Effective Systems for Stroke Rehabilitation - Case Study Example

Effective stroke rehabilitation must be early, intensive and repetitive to achieve patient’s motivation and engagement. Many physiological barriers can occur at this stage, which must be overcome. In order to achieve this objective, good patient engagement is imperative. This study offers insights into how more effective systems for stroke rehabilitation can be developed. It considers stroke rehabilitation and some barriers that the patient has experienced. In the end, it discusses the approach used in overcoming these barriers, some of which are planned, while others are not. Ultimately, this patient will finally recover from his stroke by 95%. However, the primary focus of this paper will be on what has been done, whether correctly or not, that enabled him to improve to this extent. Introduction: The subject is a 49 year old male Caucasian who is diagnosed as a case of stroke identified as a Cerebral Vascular Accident (CVA). A stroke is the sudden death of brain cells due to a problem with blood supply. When blood flow to the brain gets impaired the supply of oxygen and important nutrients is blocked. This result in injury and then the death to brain cells, entailing abnormal brain function. Blood flow to the brain can be disrupted by either a blockage (ischemic) or the rupture of an artery to the brain (hemorrhagic)(1). In this case a left hemisphere ischemic stroke has occurred. The immediate symptoms of a left-side stroke is instant and may include weakness or numbness of face, arm, or leg, especially on the right side of the body. Besides confusion, trouble in speaking or understanding (aphasia), dizziness, loss of balance vision problems (on the right side of vision in both eyes) difficulty swallowing, and headaches may occur. Symptoms that lasts longer may include problems with movement of the right-side of the body, speaking, understanding language, reading, and writing, organizing, analyzing, reasoning, planning memory and learning , completing tasks (difficulty doing activities, difficulty (planning) short attention span, vision (difficulty seeing out of the right field of vision) mental health (eg, depression, cautiousness, compulsive behavior and the lack of motivation, frustration)(2pg2)Diagnosis of stroke needs to be made as quickly as possible. Tests include an examination of nervous system, computed tomography (CT) scan which is a type of x-ray that uses a computer to make pictures of the brain. CT angiogram is another type of CT scan that evaluates the blood vessels in the brain and/or neck, is who effective in diagnosis Magnetic Resonance Imaging (MRI) is a test that uses magnetic waves to take pictures of the brain. Magnetic Resonance Angiography (MRA) is an MRI scan that evaluates the blood vessels in the brain and/or neck. Angiogram on the other hand, is a test that uses a catheter (tube) and x-ray machine to assess the heart and the its blood supply to it. Heart function tests (eg, electrocardiogram, echocardiogram) Doppler ultrasound , which is a test that uses sound waves used to examine the blood vessels are normally used and to fast the level of oxygen in the blood, and to evaluate the ability to swallow(3).The prognoses of left-hemisphere stroke is often complicated and besides having right-sided paralysis and it may also cause extreme cautiousness on the part of the sufferer. It takes a lot of motivation and encouragement to guide such a person through the process of recovery. Caregivers and patients can easily become frustrated by the slowness and confusion they may encounter. Due to the changes in the brain, caregivers often see their loved ones exhibit a high level of frustration or anger. Recovering from a stroke, especially one affecting the left-hemisphere, can be absolutely life-altering and difficult. Often unexpected or inappropriate responses on the part of stroke survivors, such as laughing at an inopportune time or throwing childish temper tantrums(4). Treatment for a left hemisphere stroke should start immediately with proper and timely attention, it is possible to increase or regain strength and movement through different means of rehabilitation. Working with rehabilitation team that can consist of speech therapists, physiatrists, physical therapists, physical and/or occupational therapists has proven to have positive impacts on mobility of patients. In addition to rehabilitation treatment at the rehabilitation center, a home exercise plan also needs to be devised for the patient. Repeated practice and activity will help increase control and flexibility and re-establish nerve circuitry. Patients can also learn specific activities to do at home that will facilitate recovery after inpatient therapy. Following the home care program with consistency is the key to increased accuracy, range of motion and strength. (5) The subject in this study is a 49 year old Hotel Operations Manager, who works an average of 50 hours per week supervising a staff of 600 employees. The patient did not have any family record of stroke but has encountered transient ischemic attack (TIA) before and after the CVA. TIAs are often warning signs of a likely stroke in future, but are hard to track because the MRI it will not reveal this. However, the risk of a stroke increases dramatically in the days after a transient ischemic attack1. He has speech trouble, difficulty in walking and lower extremity hemiparesis. The patient attributes the signs to pinched nerves or being tired. In fact when having the CVA, he has reported it to be a pinched nerve when forced to go to ER. Thus this paper will attempt to objectively delineate the rehab process that can improve the patient’s recovery process. The patient with the diagnosis of a stroke is suggested to undergo CT scan, MRI and cardiac enzyme test. The result have indicated that the patient had CVA stroke and the possibility of a number of TIA sites in the left side hemisphere of the brain. The patient had no preexisting conditions, such family history, high cholesterol, or smoking habits that would have put him at risk of stroke. Theories for this stroke range from stress to sleep apnea, but no concrete reason has ever been found. The patient is put on medication including Coumadin, Aspirin for blood thinning and Lipitor for cholesterol. He has been advise to engage in light physical activity, avoid stress and to follow safe diet guidelines and frequent medical checkups. The patient has been referred to outpatient physical therapy which is to commence four days after discharge from hospital. Day One: The patient is diagnosis with left hemisphere CVA, present with paresis and numbness of right arm and leg. The patient is in no pain (0/10) and eager to start rehab. The patient has no other pre stroke complications, is in good health before stroke, and has completed century bike ride for 32 days before stroke. The patient has history of TIAs, but has reported none during the last week and is taking Coumadin and Aspirin for blood thinning since the stroke, but is on no other medications. The patient has facial paralysis on right side and is seeing a speech therapist. Manual muscle testing is given to all four limbs and the results are recorded. Overall the patients left side is in normal range with complete right side weakness. Strength (MMT) Shoulder Left Right Flexion 2/5 5/5 Abduction 2/5 5/5 External 1/5 5/5 Elbow 5/5 Flexion 2/5 5/5 Extension 2/5 5/5 Pronation 1/5 5/5 Supination 1/5 5/5 Wrist 5/5 Flexion 1/5 5/5 Extension 1/5 5/5 Finger 5/5 Flexion 1/5 5/5 Extension 1/5 5/5 Grasp 1/5 5/5 The patient has started gait training using a cane in left hand, and on low movement shoulder exercises, flexion and abduction starting with 3 reps each and working up to 10. Also, he does lower body exercises of hip and knee flexion with 3 reps each and working up to 10 as strength improves. Patient has also been given home exercise plan (HEP), with an outline of strengthening exercises to add to program if he feels he could do it. Short term goals set for the subject include attaining the ability to perform one strengthening exercise per movement, and be able to treadmill 15 minutes for by end of week two. Long range goals (6 to 10 months) include the return to pre stoke base line. HEP is also intended alternate strengthening and endurance exercise every other day. Patient is also scheduled for outpatient care twice a week. 2 Weeks: Patient remains in good spirits and reports that he follows the home exercise plan regularly. He still has some paresis and numbness in left upper (UE) and lower extremity (LE) but has no general pain (0/10) except for off and on pain in thumb area (2/10). The problem of right side facial paralysis had resolved and the patient has discontinued seeing the speech therapist. Patient still uses cane to ambulate and reports that gate is improving but still has toe drop of left foot. Patient states that he has done a lot of work to get the benefits that he is reporting, but overall he is happy with the outcomes. Manual muscle test results show an increased level of strength in all areas except the right hand grasp and ankle PF. Shoulder Left Right Flexion 3/5 5/5 Abduction 3/5 5/5 External 3/5 5/5 Elbow 5/5 Flexion 3/5 5/5 Extension 3/5 5/5 Pronation 3/5 5/5 Supination 3/5 5/5 Wrist 5/5 Flexion 3/5 5/5 Extension 3/5 5/5 Finger 5/5 Flexion 3/5 5/5 Extension 3/5 5/5 Grasp 2/5 5/5 Patient has been following HEP and added strengthening exercises in all kinds of movement for both UE and LE. The treatment today is 15 minutes on stationary bike, 20 minutes of ball catch on balance board, 20 minutes of PROM and stretching and 10 minutes of ice. HEP will be reviewed in two months and patient will increase it to two strengthening exercises per movement, both UE and LE. He will also add some core balance training like balance board and start using treadmill without cane. FYI patient has been in good shape before stroke and the patient already has gym membership. Therefore, it is left for him to decide what exercises he adds in future, as long as it works toward attaining the HEP goals. 2 Months: Patient still reports overall weakness in both left UE and LE, and is not sure he is getting stronger or just compensating better. Patient has given up cane, but still has foot drag. He reports shoulder improving but hand grasp is still weak with thumb being the only place of occasional numbness. He has no pain (0/10) but had a fall during last week. He does seem to be showing signs of frustration, mostly with right hand but is following HEP. Manual muscle testing shows improvement but he has not come back to normal base line. Shoulder Left Right Flexion 5/5 5/5 Abduction 5/5 5/5 External 5/5 5/5 Elbow 5/5 Flexion 4/5 5/5 Extension 4/5 5/5 Pronation 4/5 5/5 Supination 4/5 5/5 Wrist 5/5 Flexion 4/5 5/5 Extension 4/5 5/5 Finger 5/5 Flexion 4/5 5/5 Extension 3/5 5/5 Grasp 2/5 5/5 The patient has increased HEP to two exercises per movement both UE, LE and started to add some core movements. Patient has also added Wii Fit to HEP for balance and endurance component. Today’s exercise and treatment 10 minutes on stationary bike, 10 minutes of medicine ball catch, 10 minutes Wii Ski game, and 10 minutes ice sore shoulder. Short and long term goals are same and intended to return to pre stroke base lines. 6 Months: Patient reports no strength gains over last 4 months and has returned to work, but other than missing a day here and there he has kept to the HEP. He also reports bouts of depression and is not as excited about workouts as he used to be. Besides he feels no pain (0/10) but has occasional numbness in left thumb and weak left hand grip. Patient is very frustrated and expressed concerns that he has made all the gains he is going to. Manual muscle testing shows no gains. Test iss incomplete due to refusal by patient. Shoulder Left Right Flexion N/T N/T Abduction N/T N/T External N/T N/T Elbow N/T N/T Flexion N/T N/T Extension N/T N/T Pronation N/T N/T Supination N/T N/T Wrist N/T Flexion 4/5 N/T Extension 4/5 N/T Finger N/T Flexion 4/5 N/T Extension 3/5 N/T Grasp 2/5 N/T Patient does not show any strength gains, but he is showing improvement in endurance with longer periods of time on stationary bike and treadmill. However, he is reporting soreness in the left knee and hip after longer times on treadmill most likely due to gait deviations due to LE weakness. Today he has done 10 minutes on stationary bike, 10 minutes PROM and stretching, 20 minutes Tai Chi. Short and long term goals remain returning to the baseline. Patients will incorporate other activities into the rehab program such as Tai Chi, and aqua therapy. 1 Year: Patient returns to rehab after an unknown number of TIAs that set back his rehabilitation. Doctors have no answer as to why this has happened to the patient and he has been referred back to outpatient care. Patient is not in good spirits and reports going through bouts of depression. He also understands that the first year is where stroke patients attain most of their recovery, and is upset that not only did he not get back to the original baseline but, on the other hand, he has regressed. Patient does a 10 minute warm up on stationary bike, 10 minute weighted ball catch, 8 minute PROM on right LE and 8 minute PROM on right UE. Patient says he is willing to work, but is very withdrawn compared to other visits. There is a discussion about the frustration of not knowing why he still has the strokes. He is set up with his old HEP and he scheduled to do outpatient two times a week. Follow Up: After missing two appointments, the patient comes in to inform us that he is moving to Florida. He appears more upbeat than last time and he seems resigned to living with and adapting to his new base level. Patient agrees to look into going to outpatient rehab in Florida and says he will reach out to a mutual friend/physical therapist that has also relocated. 1 Year 4 Months: Patient returns from Florida where he has a CVA while scuba diving. It is still unknown as to why he has strokes, and while this has set him back, at the moment patient is motivated and in good sprites. He states that his goal is to get back to the possible extent and learn to live with whatever problem that remains. Muscle testing shows that while patient has not regressed to day one, he neither shows regression. Shoulder Left Right Flexion 3/5 5/5 Abduction 3/5 5/5 External 3/5 5/5 Elbow 5/5 Flexion 3/5 5/5 Extension 3/5 5/5 Pronation 3/5 5/5 Supination 3/5 5/5 Wrist 5/5 Flexion 3/5 5/5 Extension 3/5 5/5 Finger 5/5 Flexion 3/5 5/5 Extension 3/5 5/5 Grasp 2/5 5/5 Today’s treatment and exercise involves 10 minute stationary bike and30 minutes of Wii fit. The patient seems to enjoy the Wii workout. Long term and short term goals are to work on strength and balance. 1 Year 5 Months: Patient is being discharged today after one month of rehabilitation with no signs of gain. He shows signs of depression and frustration and states that he is returning to Florida, with no scuba diving this time. He further tells that the sole reason for the trip is to put all his effort into rehab for 3 months, because he feels any possible chances for recovery is bleak and it is just easier to be active in the warm weather. 1 Year 9 Months: The patient has come for a workout and evaluation. He appears fit, happy and tanned. The patient states that he has spent the last three months walking and then running in sand and surf, combined with running and working out with paddles and floating in an outdoor pool. What started as 30 minutes a day has moved up to 3 hours a day. He thinks that he is about 90% in strength pre stroke baseline, and puts his cardio and endurance at above pre stroke. Muscle testing on LE confirms the patient’s improvement. One hour of playing basketball with patient confirmed his statement on cardio and endurance. It is unusual for a CVA patient to make gains after the one year mark, indeed it has been 1 year and 9 months since the first CVA. There is much about this case that is unknown and unusual. It is safe to say that while this patient will always be a high risk for stroke and should be on lifetime program for good health and diet, at this time he no longer needs any physical rehabilitation. So what has led to this patient’s physical recovery? It seem simplistic to just attribute it to the warm Florida days.He has been maintaining good health before the strokes, and is familiar with workouts, both a plus in the rehab process. To be sure the basics for success are laid out by his rehabilitation team, but he has been past the time when most gains come. He thinks he had reached the wall and has been deeply depressed when he went back to Florida. Is it too simplistic to say he just felt better walking on the warm beach? How do you measure being with friends or the effect of a warm day on rehabilitation? For that matter, a pet? I think the one thing that this case study shows is that there is a lot outside the measurable realm of a physical therapist that contribute to the outcome of the a patients rehabilitation. His positive attitude and determination that he will confront all the adversities square on the face, also seems to have helped the recovery process. Works Cited Allina Health. Effects of Left-Sided Stroke. Allina Health .org. 2006. Web. 9 March 2013. Joni. M. A community stroke study: Journal of Stroke and Cerebrovascular Diseases. 2001. Print. National Stroke Association. Effects of Stroke. Stroke. org. 2013. Web. 9 March 2013. Steiner, T. Ringleb, P & Hacke, W. Treatment options for large hemispheric Stroke Neurology Journal. 2001. Print. University of Wisconsin School of Medicine. Locations of Stroke: Left Brain VS Right Brain. UWHealth.org 2012. Web. 9 March 2013. What Is A Mini-Stroke? What Is A Transient Ischemic Attack (TIA)? MNT. 2009. Web. 9 March 2013. Read More