Case presentation

Stroke
Presented by:
Verma suman (final year)
 Demographic data

Name: Mohanbhai vanjara

Age: 52 years
Gender : Male
Address: Gota housing
Contact no. : 7436064166
Occupation: Driver
Chief complain: Patient
unable to move left upper limb
and slightly move lower limb.
* difficulty in ADL activities.
unable to grip objects, chappal
slipping, during walking feel
like to going fall, dizziness.
Balance problems
D.O.A: 14/5/2019
D.O.D : 17/5/2019
Refferd by : self
Hand dominance: left
 History

Past history: 2 years ago,

Mohanbhai had awoken in the
morning. He not able to move
their left hand and leg and loss
of sensation.
 - Then, he was admitted in
shrey hospital on 14/05/2019
with complain of left arm and
leg sensation loss & slurred
speech.
- patient treated with IV Fluids
& supportive treatment.
_ patient was gradually
improved.
 Present history
- Now, patient's condition is
better. His all body part
sensation is normal.
- able to stand & sit.
- able to walk with
Supporting stick.
- able to talk.
• Mode of onset : 14/5/2019
• Duration of illness: 2years
• Present condition: improved
•
• Nature of injury: stroke or
cardiovascular accident
 Personal past history:
Alcohol :everday
Vimal :3 to 4 times
Bidi :1- 3time
Present personal history:
Now, patient has stopped
taking this(alcohol, vimal) all.
Family history: not
significant
Marital history: wife
supporting
Socioeconomic history: No.
Of family member : 5
- Economic status of his
house is good. His both son
is earning.
Psychological history :
Anxiety,
Depression
Educational history: patient is
not educated. But his family
is educated so easily
understand the nature and
importance of the treatment.
Past medication history
 Present drug history

Telmiride 40 - for hypertension

 Environmental history
Location: In lane uneven
surface
Type of home: single family
home
Stairs: ground floor to 1st floor
• No. of steps : 15
• Railing present on right side.
• 1st floor only 1room &
kitchen.
• Two windows in room.
• Patient able to close and
open the doors &windows.
• In bathroom indian toilet.
 Pain history
Site : shoulder joint
Hip joint
Duration: during walking
Aggravating factor: in
shoulder ( pain start while
Shoulder range up to 110°).
In hip (pain during walking).

Relieving factor: rest no

activities.
Body chart for
pain location
 Observation

Mode of ambulation:dependent
Use walking aids Quaripod
stick
Type of gait
• Abnormal
• Circumduction gait
• Insufficient pelvic rotation
during swing phase.
• Unstable step
• During walking pelvis drop
on right side.
Built: Mesomorphic
Type of respiration: Abdomino
thoracic
Pattern of respiration:
Symmetrical
Deformity : Claw toe, winging of
scapula(left side),FFD both knee
Posture
In standing Anterior view
• Left shoulder depressed
• Shoulder is adducted
• Forearm pronated
• Wrist & finger flexed
• Hip abducted & externally rot.
• Externally rotated
• Ankle eversion
• In posterior view
• Shoulder is depressed (left
side)
• Scapular asymmetrical
• Ankle eversion
In lateral view
• Slight forward bending
• Round shoulder
In supine
• Right shoulder elevated
• Left shoulder abducted
• Elbow flexed
• Forearm supinated
• Wrist and finger flexed
• Hip external rotated
• Knee slightly flexed
Attitude of limb
Upper extremity
• Shoulder adducted
• Elbow flexed
• Forearm pronated
• Wrist and finger flexed
Lower extremity
• Hip extended and externally
rotated
• Knee extension
• Ankle eversion
• Toes flexed
 Palpation
Tenderness: Not present

Temperature : Normal

Tone : stiffness and hypertonic

 Examination
• Heart rate:90
• Respiratory rate:18
• Blood pressure:diastolic-124
• Systolic:70
• Temperature: Normal
Examination of consciousness
(Glassgow coma scale)

Best response: 15
Examination of higher mental
Function
Behaviour: Normal
Cognitive function
• Patient is alert and

oriented to time, place&

person.
• All type of memory function
is normal.
• Immediate memory
• Recent memory
• Remote memory
• Verbal memory
• Visual memory
• Intelligence: patient's
ability to solve the
mathematical problem.
• Speech and language:
• Apraxia: purposeful
movement is not
performed by the patient.
• Perception: Unilateral body
neglect.
• Eye contact: maintaining
• Dysphagia: difficulty in
swallowing.

Mini mental state examination

(MMSE)
Mohanbhai vanjara 7/8/2021

5
5
3

3
2
1
3
0
0

27
 Cranial nerve examination
1st Olfactory nerve

Patient can appreciate and

identify the odorous.
2nd optic nerve
Patient normal visual acuity is
affected.
3rd, 4th,6th (Occulomotor,
trochlear, abducent)
• Occular movements : Normal
• Command movements:
Normal
• Follow movements: Normal
Examination of pupils :
1) both side pupils sizes is
normal
2) shape of pupil is normal
3) pupillary reflexes normal
A) Direct light reflex
• Pupil dilate
5th Trigeminal nerve
Testing motor functions:
1) Temporalis & masseter
muscle is normal.
2) Pterygoids: normal
3) Tensor tympani: normal
Testing sensory functions
General sensation:The area of
the face and neck
• Fine touch : normal
• Crude touch:normal
• Temperature:normal
• Pain: normal
• Pressure: normal
Test sensation: normal
Reflexes
1) Corneal reflex : normal
2) Conjuctival: normal
7th Facial nerve
Occipitofrontalis, procerus,
Orbicularis oculi, Buccinator,
Orbicularis oris, Platysma,
stapedius this all muscle
function is normal.
Levator labii superioris
alequae nasil: Angle of mouth
 deviated right side.
• General sensation: taste
sensation anterior 2/3rd of
the tongue is normal.
• Reflexes: corneal and
conjuctival reflexe is normal.
8th vestibulocochlear nerve
Weber test: positive
Rinnel test: positive
9th Glossopharengeal nerve
Taste sensation normal in
posterior 1/3rd of the tongue.
Palatal reflex: Normal
10th Vagus nerve
Soft palate movement is
normal.
Palatal reflex :Normal
11th spinal accessory nerve
• Sternocleido mastoid
muscle: Normal
• Trapezius muscle: Affected
left side..
• Drooping of shoulder ( left
side)
12th cranial nerve
• His tongue is normal not
wasting, not fasiculation.
• Patient able to move their
tongue from side to side.
 Assess of motor system

• Loss of selective movement

• Presence of basic limb
synergy
• In left side Upper limb
flexion synergy.
• Scapular retraction
• Shoulder abduction
• External rotation
• Elbow flexion
• Forearm pronation
• Wrist and finger flexion
• In left lower limb Extensor
synergy
• Hip extension & abduction
• Hip external rotation
• Knee extension
• Ankle eversion
• Presence of spasticity in
left upper limb muscles.
• Spasticity in shoulder
adductors.
• Pronator flexors
• Elbow flexors
• Wrist and finger flexors

• Spasticity in left lower limb

• Hip adductors and external
rotators.
• Ankle planter flexors
 Range of motion
Movement AROM PROM
Left side Left side
Shoulder
Flexion
0° 0° to 110°
Shoulder
extension
0° 110° to 0°
Shoulder
Abduction
0° to 30° 0° to 110°
Shoulder 0° 0° to
Abduction
105°
Shoulder 0° to 20° 0° to 90°
External rot..
Shoulder 0° 0° to 60°
Internal rot..
Elbow 0° to 150° 0° to 150°
Flexion
Elbow 0° to 150°
Extension 0°
Forearm 0° 0° to 90°
Forearm 0° 0° to 90°
Supination
Wrist flexion 0°to 50° 0° to 90°
Wrist 0° 0° to 70°
extension
Ulnar devi. 0° 0° to 25°
Radial devi. 0° 0° to 20°
Finger flexion 0° to 30° 0° to 90°
Hip flexion 0° to 40° 0° to 70°
Hip extension 40° to 0° 70° to 0°
Hip 0° to 35° 0° to 55°
abduction
Hip 35° to 0° 55° to 0°
adduction
Hip internal 0° 0° to 5°
rot..
Hip external 0 ° to 20° 0° to 90=
rot..
Knee 0° to 120° 0°to 140°
flexion

Knee 120° to 0° 140°to 0°

extension

Ankle planter 0° to 20° 0° to 35°

flexion

Ankle dorsi 0° 0°to 20°

Flexion
 MMT

• Mmt is not taken in this

patient because of
involuntary movement
occur while performing
purposeful movement.
 Reflexes
a)Deep tendon Grade
reflex
1) jaw jerk ( C5) Normal
2) biceps (C5, C6) 3+ brisk
3) 3+ brisk
brachioradialisC5C6
4) Triceps (C6, C7) 3+ brisk
5) knee jerk L3,L4, 3+ brisk
L5
b) superficial
reflex Grade
1) Cornial reflex Normal

2) Conjuctival reflex Normal

3) Abdominal reflex Normal

4)Babinski sign Positive

 Pathological reflexes
1) Chaddocks sign : +ve
2) Oppnehium sign: -ve
3) Hoffman reflex : -ve
4) Rossolimo reflex : +ve
Glabellar reflex +ve
 Muscle tightness
Right side Left side
Calf muscle Biceps
Hamstring Forearm flexor
Calf muscle
Hamstring
Hip adductors
 Sensory examination
1)superficial Right Left
sensation
Side Side
a) pain Normal Normal

b) Touch Normal Abnormal

c) Normal Normal
Temperatur
2) Deep Right Left
Sensation Side Side
Proprioception Normal Normal

Vibration Normal Affected

Kinesthesia Normal Normal

3) cortical Right side Left side
Sensation
a) Tactile Normal Affected
localization
b) Two point Normal Affected
discriminatio
n
Normal Normal
Stereognosis
graphesthesia Normal Affected

e) Barognosis Normal Normal

Dermatomes
• Sensory impairment at the
palmer and dorsal aspect of
the left hand.
• C5,C6,C7 and T1 dermatomes
is affected.
• C1 to C4, T2 to T12, L1 to L5 &
S1 toS4 dermatomes normal.
 Vibration

• The patient not sensed the

vibration on the bony
malleolus of the ankle.
 Muscle Girth
Muscle Right side Left side
1) Biceps 27cm 27cm
2) Deltoid 30cm 30cm
3) Forearm 25cm 25cm
Mucle
4)Quadriceps 40cm 40cm
5) Gastrox 34cm 34cm
 LLD
Pelvic squaring

Umbilicus to ASIS Rt-37cm

Lt-37cm
Both ASIS in same level.
• Apparent LLD
Umbilicus to medial malleolus
Rt- 99 cm
Lt- 99cm
True LLD
ASIS to medial malleolus
Rt- 96cm
Lt- 96cm
 Co- ordination & balance
Equilibrium test Grade
1) standing feet together 3

2)standing one foot in 4

Front of other
3)walking on a straight line 2
4)walking sideways 2
5) Stand on one leg 3
6) Marching 2
Non Eqllibrium test Grade
1) Finger to nose 0
2) Finger to therapist's 0
finger
0
3) Finger to finger
4) Finger opposition 0
5) Mass grasp 0
6) pronation supination 0
7) Rebound test 2
8) Tapping (hand) 0
9) Tapping (foot) 4
10)pointing & pastpointing
0
11) alternate heel to knee,
knee to heel 3
12) Toe to examiners
finger 4
13) Heel on shin 2
14) Drawing circle 1
15) Fixation or position
holding 2
Romberg's test
+ve
Pointing and past
pointing test
• Time up and go test: patient takes
>12 second to complete the TUG is
at risk for falling.
• patient takes 26sec to complete
TUG.

• Functional reach test: starting

point : 77cm to final point :
87cm.
Multi direction reach test.
• Patient this test perfomed
by right hand because left
hand is affected and he
unable to raise left hand.
Multi direction reach test
• Forward reach test: starting
point 77cm to end point
89cm.
• Backward reach test:
starting point 77cm to
74cm.
• Lateral reach to right :
starting point 77cm to 85cm.
1) Time up and go test:
2) Functional reach test:
• In berg balance scale:
patient's total score 35 out
of 56.
• The score is 35 that
indicates medium risk of
falling.
 Bowel and bladder
examination
Bowel and bladder function
is normal.
 Gait examination
• Mode of ambulation:
Dependent
• Use walking aid : quadripod
stick
• Measurement of quaripod

stick
Wrist to floor: 83cm
Type of gait :Circumdunction
gait Or hemiplegic gait
• Step length : 63cm
• Stride length: 63cm
• Width length: 30cm
• Toe out angle: 22cm
• Cadence: 45 steps per 1
minute
• Insufficient Pelvic rotation
during swing phase.
• During swing phase pelvis
drop on right side.
• Heel strike phase absent
on left side(affected side).
• Abnormal and large step
length.
 Exercise tolerance test
6 minute walk test: 6MWT
Before heart rate: 88/1min
• 6MWT after HR:105/1min
• Patient 6MWT is
completed with external
aids supportive stick is
used.
• Patient covered a distance
 of 30 meters.
• During walking take rest
time for 1 minute.
• 6MWT after taken borg
scale score : 7
 ADL assessment
FIM scale: score 99/126
Barthel index scale: score
60/100
Katz index of independence
Of activities in daily living :
Score 3/6
77 7
63
1 7
2 6
2
6 7
7
7
7
34
6
6
6
6
6
65 99
5
0
0
0

10
10

10

15
5
• Trunk impairment scale
TIS score 11out of 23.
• Upper extremity functional
index scale.
Score: 18 out of 80.
• Lower extremity functional
scale
Score : 46 out of 80.
18
 √
√
√
√

46
Fugl meyer scale
For Stroke assessment
scale
1) Glassgow coma scale
2) mini mental state
examination scale
3) berg balance scale
4) FIM scale
5) Barthel index scale
6) katz index of
Independence in daily living
life.
7) Trunk impairment scale
8) Forward reach test
9) Time up and go test
10) 6 minute walk test
11) borg scale
12) upper extremity
functional index scale
13) lower extremity
functional scale
14) Fugl Meyer scale
 Investigation
• MRI of brain
• Angiography
Diagnosis: Left hemiplegia
Provisional diagnosis: Right
stroke &
hypertension
 ICIDH2 Scale
Part 1: Functioning and
Disability
a) Body functions and
structures - body level
b)Activities (individuals
levellevel) and participation
Part 2:Contexual Factors
a) Environmental Factors
b) personal Factors
Body structures (Anatomical)
• Brain, • Joint,
arteries of organs,
Normal muscles
brain
Primary secondary
Abnormal • Anterior • Muscle
•
Structure cerebellar Artery
affected artery and veins
Hemiplegic • Heart
patient
 Body functions (physiological)
Related to Secondary
brain and structures
artery all such range
Normal functions of motion,
pain etc
Primary Secondary
Abnormal • Aletered • Loss of
functions sensation range of
motion
Body functions (physiological)
• Visual • Loss of
neglect muscle
• Pain(hip, legth
Abnormal shoulder) tightness.
• Muscle • Loss of
Functions weakness of movement
upper or mobility.
&lower limb.
• Hypertonic
• Hyperflexia
• Difficulty in
Body functions (physiological)
• Swallowing • Edema in
• Abnormal hand
synergy • Impaired
• Alteref postural
Abnormal motor control &
Functions functions balance.
• Altered
perception
• Poor
emotional
status
• Activities ( individual level)
1) Learning & applying
knowledge : memory for daily
living activities is normal.
2) self care : brushing, dressing,
grooming, feeding or eating,
toileting activity due to lack of
function , this activity is affected.
3) Communication: with
guests, family member is
normal.
4) Mobility: Difficulties in
transfer activities from one
room to another, from sofa to
floor, getting in bed & out of
bed, stair climbing .
Sitting, standing prolong,
laying supine snd prone due to
weakness of limbs & trunk.
5) Domestic life: patient able
to opening & closing doors,
transfer object to self or bring
it down, pulling & pushing
objects.
7) Interpersonal relationship:
communication, helping etc
will be normal.
Participation restriction
•
• Social gathering- marriage,
party, shopping
• Participation in work
• Vehicle driving, sports
• Participation for job, visiting
multiplex or mall, gardens,
temple.
• These all participations will
be restricted.
Part 2 Contextual factors:
Environmental factors:
• Facilitator Barriers
Railing, Stair, 2nd
Home height of sofa, floor pts lives,
distance of indian toilet
house to clinic
2km

Social Earning of
family, pt's No any
fctors life (married) barrior
 Facilitators Barriers
• Socioecono-
mic status is
good
• behavior of No any barriot
members
Social helpful.
• Help in
factors exercise at
home.
• Help in
selfcare
• Relationship
is good.
 B) personal factors:
Facilitators Barriers
• Condition Hypertension
improved
• Deal with
• Patient stress &
Domain cooperatio depression
n is good • Job loss
• Education
lower
• domain
hand affect
 Problem list
1) gait abnormalities
2) Imbalance
3) Impaired motor function
- Tonal abnormalities
- Muscle weakness
- Synergistic pattern
- Tightness
4) Increase stiffness of
muscles.
5) Difficulty with swallowing.
6) Postural abnormalities
7) Functional disability
8) Incordination
 Reference

• Neuro & neurosurgery

illustration - Lindsay
• Pocketbook of neurology
of physiotherapy: Sheila
lennon
• Physical rehabilitation:
O'Sullivan