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.
