   About  half   of   Americans  (49%)  have  at  least  one  of  these  three  risk  factors.  Several  other  medical  conditions  and   unhealthy  lifestyle  choices  can  increase  your  risk  for  stroke.  [12]  In  the  long  term,  25-­‐74%  of  patients   will  have  to  rely  on  assistance  for  basic  ADLs  like  feeding,  self-­‐care,  and  mobility.  [1]  

Evidence/Physiotherapy  indication   Physical  therapy  (PT)  is  one  of  the  key  disciplines  in  interdisciplinary  stroke  rehabilitation.   There   is   strong   evidence   for   PT   interventions   favoring   intensive   high   repetitive   task-­‐oriented   and   task-­‐specific   training   in   all   phases   post-­‐Stroke.   Effects   are   mostly   restricted   to   the   actually   trained   functions   and   activities.   Balance   training,   gait   training   and   reeducation   of   ADLs   have   shown   improvement  with  physiotherapy.  (Veerbeek  et  al.  2014).  Interventions  in  patients  with  stroke  may   include  exercise  therapy  and  physical  interventions.  [13]      

 

Name:   DoB:   Occupation   Diagnosis         Intake   Treatment  per  week     Medication     Impairments:         VAS:   External/Personal  factors  

Referral Details/Patient history

 

Participation  

Activities  

Health  seeking  questions  

Patient  1   Mr.  H   16/09/45   Retired   Ischaemic  Stroke  Right   Hemisphere     on  08/04/15     13/04/15   8-­‐9     ß-­‐blocker,  blood  thinner     Hemiplegia  L,   incontinence,  fatigue,   attention  deficit,  loss  of   balance   No  pain   In  wheelchair.   Lives  with  his  wife  in  an   apartment  (2nd  floor  with   elevator).  Alcohol   4doses/day.  Slightly   depressed   Smoker  

Patient  2  

Patient  3  

Mr.  L   27/02/67   Banker   Ischaemic  Stroke  Left   Hemisphere   on  17/12/14     02/01/15   4-­‐5     ß-­‐blocker     Hemiplegia  R,  mood   changes,   disorientation  loss  of   balance   No  pain   Use  of  orthopedic   shoes  and  a  stick.   Lives  with  his  wife  +  1   son  (lots  of  support)  in   small  house  (bedroom   and  bathroom  on   ground  floor)  

Mrs.  B   07/09/51   Retired   Haemorrhagic  Stroke   Left  Hemishpere   on  08/01/15     17/03/15   8     Cholesterol-­‐lowering   tablets   Aphasia,  apraxia,   neglect  Right  side,  loss   of  balance  and  deficit   of  attention   Evening  headache  5/10   Use  of  rollator  outside   the  house   Just  moved  in  an   adapted  house  for  her.   She  is  really  sad  to  leave   her  old  house.   Supporting  husband  and   big  family.   Likes  to  cycle  and  guide   Likes  to  play  chess,   Likes  to  cook  and  goes   orchestras  in  musicals.   involved  in  social  life   once  a  week  to  the  flea   Only  goes  out  with  his  wife   and  take  care  of  his  son   market   Used  to  Cycle  twice  a  week   Play  chess  and  cards   Used  to  travel  and   (5-­‐10  km)   with  friends  every   climb.  Since  retirement,   weekend,  like  to  bath   aqua  fitness   in  lakes   Increase  strength  and  ROM   Improve  balance  and   Re-­‐learn  activities  of   in  Left  limbs,  improve   gait,  Increase   ADL,  mainly  cooking.   balance  &  attention   concentration  capacity   Loose  weight.  

Preliminary  Hypothesis    

Decreased  strength  and   ROM  in  left  extremities,   improve  balance  

 

Strength  (MRC)                      

Right:  All  5   Left:   Shoulder  elevation  4/5   Shoulder  abduction  3/5   Elbow  flex-­‐ext  4/5  Palma-­‐ Dorsi  flexion  3/5   Thumb  all  3/5   Hip  flexion  4/5   Hip  extension  2/5   Hip  add-­‐abd  4/5   Dorsi  flexors  3/5  

PROM      

Elbow  ext:  -­‐15  degrees   Palma  dorsi  flex:  20deg    

Hip  flexion:  45  deg   Hip  flexion:  50  deg   Hip  extension:  5  deg   Knee  extension  -­‐15  deg   Dorsi-­‐planta  flex:  5  deg   Dorsi-­‐planta  flex:  10deg  

Muscle  tonus  

Flacid  

Spastic  

Spastic  

Loss  of  sensation  

Loss  of  sensation  in  hand  

None  

Loss   of   sensation   in   hand  and  in  foot  

1st assessment (Basic testing)

 

Decreased  attention   Decreased  coordination   and  decreased  strength   in  movement  and   right  side   decreased  strength    Left:  All  5   Left:  All  5   Right:   Shoulder  elevation  4/5   Elbow  flex-­‐ext  4/5   Palma-­‐Dorsi  flexion  4/5   Hip  flexion  3/5   Hip  extension  3/5   Hip  abd  2/5   Dorsi  flexors  2/5      

Right:   Shoulder  elevation  4/5   Elbow  flex-­‐ext  3/5   Palma-­‐Dorsi  flexion  3/5   Hip  flexion  4/5   Hip  extension  3/5   Knee  extension  3/5   Dorsi-­‐planta  flexors  2/5    

 

Treatment  Plan   Treatment  goal  

Treatment  modality  

P1  

P2  

P3  

 

Recover  sensation  and  grip  strength   in  hand  

Active  and  passive  mobilization,  mirror   therapy,  use  of  sensitive  stimulants  (ex:   granulated  surface  etc.)  +  grip  strength   Strength   exercises   and   passive   mobilization   of   shoulder   and   elbow   (ex:   prayers  hands)   Balance   exercise,   one   leg   standing,   360,   sit-­‐stand   up,   strength   exercise,   pulley   therapy   Walking   between   bars,   teaching   of   walking   with   crutches,   stick,   or   use   of   wheelchair   Teach  steps  to  transfers  from  sit  to  bed,   from  bed  to  chair  etc.  

✓  

 

✓  

 

✓  

 

✓  

✓  

✓  

✓  

✓  

✓  

✓  

 

 

Endurance  training,  Circuit  training,   games,  biking,  gait  training  etc.  

✓  

✓  

✓  

✓  

✓  

✓  

Short term Goals

 

Regain  ROM  and  strength  in  Upper   Extremities   Improve  strength  in  Lower   extremities  and  improve  balance   Improve  gait  and  walking  aid  

 

Long term Goals

Improve  transfers   Improve/maintain  physical  capacity   &  independence  

Improve   ability   to   focus   and   to   pay   Memory  games,  focusing  exercises,  install   attention  to  surrounding   cues,  stimulates  concentration  

The   treatment   was   applied   to   the   patients   following   the   short   and   long-­‐term   goals.   Activities   and   settings  were  fit  to  the  patient  in  order  to  promote  a  better  motor  control  (ITE  form).  The  article  Van   peppen   et   al.   (2007)   [14]   has   performed   a   systemic   review   of   outcome   measures   for   people   with   stroke.   They   proposed   tools   based   on   consistency   with   the   ICF,   disability   and   health,   high   level   psychometric   properties   and   good   clinical   utility.   (WHO,   2001)   [15].   To   support   the   choices   of   relevant   exercises   and   treatment   plan,   I   used   the   KNGF   guidelines   for   Stroke   [16]   and   the   article   Veerbeek  et  al.  2014  that  realized  a  meta-­‐analysis  of  the  treatment  settings  regarding  this  pathology.   [13]    

Evaluation   ⇨  Clinimetrics  data:   1st  assess  

 

Retest  

1st  assess  

Retest  

1st  assess  

Retest  

Trunk  Control  Test  

50  

62  

62  

75  

75  

75  

Berg  Balance  Scale  

18  

23  

25  

31  

39  

43  

10  Meter  walk  test  

/  

/  

91  secs  

85  secs  

53  secs  

51  secs  

Timed  up  and  Go  

/  

/  

56  secs  

51  secs  

29  secs  

26  secs  

Single  leg  stance     Sit  &  Stand  up  x10  

R:  5  secs   L:  1  secs   178  secs  

9  secs   4  sec   153  secs  

3  secs   7  secs   84  secs  

4  secs   10  secs   75  secs  

23  secs   15  secs   50  secs  

23  secs   17  secs   55  secs  

Barthel  Index  

30  

40  

50  

55  

60  

70  

  Patient’s  Comparison   After  analyzing  the  table  above,  we  observe  that  they  made  progression  in  general.  When  we   observe  data  we  realize  these  evolutions.  When  we  combined  the  data  from  clinimetric  tools  and  the   short-­‐term  treatment  goals,  we  see  that  they  do  correspond  to  what  we  were  aiming  for.  My   treatment  goals  were  focused  on  giving  back  independency  whereas  it  was  for  ADL  or  for  activities   such  as  walking.  The  three  patient  used  for  this  analyze  were  different  in  their  symptoms,  therefore   it  was  not  obvious  at  first  sight,  that  we  could  compare  them.  Each  of  them  had  different  goals.  Mr  H.   for  example  wants  to  be  able  to  cycle  back,  even  if  it  was  on  a  indoor  bike,  whereas  Mrs  B.  wants  to   cook  like  she  used  to  do  before  her  stroke.  Mr  P.  wanted  to  gain  in  concentration  and  wanted  to   become  independent  so  he  can  take  care  of  his  son  as  he  was  doing  before.  The  practicing  of  gait  and   improving  of  balance  has  been  applied  to  each  of  them,  but  additional  intervention  focus  on  their   need  and  on  their  will,  was  applied.  Communication  with  Mrs  B  was  very  difficult  since  she  was   suffering  from  sever  aphasia  and  apraxia,  but  thanks  to  real  basics  hand  exercises  she  knew  that  I   understand  what  she  wanted  so  she  was  compliant  to  what  I  was  asking  her.  Mr  P.  made  great   progress  in  concentration  and  in  balance  managing.  Those  3  patients  accepted  that  I  use  their  case   for  this  report,  and  they  were  thankful,  as  I  was  taking  care  of  them  in  order  to  achieve  their  goals.  It   was  a  great  experience  to  work  with  them  as  all  of  them  was  very  motivated  and  heading  toward  the   same  direction  as  I  was  during  sessions.  

References rd   ● [1]  Stokes  M,  Stack  E.  Physical  management  for  neurological  conditions.  3 ed.   Livingstone:  Elsevier;  2011.     ● [2]  Goldstein  LB,  Bushnell  CD,  Adams  RJ,  Appel  LJ,  Braun  LT,  Chaturvedi  S,  et  al.   Guidelines  for  the  primary  prevention  of  stroke:  a  guideline  for  healthcare  professionals   from  the  American  Heart  Association/American  Stroke  Association.Stroke   ● [3]  Morgenstern  LB,  Hemphill  JC  3rd,  Anderson  C,  Becker  K,  Broderick  JP,  Connolly  ES  Jr,   et  al.  Guidelines  for  the  management  of  spontaneous  intracerebral  hemorrhage:  a   guideline  for  healthcare  professionals  from  the  American  Heart  Association/American   Stroke  Association.Stroke   ● [4]  American  Heart  Association.  2001  Heart  and  Stroke  Statistical  Update.  Dallas,  Texas:   American  Heart  Association,  2000.   ● [5]  CDC,  NCHS.  Underlying  Cause  of  Death  1999-­‐2013  on  CDC  WONDER  Online   Database,  released  2015.  Data  are  from  the  Multiple  Cause  of  Death  Files,  1999-­‐2013,  as   compiled  from  data  provided  by  the  57  vital  statistics  jurisdictions  through  the  Vital   Statistics  Cooperative  Program.  Accessed  Feb.  3,  2015   ● [6]  Mozaffarian  D,  Benjamin  EJ,  Go  AS,  et  al.  Heart  disease  and  stroke  statistics—2015   update:  a  report  from  the  American  Heart  Association.  Circulation.  2015  ;e29-­‐322.)   ● [7]  Rosamond  WD,  Folson  AR,  Chambless  LE,  Wang  C-­‐H,  McGovern  PG,  Howard  G,   Copper  LS,  Shahar  E.  Stroke  incidence  and  survival  among  middle-­‐aged  adults:  9-­‐year   follow-­‐up  of  the  Atherosclerosis  Risk  in  Communities  (ARIC)  Cohort.  Stroke  1999;30:736-­‐ 743.   ● [8]  CDC.  Prevalence  of  stroke  —  United  States,  2006–2010.  MMWR.  2012;61(20):379– 82.   ● [9]  Adams  PF,  Hendershot  GE,  and  Marano  MA.  Current  estimates  from  the  National   health  Interview  Survey,  1996.  National  Center  for  Health  Statistics.  Vital  Health   Statistics  10(200).  1999.   ● [10]  Murray  JL,  Lopez  AD,  ed..  The  global  burden  of  disease:  a  comprehensive   assessment  of  mortality  and  disability  from  diseases,  injuries,  and  risk  factors  in  1990   and  projected  to  2020,  Cambridge,  Mass:  Harvard  University  Press,1996.  

● [11]  Wolf  PA,  D’Agostino  RB,  Belanger  AJ,  Kannel  WB.  Probability  of  Stroke:  A  risk  profile   from  the  Framingham  Study.  Stroke  1991;22:312-­‐18.   ● [12]  CDC.  Vital  signs:  awareness  and  treatment  of  uncontrolled  hypertension  among   adults—United  States,  2003–2010.MMWR.  2012;61(35):703–9.   ● [13]  Veerbeek  JM,  van  Wegen  E,  van  Peppen  R,  van  der  Wees  PJ,  Hendriks  E,  et  al.   (2014)  What  Is  the  Evidence  for  Physical  Therapy  Poststroke?  A  Systematic  Review  and   Meta-­‐Analysis.  PLoS  ONE  9(2):  e87987.  doi:10.1371/journal.pone.0087987     ● [14]  Van  Peppen,  R.P.S.,  Hendriks,  H.J.M.,  Van  Meeteren,N.L.U.,  et  al.,  2007.  The   development  of  a  clinical  practice  stroke  guideline  for  physioherapists  in  The   Netherlands:  A  systemic  review  of  available  evidence.  Disabil.  Rehabil.  10,  767-­‐783.   ● [15]  WHO,  2001.  ICF-­‐introduction,  the  International  Classification  of  functioning,   Disability  and  Health.  Geneva.  http://www.who.int/classification/icf/intros/ICF-­‐ENG-­‐ Intro.pdf.   ● [16]  Stroke  guidelines  KNGF  2014:  https://www.fysionet-­‐ evidencebased.nl/images/pdfs/guidelines_in_english/stroke_practice_guidelines_2014. pdf.  

patient category report

MARTIN CLEMENT. CLINICAL ... On average, one American dies from stroke every 4 minutes and every year, more than 795,000 people in .... [3] Morgenstern LB, Hemphill JC 3rd, Anderson C, Becker K, Broderick JP, Connolly ES Jr, et al.

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