Right MCA Ischemic Stroke with Left Hemiparesis Occupational therapy programme for Medical Neurology

1. UNIVERSITI TEKNOLOGI
MARA (UiTM)
AZIMAH BINTI HASSAN
940507-02-5320
DIPLOMA IN
OCCUPATIONAL THERAPY

2. DEFINITION OF CVA
• Sudden death of some brain cells due to lack of oxygen
when the blood flow to the brain is impaired by blockage
or rupture of an artery to the brain. A CVA is also
referred to as a stroke.
Retrieved from www.thestrokefoundation.com
• Symptoms of stroke depend on area of brain affected

3. DISRUPTION IN MIDDLE CEREBRAL ARTERY
Contralateral hemiplegia
Contralateral hemisensory loss
Ideational apraxia
Depression
Lack of judgement

4. TYPES OF CVA
 TIA (Transient Ischemic Attack)
- known as “mini stroke”
- temporary blockage of artery
 Ischemic
- blockage of artery
- 2 types: embolic and thrombotic
 Hemorrhagic
- ruptured of blood vessel
- 2 types: intra-cerebral and subarachnoid

5. BRUNNSTROM’S RECOVERY STAGES OF HAND
STAGE III
Mass grasp or hook grasp. No voluntary finger extension. No voluntary release.
STAGE II
Little or no active finger flexion
STAGE I
Flaccidity
STAGE VI
All types of prehension.
STAGE V
Palmar prehension (spherical and cylindrical grasp). Voluntary finger extension in
variable ROM.
STAGE IV
Lateral prehension (thumb release). Semivoluntary finger extension in small ROM.

6. DEMOGRAPHIC DATA
• Name : Mrs Y
• Address : Kg. Baru, Gurun
• Age : 56 Years Old
• Sex : Female
• Race : Chinese
• Religion : Buddha
• Marital Status : Widow
• Job : Plumbing contractor
• Date of Onset : 10/12/2014 @ 8.30pm
• Date of Admission : 10/12/2014 @ 9.17pm
• Date of referral : 22/12/2014
• Dominant Hand : Right Hand
• Affected Hand : Left Hand
• Diagnosis : Right MCA Ischemic Stroke with Left Hemiparesis

7. CASE HISTORY
• Patient had a stroke at her home
• Experienced numbness and weakness at her left arm
• Attempted to go to the bathroom and collapsed on the floor
• Noticed by her maid as the left side of her face was drooping
• Admitted to primary care hospital for almost 2 weeks
• Presented with right frontal-parietal infarct through CT scan
• Faced difficulty to move the left side of her body
• Movement gradually returned, but currently she still has
weakness on her left extremity.

8. MEDICAL HISTORY
• Patient had underlying hypertension
• Exhibited reactive depression since her recent hospitalization
• Prescribed with
- Atenolol 50 mg PO bid
- Clonidine 0.1 mg PO bid
- Aspirin 325 mg PO qd
• Referred to occupational therapy service after second week
post-admission

9. WORK HISTORY
• Previously worked as a plumbing contractor
• Provides plumbing service and installation for residential and
commercial customers
• Experienced tired and stress with her commitment:
- obtaining licenses
- preparing written work cost estimates and negotiate contracts

10. SOCIAL HISTORY
• Before recent hospitalization, patient lived alone at her home in an
urban neighborhood
• Spent her weekend by participating in martial art class
• Often went for holiday with her children when they return home
• Developed several interests including reading magazines and cooking

11. FAMILY HISTORY
 + 
59 y/0 56 y/0
  
32 y/0 29 y/0 24 y/0
• Patient is a widow and has three children
• All of her children are working and live in cities
• One of her children live in nearby town and visits weekly
• Has history of hypertension from maternal side

12. EVALUATION

13. SUBJECTIVE ASSESSMENT
• GENERAL APPEARANCE
- Patient came to department with her maid.
- Patient appeared neat and tidy.
• SPEECH
- Patient spoke coherently with adequate quantities of speech.
• EYE CONTACT
- Patient able to make eye contact with therapist and others.
• MOBILITY
- Patient ambulated to department by using quadripod
walking stick

14. OBJECTIVE ASSESMENT

15. Occupational Performance Area Assessments
ADL Modified Barthel Index (MBI)
Work Role Checklist
Leisure Interest Checklist
Occupational Performance
Component
Assessments
Cognitive Mini Mental State Examination
Sensory
• Light touch
• 2 - point discrimination
• Pain
Semmes-Weinstein Monofilaments Test
2 – Point Discriminator
Visual Analog Scale (VAS)
Neuromuscular
• Range of Motion (ROM)
• Muscle strength
• Muscle tone
• Balance
• Coordination
Upper Extremity Hand ROM and Wrist Chart
Manual Muscle Testing (MMT)
Modified Ashworth Scale (MAS)
Berg Balance Scale
Coordination test
Psychological Beck ‘s Depression Inventory
Psychosocial Interview and observation

16. OCCUPATIONAL PERFORMANCE AREA

17. Activity Criteria Initial assessment
Personal hygiene
Unable to perform the task (0)
Substantial help required (1)
Moderate help required (3)
Minimal help required (4)
Fully independent (5)
3
Bathing 5
Feeding
Unable to perform the task (0)
Substantial help required (2)
Moderate help required (5)
Minimal help required (8)
Fully independent (10)
10
Toilet 10
Stair climbing 8
Dressing 8
Bowel control 10
Bladder control 10
Chair/bed transfer
Unable to perform the task (0)
Substantial help required (3)
Moderate help required (8)
Minimal help required (12)
Fully independent (15)
12
Ambulation 15
Total 92/100
i. Activity of Daily Living (ADL) by using MBI

18. MBI INTERPRETATION
• Minimal dependency level
• Total hours of help required per week is less than 10 hours
• In personal hygiene (clipping nails), patient has difficulty to clip nail at her
right hand due to poor strength at left wrist and finger musculature
• In dressing, patient has difficulty to don blouse due to poor strength at her
left upper extremity
• In stair climbing, patient need moderate assistance and supervision due to
poor balance

19. ii) Work by using Role Checklist
• Before recent hospitalization, patient was a plumbing contractor
• However, after having stroke patient stopped working and stayed at home with her maid
• According to Role Checklist, patient does not want continue to work
Role Past Present Future
Student √
Worker √
Volunteer
Caregiver √ √ √
Home maintainer √
Friend √ √ √
Family member √ √ √
Religious participant
Hobbyist √ √ √
Participant in
organization
√ √

20. iii) Leisure by using Interest Checklist
According to Interest Checklist, patient still interested to involve in:
• participating martial art class during weekend with other peers
• cooking and reading magazines during free time

21. OCCUPATIONAL PERFORMANCE
COMPONENT

22. DOMAIN COMMENT SCORE
ORIENTATION Year, date, day, month = Client able to state season.
Place = Client recognize and know where she is.
5/5
5/5
REGISTRATION Client can names 3 different object (bed, apple, shoe) in the first trial 3/3
ATTENTION &
CALCULATION
Client need to calculate 20 - 3 for 5 times.
Client able to give 5 correct answer s respectively
5/5
RECALL Client able to recall 3 objects correctly. 3/3
LANGUAGE Able to name object (pencil & watch).
Able to repeat “Tidak mungkin dan tidak mustahil”.
Able to follow instruction given “ambil kertas dengan tangan kanan, lipat dua
dan letakkan di atas lantai”.
Client able to read “tutup mata anda” and follow what it said.
Client able to make a sentence.
Client able to copy picture exactly.
2/2
1/1
3/3
1/1
1/1
1/1
TOTAL SCORE Interpretation, : mild to moderate cognitive impairment. 30/30
( Source : www.medicine.uiowa.edu/igec/tools/cognitive/MMSE.pdf )

23. i. SENSORY
Color Monofilament size Force in grams (g) Cutaneous Sensory Perception
Green 2.83 0.07 Normal light touch
Blue 3.61 0.2 Diminished light touch
Purple / pink 4.31 2.0 Diminished protective sensation
Red 4.56 4.0 Loss of protective sensation
Orange 6.65 200 Untestable

24. • Light Touch by using Semmes-Weinstein Monofilaments Test
- Patient perceived 3.61 at major part of both hands due to numbness
- Pain by using Visual Analog Numerical Scale (VAS)
- Patient marked score 0/10 during rest at left upper limb
- Patient marked score 1/10 during passive shoulder flexion due to stiffness
Ulnar nerve Median nerve Radial nerve
Right hand
• Palmar
• Dorsal
3.61
3.61
2.83
3.61
3.61
3.61
Left hand
• Palmar
• Dorsal
3.61
3.61
2.83
3.61
2.83
3.61

25. ii. NEURO-MUSCULOSKELETAL
• Range of Motion
- patient has full AROM and PROM at right extremity
- patient has limited AROM at left upper limb
- patient has full PROM at left upper limb and both lower limb

26. • Muscle strength through MMT (Manual Muscle Testing)
Location Flexion Extension
Upper limb Score Score
Shoulder 2/5 2/5
Elbow 2/5 2/5
Wrist 2/5 1/5
Fingers 1/5 1/5

27. Muscle Tone by using Modified Ashworth Scale
GRADE DESCRIPTION
0 Normal tone
1
Slight increase in muscle tone, manifested by catch and release at
the end of ROM when the affected part is moved in flexion or extension
2
Slight increase in muscle tone manifested by catch, followed by minimal resistance
through out the remainder (less than half of the ROM)
3
More marked increase in muscle tone through most of the ROM but affected part
easily moved
4 Considerable increase in muscle tone, passive movement difficult
5 Affected part rigid in flexion and extension
• Patient is categorized in Grade 3
• Patient has marked increase in muscle tone through most of the ROM
but the left upper limb is easily moved

28. • Balance by Using Berg Balance Scale
Sitting to standing 1
Standing unsupported 3
Sitting with back unsupported but feet supported on floor on a stool 4
Standing to sitting 4
Transfers 3
Standing unsupported with eyes closed 3
Standing unsupported with feet together 1
Reaching forward with outstretched arm while standing 1
Pick up object form the floor from a standing position 1
Turning behind over left and right shoulders while standing 1
Turn 360 degrees 1
Place alternate foot on step or stool while standing unsupported 0
Standing unsupported one foot in front 0

29. • Interpretation :
According to the result, patient scored 22 in which she has
medium fall risk
41 – 56 Low fall risk
21 – 40 Medium fall risk
0 – 20 High fall risk

30. • Coordination Test (non-equilibrium tests)
Test Right Left Comment
Finger to nose / -
Unable to test affected hand due to
hypertoneFinger to therapist finger / -
Finger to finger / -
Unable to test affected hand due to
hypertoneAlternate nose to finger / -
Finger opposition / -
Unable to test affected hand due to
hypertone
Mass grasp / -
Pronation/supination / -
Rebound test of holmes / -
Tapping (hand) / -
Drawing a circle (hand and foot) / -
Fixation/position holding (upper
and lower limb)
/ -

31. iii. Psychological Function through Beck’s Depression Inventory
• According to the assessment, patient has mild mood disturbance.
iv. Psychosocial function through interview
• Patient has good relationship with family members.
• Patient spends time alone at home during weekend.
• Patient has fair coping skills.
• Patient has fair self control.

32. PATIENT’S ASSETS
• Patient is compliance with occupational therapy program
• Patient does not has financial problem
• Patient able to adhere with the instruction
• Patient able to communicate well with others

33. PROBLEMS IDENTIFICATION
Occupational performance area (OPA)
1. Has difficulty to perform in ADL
• In personal hygiene (cutting nails), patient has difficulty to cut nails
due to poor strength of wrist and fingers musculature
• In dressing , patient has difficulty to don due to poor muscle strength
• In stair climbing, patient needs moderate assistance and supervision
due to poor balance
2. Unable to perform in previous leisure activity specifically in
martial art class and cooking due to physical limitation

34. Occupational performance component (OPC)
1. Exhibits hypertonic at left upper limb
2. Exhibits poor muscle strength at left upper limb
3. Exhibits limited joint AROM at left upper limb
4. Exhibits poor hand function at left upper limb
5. Exhibits poor muscle strength at left lower limb

35. FORMULATING AIMS
Short term goal
• To normalize muscle tone at left upper limb
• To facilitate muscle strength at left upper limb
• To elicit joint AROM at left upper limb
• To enhance hand function at left upper limb
• To promote muscle strength at left lower limb
Long term goal
• To promote functional independence in ADL specifically in
personal hygiene, dressing and stairs climbing

36. TREATMENT APPROACH
• Biomechanical FOR
The approach is focused on addressing basic client factor to improve
occupational performance. Intervention is in the form of exercises,
splinting or orthopedic approach in which the outcome must reflect
engagement in occupation.
(Pedretti, 2006)
In this case, biomechanical approach is use to ensure patient get
maximum level of functioning of left upper limb in order to enable
patient performing activity daily living as usual.

37. • Neurodevelopmental FOR
The approach is emphasized on normalizing muscle tone,
inhibiting primitive reflexes and facilitating normal postural
reactions. In this case, the treatment is implemented by handling
techniques with the application of weight bearing over the affected limb.
In addition, the use of normal pattern of coordinated movements
is encouraged at both sides of body and avoidance of any sensory input
that may adversely affect muscle tone.
(Pendleton & Schultz-krohn,2006)

38. • Rehabilitation FOR
The approach is focused on client ability to return to the fullest
physical, mental, social, vocational and economic functioning
as is possible.
Treatment are focused on avoiding and reducing impairment
of the effected hand by using adaptation and give purposeful,
meaningful activity to the patient.
(Pedretti , 2006)

39. TREATMENT IMPLEMENTATION

40. Problem 1 Exhibits hypertonic at left upper limb
Aim To normalize muscle tone at left upper limb
Intervention
Technique / Modalities Inhibition technique
Method
(Weight bearing)
1. Place patient in sitting position
2. Facilitate shoulder movement with elbow extension
3. Elicit flexion and extension of elbow once shoulder control increase
4. Weight shifting is applied to promote weight bearing at the involved
extremity
Duration 5 – 10 minutes
Grading Increase the number of repetitions
Precaution Aware with wrist pain caused by mal-alignment of carpals
Rationale
Weight bearing is a postural support can prevent tissue shortening of the
elbow, wrist, and finger flexor. It can also be used to strengthening the
scapula musculature and the triceps.

41. Problem 2 Poor muscle strength at left upper limb
Aim To promote muscle strength at left upper limb
Intervention
Technique / Modalities Bilateral isokinetic training
Method
(Hand cycling)
Place the affected hand on the pedal
Maintain slight elbow flexion
Start pedaling with graded resistance
Grading
Increase the resistance by adding weight load to the equipment
Increase the duration of the cycling period
Precaution
The affected hand should be carefully positioned to prevent
skin irritation
Rationale
The intervention emphasizes the use of bilateral arm movement
with ADLs and is hypothesized to be more functional than
unilateral arm. It activates the damaged hemisphere through
inter-hemispheric connections simultaneously.
(C.P Latimer, et al., 2010)

42. Problem 3 Limited AROM at left upper limb
Aim To elicit AROM at left upper limb
Intervention
Technique / Modalities Active – assisted exercise
Method
(Shoulder arch)
- Place shoulder arch in front of patient
- Instruct patient to bring the ring with the affected hand along the
arch
- Repeat the activity
Precaution Avoid perform the activity in prolonged time to prevent additional
stress on shoulder and neck
Grading Increase the resistance by increasing the arch height
Rationale In order to improve ROM and strength, forceful exercise is necessary to
use which is there has some type of force that was used to body part
when soft tissue is either near on the available length
(Pendelton & Schultz-Krohn,2006)

43. Problem 4 Poor hand function at left upper limb
Aim To enhance hand function at left upper limb
Intervention
Technique / Modalities Task – Specific Training Technique
Method
(Stacking cone)
1. Ensure patient is sitting on the chair
2. Instruct patient to hold the cone with both hand.
3. Move the cone across midline from right to left.
Then move back the cone from left to right.
4. Repeat the activity
5. Therapist should guide the patient on holding the cone to promote
normal pattern of coordinated movement
Grading
Increase the task repetitions
Increase the durations of activity
Rationale
Task specific, low – intensity regiments designed to improve use and
function of the affected limbs have reported significant improvements.
(Page, 2003)

44. Problem 5 Poor muscle strength at left lower limb
Aim To enhance muscle strength at left lower limb
Intervention
Technique / Modalities Functional strength training (FST)
Method
(Static cycling)
Ensure patient sit on the seat safely
Place the affected leg on the paddle with bandage to avoid falling
Monitor patient to perform cycling within certain duration
Grading Increasing the duration of the cycling period
Rationale
Strengthening interventions increase strength, improve activity and
do not increase spasticity.
(Ada et al., 2006)

45. Problem 6
Has difficulty to perform in ADL
• Difficulty in personal hygiene (nail cutting) at left hand
due to inability in grasping and pinching
Aim
To promote functional independence in ADL specifically
in personal hygiene
Intervention
Technique /
Modalities Compensatory technique through adaptive equipment
Method Use large grip nail clippers for comfortable handling
Precaution Ensure the equipment is safe to use

46. Problem 7
Has difficulty to perform in ADL
• Difficulty in dressing (donning clothes) at left arm due to
inability to pinch and grasp with lack of ability to reach
Aim To promote functional independence in ADL specifically in dressing
Intervention
Technique /
Modalities
Compensatory technique through one - handed technique
Method
1. Position shirt on lap with inside facing up and collar toward chest
2. Place involved arm into the sleeve by the unaffected arm
3. Pull shirt up onto arm past elbow
4. Insert unaffected arm into sleeve
5. Adjust shirt on affected side up and onto shoulder
6. Lean forward, duck head and pass shirt over it
7. Adjust the shirt
Precaution
Encourage patient to wear larger shirt and keep buttons
fastened before donning to avoid frustration.
Self buttoning is a labor intensive and frustrating task for patient with
hemiplegia (Mary&Catherine, 2008)

47. Problem 8
Has difficulty to perform in ADL
Difficulty in mobility (stair climbing) due to decreased weight bearing
at left lower limb
Aim
To promote functional independence in ADL specifically in mobility
(stair climbing)
Intervention
Technique / Modalities Stair climbing technique with assistive device
Method
Ascending
1. The unaffected lower extremity leads up
2. The cane and affected lower extremity follows
Descending
1. The effected lower extremity and cane lead down
2. The unaffected lower extremity follows
Precaution Aware with the surface of the floor to prevent trip over
Grading Increasing the endurance by facilitating duration of the stair climbing

48. REASSESSMENT
GENERAL APPEARANCE
- Patient came to department with her maid.
- Patient appeared neat and tidy.
SPEECH
- Patient spoke coherently with adequate quantities of speech.
EYE CONTACT
- Patient able to make eye contact with therapist and others.
MOBILITY
- Patient ambulated to department by using quadripod
walking stick

49. Activity Criteria Initial assessment
Personal hygiene Unable to perform the task (0)
Substantial help required (1)
Moderate help required (3)
Minimal help required (4)
Fully independent (5)
4
Bathing 5
Feeding Unable to perform the task (0)
Substantial help required (2)
Moderate help required (5)
Minimal help required (8)
Fully independent (10)
10
Toilet 10
Stair climbing 8
Dressing 10
Bowel control 10
Bladder control 10
Chair/bed transfer Unable to perform the task (0)
Substantial help required (3)
Moderate help required (8)
Minimal help required (12)
Fully independent (15)
15
Ambulation 12
Total 94/100
Activity of Daily Living (ADL) by using MBI (Modified Barthel Index)

50. OCCUPATIONAL PERFORMANCE COMPONENT (OPC)
Pain by using Visual Analog Numerical Scale (VAS)
• Patient marked score 0/10 during rest at left upper limb
• Patient marked score 0/10 during passive shoulder flexion

51. • Balance by Using Berg Balance Scale
Sitting to standing 3
Standing unsupported 4
Sitting with back unsupported but feet supported on floor on a stool 4
Standing to sitting 4
Transfers 4
Standing unsupported with eyes closed 4
Standing unsupported with feet together 1
Reaching forward with outstretched arm while standing 2
Pick up object form the floor from a standing position 1
Turning behind over left and right shoulders while standing 2
Turn 360 degrees 1
Place alternate foot on step or stool while standing unsupported 2
Standing unsupported one foot in front 0

52. • Interpretation :
According to the result, patient scored 32 in which she has
medium fall risk
41 – 56 Low fall risk
21 – 40 Medium fall risk
0 – 20 High fall risk

53. • Weight bearing exercise
• Passive stretching (PROM exercise)
• Trunk control exercise
• Bridging technique
HOME PROGRAMMES

54. FUTURE PLAN
• Hand function training
• Coordination training
• Balance training
• Gait training

55. PROGNOSIS
Medical
• Based on medical review, patient prognosis is good where:
 Patient is compliance with the medicine
Rehabilitation
• Based on Occupational Therapy (OT) aspect, patient prognosis is good where:
 Patient shows improvement in performing ADL .
 Patient is compliance with the appointment of treatment.
 Patient is motivated to perform passive and active exercise at home.

56. REFERENCES
• Catherine A. Trombly, Occupational Therapy Dysfunction 4th Edition
• Creek, J., & Lougher, L. (2011). Occupational Therapy and Mental Health (4th ed.). China:
Churchill Livingstone Elsevier.
• Davies, P. M. (1985). Step To Follow : A Guide to the Treatment of Adult Hemiplegia Based on the Concept
of K. and B. Bobath. New York, America: Springer-Verlag
• Gillen, G., & Burkhardt, A. (2004). Stroke Rehabilitation : A Function-Based Approach(2nd ed.). United
States, America: Mosby, Inc.
• Hopkins. H.L, Smith. H.D (1993) 8th edition. Willard and spaceman's Occupational Therapy. Lippincott Co:
Philadelphia
• Pendleton, H. M. H., & Schultz- Krohn, W. (2006). Pedretti’s Occupational Therapy:Practice for physical
dysfunction: St.Louis, MO: Mosby
• Sawner, K. A., & La Vigne, J. M. (1992). Brunnstrom's Movement Therapy in Hemiplegia : A
Neurophysiological Approach (2nd ed.). United States, America: Lippincott Williams & Wilkins.
• Turner. A. (1981) The Practice of Occupational Therapy. Churchill Livingstone: Edinburgh