Rehabilitation Following a MCA Stroke - Case Study Example

Rehabilitation following a MCA stroke Sudden onset of focal neurological deficit arising out of infarction or ischemia in the territory supplied by the middle cerebral artery or MCA is known as middle cerebral artery stroke. MCA is the largest cerebral artery and is the most commonly affected artery in stroke (Slater, Curtin, Johs, et al, 2009). The artery mainly supplies the outer convex surface of the brain, most of the basal ganglia and anterior and posterior internal capsules (Slater et al, 2009). Thus infarction of this main artery leads to a diverse neurologic sequelae. An understanding of the specific neurologic deficits following MCA stroke helps physiotherapists set target goals and work towards the rehabilitation of the patient. In this essay, rehabilitation of a patient with left MCA stroke will be dicussed in a physiotherapists perspective guided by evidence-based research. Main problems in the patient In Mrs. James, a branch of the left middle cerebral artery has been affected. Thus the deficits relate to the areas of distribution of left middle cerebral artery. The World Health Organisations International Classification of Functional and Disability Health Framework (United Nations ESCAP, 2009) is a useful tool to ascertain the current problems in Mrs. James due to the stroke. Dimensions of functioning affected 1. Body functions and body structures Occlusion of the main trunk of the MCA leads to contralateral hemiplegia, deviation of the eye towards the side of the infarct, contralateral hemianopia and also contralateral hemianesthesia (Slater, Curtin and Johns, 2009). Thus Mrs. James has right-sided hemiplegia, deviation of the right eye to the left, right sided hemianopia and right sided hemianesthesia. The head also deviates to the left side. Since the non-dominant hemisphere is involved, the patient will have impaired perception of deficits known as anosognosia and qualitative deficits of speech. The left cerebral hemisphere is the dominant part of the cerebrum and thus is the main part for speech and language (Slater et al, 2009) and hence Mrs. James has speech-related problems. Since middle cerebral artery supplies the convex part of the cerebrum, cognitive impairment also occurs. 2. Activities One week after stroke, Mrs James is able to sit independently and stand with assistance from one person. 3. Participation Mrs. James shows interest in going home and getting back to regular household chores as quickly as possible. Dimensions of disability 1. Impairments Mrs. James has sensorimotor impairments. She is not able to walk, get up on her own and is unable to perform tasks related to the sensory-motor system. She has problems with speech. When the lesion is in the sylvian fissure of the dominant hemisphere, the patient will have dysphasia which may be fluent or nonfluent (Slater et al, 2009). When the infarct occurs in the insula or the frontoparietal operculum, the patient will have Brocass aphasia or motor aphasia. In this type of aphasia, the patient will be able to comprehend verbal and written language, but will not be able to express spoken or written language. In those in whom there is difficulty in the coordination of the oropharyngeal and respiratory components, dyspraxia results and the patient will have telegraphic verbal response. Affectation of the lower division of MCA bifurcation or its lower branches results in Wernickes aphasia or sensory aphasia in which the person is able to talk, but has no theme in whatever she talks. The patients may have agrammatism too. The patient will also have apraxia which is the inability to perform tasks which were learnt previously. Due to dyspraxia, the patient is uncoordinated and cannot imitate any action. Other impairments which may be present include autonomic dysfucntion, perceptual disorder, memory impairment, loss of initiative, emotional disturbance, atered problem solving and slow thinking (Slater et al, 2009). 2. Activity limitations Mrs. James is not able to walk on her own. She requires the assistance of one person to stand. She requires the maximum help of one person to wash and dress. She has some voluntary movements in her affected arm. She cannot go to toilet on her own. She cannot talk comprehensively. She cannot eat on her own. She cannot dress or undress. 3. Paticipation restrictions Mrs. James is unable to do the household chores as before and thus cannot cook and take care of her grandchildren. She cannot visit her friends and family by bus as she used to before her stroke. She cannot dance, take a walk from her house and volunteer at local charity shop. Setting goals Goals must be set by involving the patient and her family members. The ultimate goal of treatment is smooth transition to the community life which was present before stroke. The goals must be realistic and measurable and must be reevaluated at regular intervals (National Stroke Foundation, 2005). The goals must also be relevant to patients priorities. Short term goals 1. Grooming goals: Relearn basic skills like washing, dressing, bathing, toiletting, combing, brushing teeth, etc (Vega, 2009). 2. Functional goals: Re-learning things like carrying objects from one place to another, rolling over in bed, and balancing body in a steady standing position. 3. Feeding goals: Picking up and use of utensils, chewing food and swallowing. 4. Strength goals: Increasing the movement and strength of the affected limbs. Eatablishing strength automatically causes improvement in other activities and fucntions. Long term goals 1.Independence in ambulation and independence in day-to-day activities (Vega, 2009). 2. If feasible, able to meet friends and family memebrs by travelling by bus. Rehabilitation One week after stroke and out of the intensive care unit, what Mrs. James needs is a good rehabilitation program. Rehabilitation may be defined as "the planned withdrawal of support in order to enable the patient to become as independent as possible" (Slater et al, 2009). Rehabilitation can be achieved by coordination between members of an interdisciplinary team. One of the members of the team will be physiotherapist who has a major role in rehabilitation. Physiotherapists work with the patients to help them regain motor strength, motor control, physical conditioning and physical mobility so that they are able to return to independent living. The first step in physical rehabilitation is comprehensive evaluation of various aspects of the functions of the patient like mobility, coordination, balance, sensation, motor function and proprioception. These attributes can be evaluated with the help of detailed assessment comprising of manual muscle testing, gait analysis, functional assessment, postural evaluation and Berg balance scale test. Other aspects which need evaluation are the support from family and caregivers and the living environment of the patient. Physical therapy The cornerstone of rehabilitation is education of the patient and also of the caregivers and family members (Adams, Adams, Brott et al, 2003). During the initial stages, Mrs. James will have poor trunk control control and will not be able to bear weight on the affected extremity. She will not be able to advance her leg during the swing phase of the gait. Thus the initial physical therapy should focus on posture, control of the trunk and transfer of weight to right the lower extremity (SIGN, 2002). There are several treatment techniques which may be employed by the physiotherapist. Some such techniques are proprioceptive neuromuscular facilitation (PNF), neurodevelopmental technique (NDT), manual therapy, balance training, neuromuscular electrical stimulation (NMES), acquatherapy, biofeedback, cardiovascular training, frequency-specific microcurrent and myofascial release (Slater et al, 2009). The treatment must be started with NDT or PNF-based mat exercises. Balance work on Swiss ball is useful to gain control of trunk. After this, standing weight-bearing exercises and weight-shift exercises must be introduced. which help the patient take her initial stpes in the parallel bars (Slater et al, 2009). At this stage, NMES must be introduced to ehance the function of the muscles. The next step is to provide training for partial body weight–supported gait and this training can be provided on or off treadmill. While training for this, the patient must be secured for safety in a harness system that is able to support the weight of the patient. First step in gait is helped with or without assistive device like cane or walker (Slater et al, 2009) Other than cane or walker, there are many other adaptive devices and medical equipment to help the patient become more independent. If ankle dorsiflexion is present, ankle-foot orthosis must be applied to prevent foot drop and also to maintain extension of the knee during weight bearing (Slater et al, 2009). Wheelchair allows good extent of mobility and must be introduced much before independent walking for immediate increase in independence. The wheel chair must be adjusted so that the patient fits in properly (Slater et al, 2009). After mobilisation to walk independently, the patient must be retrained to perform various activities of daily living like bathing, dressing, undressing, toileting, cooking, eating, serving, etc. This job is done by occupational therapists. To achieve independence in performing daily activities, there are 3 techniques which are commonly employed. they are use of adaptive equipment, use of compensatory strategies and redevelopment of lost skills (Slater et al, 2009). Occupational therapy The focus in occupational therapy in the initial stages is basic care. Once this is established, higher activities like homemaking and return to wok can be established. Sensation impairment can be handled with sensory-specific training, sensory-related training and cutaneous electrical stimulation (SIGN, 2002). Occupational therapy uses the regained mobility and strength established by physical therapy and transforms it to perform functional tasks. Even in this form of therapy, importance is given for patient education and training of the caregiver. Rehabilitation of the upper extremity is the job of an occupational therapist. Initially, the muscle strength, range of motion and sensation of the upper limbs is evaluated to determine the extent of treatment to be provided. Initial assessment is essential to regain optimal fucntion and also to prevent injuries like contractures, loss of range of movements and increased subluxation. To maintain functional position of the hand and also to prevent excessive flexion and extension at the wrist join, a wrist-hand orthosis may be employed. Speech therapy Since Mrs James has speech-related problems, a speech-language pathologist also must be involved for comprehensive rehabilitation. Speech therapists can facilitate rehabilitation for impairments like apraxia of speech, aphasia, dysphagia and dysarthria. The main area which speech therapists focus in aphasia is receptive and expressive language skills. Treatment for the development of expressive language mainly aims at transforming ideas and thoughts into verbal expression, gestures and written language (Slater et al, 2009). For developing receptive language, comprehension of verbal language, written expression and comprehension of various gestures is worked upon. While handling apraxia, the speech therapist must determine the range of deficits and focus on systematic practice of production of sound. Initially simple sounds must be started followed by complex words and later to automatic spontaneous speech. If the patient has severe apraxia of speech, a combination of verbal expression, writing, gestures and augmentative devices must be used (Slater et al, 2009). Recreational therapy Leisure-time activity introduction helps provide motivation and also allows assessment and treatment of deficits. Recreation helps the patient to build confidence and facilitates community reintegration (Slater et al, 2009). Cardiovascular fitness Prolonged immobility after stroke results in severe cardiovascular deconditioning. Hence during rehabilitation, cardiovascular fitness must be aimed at. This can be initiated in the form of exercise and walking only after lower limb strength has regained. (Slater et al, 2009) Prevention of falling Research has shown increased incidence of falling in patients who have recovered from stroke. Thus, during rehabilitation, the patient must be trained not to fall. Some of the exercises which help in the prevention of falls are symmetrical standing training, repetitive sit-to-stand training, individually prescribed home-exercise program, individual home hazard assessment and modification, etc (National Stroke Foundation, 2005). Other aspects Other important aspects which need to be handled in rehabilitation are nutrition and swallowing, prevention of infecions, control of pain, prevention of bedsores, therapeutic positioning and psychological counselling for mood disturbance (National Stroke Foundation, 2005). Conclusion Physiotherapists have a major role in the rehabilitation of patients with stroke. The process of rehabilitation must be initiated after thorough evelauation and assessment of the present functional capacity and extent of impairments and deficits. It must be guided by the goals set in coordination with the patient and her relatives. These goals must be realistic and must be revised during the course of treatment. Effecive rehabilitation is possible through proper education of the patient, his caregivers and family memebers and also through multidisciplinary approach. References Adams, H.P., Adams, R.J., Brott, T., et al. (2003). Guidelines for the Early Management of Patients With Ischemic Stroke. Stroke, 34, 1056. National Stroke Foundation. (2005). Clinical Guidelines for Stroke Rehabilitation and Recovery. Retrieved on 31st October, 2009 from https://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/cp105.pdf Scottish Intercollegiate Guidelines Network or SIGN. (2002). Management of patients with stroke. Retrieved on 31st October, 2009 from http://www.sign.ac.uk/pdf/sign64.pdf Slater, D.I., Curtin, S.A., Johns, J.S., Schmidt, C., and Newbury, R. (2009). Middle cerebral artery stroke. Emedicine from WebMD. Retrieved on 31st October, 2009 from http://emedicine.medscape.com/article/323120-overview United Nations ESCAP. (2009). Training Manual on Disability Statistics. Retrieved on 31st October, 2009 from http://www.unescap.org/Stat/disability/manual/Chapter2-Disability-Statistics.asp Vega, J. (2009). What Are the Goals of Hemiplegia Rehabilitation? 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