PPC tut 11b

Case Overview: Kate's History and Presentation

• History of Presenting Illness (HPI): Kate's history begins with her initial presentation to a regional hospital and follows her journey through a tertiary medical center.

• Glasgow Coma Scale (GCS): This scale measures a patient's level of alertness and responsiveness.

  • Kate's initial GCS was $14$ (near-full alertness).

  • Her GCS later dipped to $9$ at the regional hospital, indicating a significant decrease in responsiveness.

• CT Scan Findings: The scan revealed a hemorrhagic stroke (white bleed) in the left temporal-parietal lobe, specifically a subarachnoid hemorrhage.

• Neurological Impact: Based on the scan, it was expected that Kate would exhibit right-sided impairments, as the left side of the brain controls the right side of the body.

Medical and Surgical Interventions

• External Ventricular Drain (EVD): This device was inserted at the regional hospital to monitor and manage intracranial pressure by draining excess cerebrospinal fluid from the brain's ventricles.

• Surgical Procedures Definitional Differences:

  • Craniotomy: Surgical removal of a portion of the skull to access the brain (e.g., for clipping an aneurysm or removing a blood clot).

  • Craniectomy: The permanent or temporary removal of a portion of the skull to allow the brain room to swell (common in Traumatic Brain Injury, TBI).

  • Cranioplasty: A later surgical procedure where the original bone or a synthetic plate is put back to repair the skull opening.

• Kate's Surgery: She underwent a craniotomy at a tertiary hospital to clip the aneurysm and remove the blood clot responsible for the bleed.

Clinical Findings: Impairments

• Cognitive and Communication Impairments (Non-motor):

  • Aphasia: Kate presents with both receptive and expressive aphasia.

  • Receptive Aphasia: Difficulty understanding language and the meaning of words. A patient might confuse words (e.g., saying "purple" when they mean something else).

  • Expressive Aphasia: Difficulty producing language or finding the right words. In extreme cases, patients may only have one or two words in their vocabulary (e.g., "yes" or "no").

  • Word-Finding Difficulties: Noted specifically in Kate's case; she may struggle to retrieve specific terms during conversation.

  • Short-Term Memory Problems: These issues affect her ability to retain information and follow exercise prescriptions without adaptation.

• Motor Impairments:

  • Strength: Manual Muscle Testing (MMT) shows Kate is improving, with scores of approximately $4/5$ on the right side. Her impairments are strictly right-sided.

  • Spasticity: Specifically found in the right ankle plantar flexors.

  • Contracture: Clinically noted as a $5^{\circ}$ contracture at the ankle.

  • Coordination and Proprioception: Impairments noted in the right lower and upper limbs, affecting balance and fine motor control.

Interpretation of Tardieu Findings

• Velocities (V):

  • $V1$ (Velocity 1): Moving the limb at a slow speed. This is used to test for contracture. If a catch occurs during a slow stretch, it indicates a structural contracture.

  • $V3$ (Velocity 3): Moving the limb as fast as possible. This is used to elicit an overexcited stretch reflex (spasticity).

• Kate's Results:

  • At $V1$, a catch was found at $5^{\circ}$, indicating a contracture of the plantar flexors.

  • At $V3$, fatigable clonus (a beating movement) was found at $2^{\circ}$, followed by an additional $3^{\circ}$ of range. This confirms the presence of spasticity alongside the contracture.

Analysis of Standing and Reaching (Group 1)

• Missing Components/Adaptive Strategies:

  • Kate tends to shift her weight heavily onto her unaffected (left) side.

  • When reaching toward her affected side, she shifts her hips rather than moving through the required segments.

  • Lack of head movement in the direction of the reach.

• Intervention Plan:

  • Exercise: Target weight shifting while standing.

  • Setup: Wall behind for safety and a table for support on the side.

  • Action: Transition from simple weight shifts to reaching for an object (e.g., hand sanitizer) while leaning toward the table.

  • Progressions: Reaching further, removing support, or increasing speed.

• Feedback: Use very simple, succinct language (e.g., "shift," "tap") due to aphasia. Mirroring the movement can also be helpful.

Analysis of Sit to Stand (Group 2)

• Missing Components/Adaptive Strategies:

  • Foot Alignment: Right foot is placed too far forward (tandem stance).

  • Momentum: Use of excessive trunk momentum to swing the body up due to lack of control.

  • Lower Limb Alignment: Right leg externally rotates, and the knee falls into valgus (collapses inward) during the movement.

  • Extension Phase: Lack of full hip and knee extension at the top; sometimes she hyperextends the knee once standing.

• Intervention Plan:

  • Exercise: Heel slides or knee flexion training using a skateboard or slide sheet while seated.

  • Rationale: Training the ability to bring the foot behind the knee (knee flexion) to ensure better weight bearing and less reliance on momentum.

• Outcome Measures: Timed Up and Go ($TUG$), $30\,second$ Sit to Stand test, or a timed $5$ Repetition Sit to Stand (preferred for sensitivity to change).

Analysis of Walking (Group 3)

• Gait Deficits:

  • Stance Phase: Reduced ankle dorsiflexion, reduced hip/knee extension, and reduced plantarflexion.

  • Swing Phase: Reduced knee and hip flexion; toes fail to clear the floor properly.

  • General: Slow walking speed, increased base of support, and lack of bilateral heel strike.

• Intervention Plan:

  • Exercise: Knee control during early to mid-stance.

  • Setup: Wall for support, placing the unaffected leg on a chair to force weight-bearing/control onto the affected leg.

  • Action: Small, controlled knee bends (knee yield) to avoid hyperextension.

• Dosing: $20$ repetitions, measuring success by the number of reps completed with good quality (e.g., $17/20$).

Analysis of Upper Limb (Group 4)

• Deficits in Grasping and Reaching:

  • Adaptive Strategies: Excessive trunk flexion (leaning forward), shoulder elevation, abduction, and internal rotation to compensate for lack of shoulder flexion.

  • Fine Motor: Excessive preshaping of fingers; inability to isolate finger movements (scooping things with the whole hand).

  • Accuracy: Poor accuracy when placing objects; hitting/knocking over targets.

• Intervention Plan:

  • Exercise: Reaching to a target while restraining the trunk.

  • Setup: Restraining the trunk against the chair back to prevent leaning, forcing the use of shoulder flexion and protraction.

• Outcome Measures: Nine-Hole Peg Test, Motor Assessment Scale ($MAS$), or standardized coordination tests.

Clinical Reasoning and Training Principles

• Communication Strategies: For patients with aphasia, use "Knowledge of Results" ($KR$) (e.g., "You did ten") rather than complex "Knowledge of Performance" ($KP$) (e.g., detailed physiological descriptions). Keep instructions to three words instead of five.

• Task-Specific Training: Exercises should resemble the final goal. For example, sitting to stand work is more effective when done from a chair rather than in long-sitting on a bed.

• Progression and Regression:

  • Progression: Increase speed, increase height, remove manual support, or increase repetitions.

  • Regression: Increase manual guidance, reduce range of motion, or add more environmental stability.

Questions & Discussion

• Question: Does everyone understand the importance of the Glasgow Coma Scale ($GCS$)?

• Response: It measures alertness and responsiveness; lower numbers indicate less responsiveness.

• Question: What is the difference between craniectomy, craniotomy, and cranioplasty?

• Response: Craniotomy is removal to access the brain; craniectomy is removal to allow for swelling; cranioplasty is returning the bone or a plate later.

• Question: Is there contracture at the ankle for Kate?

• Response: Yes, a catch at $V1$ shows a $5^{\circ}$ contracture.

• Question: Why choose timed Sit to Stand over a $30\,second$ count?

• Response: Timed tests (e.g., $5$ reps) avoid "ceiling effects" and are more sensitive to small improvements in seconds and decimal points.

• Question: Would you use a mirror for her training?

• Response: Yes, it can work well for some stroke patients to provide visual feedback, though it can be confusing for others.