PHYSIOTHERAPY

MANAGEMENT POST
ISCHEMIC STROKE
BY
EZEJI, PAULCHRIS TOCHUKWU
(NEUROLOGY UNIT PRESENTATION)
17/3/2021
 INTRODUCTION
Stroke, also known as Cerebrovascular
Accident (CVA), according to the World
Health Organisation (WHO), is an
accident to the brain with "rapidly
developing clinical signs of focal or
global disturbance to cerebral function,
with symptoms lasting 24 hours or longer,
or leading to death, with no apparent
cause other than of vascular origin.
INTRODUCTION CONT’D
Ischemic stroke occurs when there is
an occlusion of a blood vessel
impairing the flow of blood to the
brain. (Bruce, 2007).
It happens when the brain's blood

vessels become narrowed or blocked,

causing severely reduced blood flow
(ischemia).
INTRODUCTION CONT’D
Blocked or narrowed blood
vessels are caused by fatty
deposits that build up in blood
vessels or by blood clots or other
debris that travel through the
bloodstream and lodge in the
blood vessels in the brain.
CLINICAL ANATOMY
CLINICAL ANATOMY CONT’D
Blood is pumped from the heart
and carried to the brain by two
paired arteries:
Internal carotid arteries: supply the

anterior (front) areas of the brain.

Vertebral arteries: supply the
posterior (back) areas of the brain.
CLINICAL ANATOMY CONT’D
The right and left vertebral arteries
join together to form a single
basilar artery.
The basilar artery and internal

carotid arteries communicate in a

ring at the base of the brain called
the Circle of Willis.
CLINICAL ANATOMY CONT’D
The middle cerebral artery is the
artery most often blocked during
Ischemic stroke.
PATHOLOGICAL ANATOMY
TYPES OF ISCHEMIC STROKE
Thrombotic: When a blood clot
forms in a main brain artery or within
the small blood vessels deep inside
the brain.
Embolic: A blood clot, air bubble or

fat globule forms within a blood

vessel elsewhere in the body and is
carried to the brain.
TYPES OF ISCHEMIC STROKE
Systemic Hypo-perfusion: A
general decrease in blood supply
caused by chronic uncontrolled
hypertension.
Venous Thrombosis: Caused by a

thrombus (blood clot).

 EPIDEMIOLOGY
According to the World Health
Organization (WHO):
15 million people suffer stroke

worldwide each year.

5 million die
5 million are left permanently

disabled.
 EPIDEMIOLOGY
Ischemic stroke accounts for 85%
of all acute strokes.
Men have been found to experience

more ischemic strokes than women

(Reeves, 2008).
 ETIOLOGY
Hypertension
Diabetes mellitus
Hypercholesterolemia
Physical inactivity
Obesity
Smoking
 CLINICAL FEATURES
Sudden numbness
Weakness of the face, arm or leg,

especially involving one side of the

body
Sudden confusion
Trouble speaking or understanding
Loss of vision in one or both eyes
CLINICAL FEATURES CONT’D
Trouble walking
Dizziness
Loss of balance or coordination
Sudden, severe headache with no

known cause (Physiopedia, 2021)

 OUTCOME MEASURE BARTHEL
INDEX

Incontinent Occasional Continent

accident
Bowels 0 1 2
Bladder 0 1 2
Needs help Independent
Grooming 0 1
Dependent Needs help Independent
Toilet use 0 1 2
Feeding 0 1 2
 OUTCOME MEASURE BARTHEL INDEX

Unable Major help Minor help Independe

nt
Transfer 0 1 2 3
Immobile Wheel chair With help Independent
of one
person
Mobility 0 1 2 3
Dependent Needs help Independent
Dressing 0 1 2
Stairs 0 1 2
Dependent Independent
Bathing 0 1
 MEDICAL MANAGEMENT
General treatment includes:
Respiratory and cardiac care
Fluid and metabolic management
Blood pressure control
Prevention and treatment of
conditions such as:
• Seizures
 MEDICAL MANAGEMENT
CONT’D
• Venous thromboembolism
• Aspiration pneumonia
• Management of elevated intracranial

pressure
 PHYSIOTHERAPY
MANAGEMENT ACUTE STAGE
Positioning strategies: In supine

lying, in side lying on normal side

and in side lying on affected side
Prevent pressure sores by proper

positioning(frequent turning) and

relieve pressure points by padding
and cushioning (Darcy, 2007).
 PHYSIOTHERAPY
MANAGEMENT ACUTE STAGE
Prevent from deconditioning:
Early mobilization in the bed
Pelvic bridging exercise
Improve respiratory and circulatory

function:
Breathing exercise
Chest expansion exercise
Passive exercise for the ankle and toe
 PHYSIOTHERAPY
INTERVENTION
Position affected side towards door or

main part of the room

Weight bearing exercise
Electrical stimulation to the affected

muscles
Soft tissue, joint mobilization and

range of motion exercise

 PHYSIOTHERAPY
INTERVENTION
Stretching program and splinting
Strengthening exercises to the

affected muscles
Cycling and treadmill training

(Darcy, 2007)
CASE REPORT
 BIO DATA
Name : A. P
Age: 63years
Sex : Male
Occupation : Engineer
Address : Umualuku Ehime Mbano
Religion : Christianity
Nationality : Nigerian
 COMPLAINT
Inabilityto make use of the left
upper and lower limbs.
 HISTORY SOURCE
Patient’s relative
 HISTORY
On the 29 of May 2018,
th

patient’s relation realized that he

could not use the left upper and
lower limbs and he could not talk
properly.
Patient had malaria and typhoid

prior to this incident.

 HISTORY CONT’D
Patient was rushed to a peripheral
hospital where his blood pressure
was stabilized.
He was taken to military hospital

Port Harcourt where he was

managed for 1/12.
 HISTORY CONT’D
After patient was deemed
medically fit for transfer, he was
then referred to Federal Medical
Centre, Owerri, after relation
decided to ask for the referral
since they live in Owerri.
PmHx: malaria and typhoid

PsHx: Nil

DgHx: vitamin C and neurovite

FSHx: Patient is married with 5
children (2 boys and 3 girls),
patient drinks borehole water,
uses water closet, no longer
smokes, takes alcohol.
 O/E
An elderly man was wheeled
into the assessment cubicle. He
was cheerful, afebrile to touch,
anicteric, acyanosed, well
oriented in time, place and
person (TPP) and not in any
obvious respiratory or painful
distress.
 VITAL SIGNS
Blood pressure: 120/70mmHg
Pulse rate: 77b/m
Respiratory rate: 22c/m
SEGMENTAL ASSESSMENT
Head and Neck:
Good neck control
Resolving left facial asymmetry
Thorax and Abdomen: weak
musculature
Upper limbs:
Right : NAD
Left:
GMP: 0/5
Muscle tone: Normal
Sensation (deep and light): Intact
 Upper limb:
PROM
Joint Left
Shoulder Full and painful in all planes
of movements
Elbow Full and pain free in all
planes of movements except
elbow flexion
Wrist Full and pain free in all
planes of movements except
Lower limbs:
Right : NAD
Left:
GMP: 0/5
Muscle tone: Normal
Sensation (deep and light): Intact
 Lower limb:
PROM
Joint Left
Hip Full and pain free in all
planes of movements except
hip flexion
Knee Full and pain free in all
planes of movements
Ankle Full and pain free in all
planes of movements except
 FUNCTIONAL ABILITIES AND DISABILITIES

Patient can bridge but pulls towards

weak side (left)
Patient cannot sit without support
Patient cannot stand
Patient cannot walk
 IMPRESSION
Left-sided hemiplegia secondary
to right hemispheric CVA
 AIMS (Short term)
To maintain physiological
properties of the muscles
To maintain muscle tone
To prevent spasticity
To improve muscle strength
To relieve pain
To relearn sitting, standing from

sitting & walking

 MEANS
IRR to the left upper and lower limbs
Electrical muscle stimulation to the

muscles of the left upper and lower

limbs
Passive mobilisation to the left upper

and lower limbs

STM with Zetgel to the left upper and

lower limbs
 MEANS
Tactile stimulation to the affected
limbs
Curl up exercises
Trunk stabilisation exercises

(Bridging)
Strengthening exs to the left UL and

LL
 MEANS
Weight bearing exercise to the left
upper and lower limbs
Reciprocal pulley
Ankle pump
Positioning
Home programme
 BARTHEL INDEX SCORE
Score
Bowel 2
Bladder 2
Grooming 0
Toilet use 1
Feeding 2
Transfer 2
Mobility 3
Dressing 1
Stairs 1
Bathing 0
 REVIEW
After 9 visits, standing from sitting
without support was attempted and
patient succeeded 80% of the time and
weight bearing on left LL continued.
On next visit, patient could stand from

sitting with support. Standing

reeducation commenced.
 REVIEW
Left UL GMP: 0/5
Spasticity present
Plan:
Cryotherapy for the Left UL
Splinth with Spastic Breaker (Left UL)
Sustained stretch
EMS to the wrist extensors
Auto-assisted and free active exercises

for the Left SHD muscles.

 REVIEW
After 3 more visits, patient could stand
without support and gait reeducation on
parallel bars commenced.
Cont. mgt as outlined above, include

squatting with wall bar

Ergometry.
Stair climbing
 REVIEW
Patient can now sit without support
Patient can stand and walk with walking

aid
Total index score: 70/100 (Moderate

dependency)
Note: 0 to 20 (Total dependency)
21 to 60 (Severe dependency)
61 to 90 ( Moderate dependency)
91 to 99 ( Slight dependency)
 REVIEW
GMP: Left LL: 4/5, Left UL: 2/5
Spasticity still present on Left Biceps

FOLLOW-UP
Patient still comes for treatment till
date.
 REFERENCES
 L. R. (2007). Brain ischemia. Retrieved March 12, 2021,
from https://www.sciencedirect.com/topics/medicine-and-
dentistry/brain- ischemia#:~:text=Cerebral
%20ischemia%20occurs%20w hen%20blood%20flow%20to
%20the,oxygen%20and%20 glucose,%20and%20causes
%20an%20infarction/ischemic% 20stroke
 Darcy A. Umphred (2007). Neurological Rehabilitation 5th
edition.
 Reeves M. J, Bushnell C. D, Howard G, Gargano J.W, Duncan P.
W, Lynch G, et al (2008). Sex differences in stroke:
epidemiology, clinical presentation, medical care, and
outcomes. Lancet Neurology ;7:915–926.
 www.Physopedia.com/stroke/ 8th March, 2021; 4:00pm