REHABILITATION OF POST STROKE INFARCT CHRONIC PHASE DUE TO PARTIAL ANTERIOR CIRCULATION SYNDROMES

REHABILITATION OF INTRACEREBRAL HAEMORRHAGE STROKE SUBACUTE PHASEPresented By:Erik Setiawan, dr

Supervised by :Novitri, dr, Sp.KFRTertianto Prabowo, dr, Sp.KFR

1st CASE PRESENTATION Friday, 2 May 2014

1INTRODUCTION2WHO: rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than of vascular originDEFINITIONBased on WHO, definition for stroke is...3Risk FactorsBrain Vascularisation

5

Brain VascularisationBrain Vascularisation

The principal blood supply for the brain comes from two arterial systems :the anterior circulation, fed by the internal carotid arteries, and the posterior circulation, which receives blood from the vertebral arteries. The vertebral arteries join at the junction of the medulla and pons (or pontomedullary junction) to form the basilar artery, which lies unpaired along the midline. The anterior circulation is also called the carotid circulation, and the posterior circulation, the vertebral-basilar circulation. 5

The circle of WillisThe anterior and posterior arterial systems connect at several locations, by the communicating arteries. The posterior communicating artery allows blood to flow between the middle and posterior cerebral arteries, and the anterior communicating artery allows blood to flow between the anterior cerebral arteries on both sides of the cerebral hemispheres.5

The anterior cerebral artery supplies the dorsal and medial portions of the frontal and parietal lobes. The middle cerebral artery supplies blood to the lateral convexity of the cortex. The posterior cerebral artery supplies the occipital lobe and portions of the medial and inferior temporal lobes.

7Based on clinical features and temporal profile:Improving Stroke ( RIND = Reversible Ischemic Neurologic Deficit )Worsening Stroke ( SIE = Stroke in Evolution )Stable Stroke ( Completed Stroke)CLASSIFICATION1. Improving Stroke ( RIND = Reversible Ischemic Neurologic Deficit), i.e., when the neurologic deficit is totally cured in the period of 24 hours to 3 weeks.2. Worsening Stroke ( SIE = Stroke in Evolution ), i.e., when the neurologic deficit becomes progressive severe, both quantitatively and qualitatively, and both from anamnesis and follow up. 3. Stable Stroke ( Completed Stroke ), when neurological deficit goes on completely with a very small changes in a given period.

8And classification based on intracranial pathological features9Intracranial Hemorrhage10% of all cases of strokeMost common cause: hypertensionSite of rupture : deep perforating cerebral arteries, but unlike lacunar strokes -> doesnt obey anatomic distribution of a vessel, but dissects through tissue planesRupture of microaneurysms (Charcot-Bouchard aneurysms) -> pockets of extravasated blood/ pseudoaneurysms, -> previous microscopic ruptures within the vascular wall -> develop in hypertensive ptsMajority : putamen or thalamus, 10% : cerebellumClinical onset : dramatic -> severe headache, rapidly progressive neurologic deficits.Brain displacement -> transtentorial herniation & death (first few days)Acute mortality > infarction, Survive : rapid neurologic recovery (first 2-3 months) > infarctionMotor Control and StrengthMotor Coordination and balanceSpasticitySensation

CLINICAL SYMPTOMSMotor Control and StrengthStroke hemiplegia; Synergy patterns, mass contraction of multiple muscle groups -> individual voluntary movementMotor Coordination and balanceTrunk control and stability, coordination of movement patterns, and balance all involve complex extrapyramidal systemsSpasticitySpasticity is a velocity-dependent increase in resistance to muscle stretch that develops after an upper motor neuron injury within the central nervous system. Loss of upper motor neuron control causes disinhibited alpha and gamma motor neuron activity and heightened sensitivity to class 1a and 2 muscle spindle afferents. Consequently, monosynaptic and multisynaptic spinal reflexes become hyperactive.Often, as voluntary motor activity returns, a reduction in tone and reflex response is noted, but if recovery is incomplete, spasticity usually remainsSensationLoss of sensation after stroke can have a significant effect on joint and skin protection, balance, coordination, and motor control.Pain and temperature sensation are relayed centrally by fibers that enter the spinothalamic tract from the contralateral dorsal root ganglion and ascend to the ventral posterior lateral nucleus of the thalamus.Sensory fibers for joint proprioception and stereognosis ascend ipsilaterally from the dorsal root ganglion within the dorsal column, and cross to the contralateral side within the lower medulla after synapsing with the nucleus gracilis and cuneatus. The fibers then ascend in the medial lemniscus to the ventral posterior lateral thalamus. The ventral posterior lateral thalamus relays sensory information to the primary sensory cortex, located posterior to the central sulcus in the postcentral gyrusAlthough injury to the sensory pathways typically causes hypoesthesia or reduced sensation, patients with lesions in the thalamus or spinothalamic tract occasionally experience severe pain that can interfere with functional recovery and rehabilitative care11Acute Phase (several days to two weeks post stroke).Subacute Phase (Recovery Phase) : (2 weeks to 6 months)Chronic Phase (Advanced Phase): (>6 months).

TIME COURSE OF THE DISEASEAcute Phase: characterized with hemodynamic and neurologic conditions that have not been stabile (several days to two weeks post stroke).Subacute Phase (Recovery Phase) : characterized with recovery and reorganization of nerve system (2 weeks to 6 months), important to recover functionally.Chronic Phase (Advanced Phase): characterized with accomplishment of nerve system reorganization. The next recovery that is still possible to continue is a functional recovery process based on adaptation and compensation against the existing disability (>6 months).

12Brunnstrom Stages of Motor RecoveryREHABILITATION OF STROKEStageCharacteristicsStage 1No activation of the limbStage 2Spasticity appears, and weak basic flexor and extensor synergies are presentStage 3Spasticity is prominent; the patient voluntarily moves the limb, but muscle activation is all within the synergy patternsStage 4The patient begins to activate muscles selectively outside the flexor and extensor synergiesStage 5Spasticity decreases; most muscle activation is selective and independent from the limb synergiesStage 6Isolated movements are performed in a smooth, phasic, well-coordinated mannerbasic strengthening, range of motion exercises, balance training, and postural control.Pattern of motor recovery after stroke: at onset, the arm is more involved than the leg but motor recovery in the arm is less than the leg. The prognosis for return of useful hand function is poor when there is complete arm paralysis at onset or no measurable grasp strength by 4 weeks.Motor recovery evaluation including an evaluation of tone, strength, coordination and balance.Stage I day 2-3 in patient of stroke from infarct (day-14 in hemorrhage.) The main goal of rehabilitation program nowadays is to prevent the complicated immobilization and prolonged bed rest. PROM AAROM. Bed mobilization.Stage II main problem : spasticity. Intensive mobilization, hand function exercise in order able to do daily activitiesStage III- IV Synergic pattern is broken into more coordinated movement as wished or orderedStage V VI the exercise activities are more focused on skill exercises and maintaining self-care13SpasticityDaily stretching, especially of the shoulder, wrist, fingers, hip, and ankles.Depression and Psychosocial ConsiderationSadness, grief, anxiety, depression, despair, anger, frustration, and confusionDepression : 30-60% poststroke -> limit participation & outcome by inhibiting motivationShoulder SubluxationCareful positioning of the shoulder serves to minimize subluxation and later contractures

DepressionThe new onset and persistence of disability can give rise to a variety of psychologic reactions in patients who have sustained a stroke, including sadness, grief, anxiety, depression, despair, anger, frustration, and confusion.Most pts: combination organic & reactive causes of mood disorders

During the flaccid stage, especially when there is sensory proprioceptive impairment, the cuff muscles (especially the supraspinatus) can be elongated.Early hemiplegic stage the scapula assumes a depressed position -> The lowering of the outer aspect of the scapula changes the angulations of the glenoid fossa causing it to be malaligned for the humeral head. The usual functional scoliosis that occurs in the hemiplegic, that is, leaning toward the hemiplegic side, the scapula is relatively depressed and rotated.Spasticity of the latissimus dorsi depresses the scapula and places traction as well as internal rotation forces upon the humerus. Paresis of the serratus may contribute to scapular angle change. Spasticity of the rhomboids and/or levator scapula, can influence subluxation of the glenohumeral joint by depressing and rotating the scapula downward.Careful positioning of the shoulder serves to minimize subluxation and later contractures as well as possibly promote recovery, while poor positioning may adversely affect symmetry, balance and body imageBender and McKenna (2001) noted that the recommended position for the upper extremities is towards abduction, external rotation and flexion of the shoulder

Shoulder painsubluxation, contractures, complex regional pain syndrome (CRPS), rotator cuff injury, and spastic muscle imbalance of the glenohumeral joint

Shoulder pain & paresis shoulder immobilization neurogenic heterotropic ossification limited A&PROM frozen shoulder.Subscapularis.m in hemiplegic shoulder synergy syndrome shoulder adducted internally rotated position pain& tenderrness over deltoid insertion area in upper outer humerus pain on palpation biceps tendon limited A&PROM.Th/frozen shoulder : spontaneous recoveryROM excPain relief : local ice, heat, ultrasound application, TENS, NSAID/analgesicManipulationSurgery 14Prognosis ad vitam: depends on stroke type, site and size brain lesion, risk factor, comorbid disease or condition and complication.Prognosis ad sanationam: The probability of stroke recurrence is highest in the post acute stroke period. Risk factors for initial stroke also increase the risk of recurrence.

PROGNOSISAd vitam: The 30-day survival for patients with infarction is 85% but for patients with haemorrhage, survival is reported to be 20-52%. Coma following a stroke onset indicates a poor prognosis. volume of the lesion, outcome poorest if lesion more than 10% of intracranial volume. Medical complications such as pulmonary aspiration, pneumonia, malnutrition, vein thromboembolism Ad sanationam: For survival of an initial stroke, the annual risk of a second stroke is approximately 5%, with a 5 year cumulative risk of recurrence of around 25%, although may be high as 42%. RF especially hypertension, heart disease, diabetes mellitus and obstructive sleep apnea15Prognosis ad functionam, depends on:Onset post-strokeMost improvement is noted in the first 6 months, although as many as 5% of patients show continued measurable improvement to 12 months post-onset. Site and size of neuroanatomical lesion.Comorbid diseases or conditions.ComplicationsPatients motivation and family supportAvailability of professional rehabilitation personnel & facilityCase ReportMr Y, 52 years old, right handed, married, moslem, lives in Kiaracondong, Bandung. He was consulted from Neurology Department of Hasan Sadikin Hospital during his hospitalization on 8-20 March 2014 with diagnosis intracerebral hemorrhage stroke left carotid system risk factor hypertension, hypertension stage II, dyslipidemia

Chief Complain:Weakness on his right limb

ANAMNESIS (5 April 2014) 2 months ago (8 March 2014)Sudden right limbs weakness upon waking up from sleep. Cant move right arm & leg at allSlurred speech +, mouth deviation to leftNumbness on right legDidnt lose consciousness, but looked confused for a whileER Pindad Hospital -> BP 260/190Referred to Hasan Sadikin Hospital: ruptured brain blood vessels & hospitalized 14 days3 days hospitalizationAble to move right hip and knee: full ROM, but no against gravity, right elbow: slight movementNo defecation nor urination disturbanceProgram: proper bed positioning, turning/ 2 hr, PROM right limbs, AROM left limbs, oromotor massage (NGT+)

1 week hospitalizationSlurred speech , people understands him betterNGT removed, never choked when drank water nor ate meals with riceCould raise right arm, hand, fingers, foot, toes: not full ROM in against nor eliminated gravityMove right forearm: full ROM in gravity eliminatedMove right hip & knee: full ROM against gravity, yield against resistanceSide lie & sit independently, stand with supportNumbness of right leg decreasedWife helped him ate and changed clothes2 weeks hospitalization -> dischargedProgram: stand by his bed with support & walk around the house with support as toleratedPROM right limbs & AROM left limbs 3x/dShoulder positioning when lying supine, sitting, standing, walkingMedications: Captopril 3x50mg, Amlodipin 1x5mg, Simvastatin 1x10mgControls to Pindad Hospital2 weeks after dischargedSpeech still slurred but people understands him betterSometimes choked when drank water using strawWalk around the house & neighborhood w/o supporting device nor creeping on walls +- 300 m with a couple rest stops. Cant climb& down stairs. Never falls. No numbness on right legCould brush his teeth, ate & drank independently using left hand. Right hand cant helpWife helped him bathing by picking up dipper & washing him. He could handle soap using left hand & occasionally right handGrooming, toileting, dressing independently, mainly using left handRegularly exercises right limbs with wife 3x/dNo pain on movement19History of hypertension (+) 3 years ago, highest BP 180/? & average BP 160/110. No routine control nor take regular medication.History of dyslipidemia (+) known when hospitalized -> Simvastatin 1x10 mg.History of diabetes mellitus, cardiovascular disease, high uric acid was deniedHistory of prior stroke was deniedHistory of hearing loss of left ear (+) 2 years ago. Habit of cleaning ears with stick or match. Never consulted to ENT doctorHistory of past illness20History of Familial DiseasesHistory of familial hypertension, diabetes mellitus, and heart disease is denied

History of Habits:Smoking (+) 2 packs/ day since 1975, stopped after strokeEating fatty food (+)Doing sport or exercise (-)Speech defect on pronouncing /r/ before stroke

Psychosocial History :Graduated from senior high school. Married to second wife and has 3 children (2 from his first wife & 1 from the second). Two older children are married & youngest child is still in junior high school. Lives in mother-in-law house with his 2nd wife, his youngest child, his mother-in-law, his 2nd wifes siblings and their family. House: 2 floors, sized 3x16 meters, 4 bedrooms, & filled with 10 persons. Its facility from TNI-ABRI lent to his late father-in-law & mother-in-law and will be taken away after his mother-in-law pass away. He hopes that he can work again soon to rent another house.He uses squatting toilet and doesnt find difficulty. The toilet has ceramic floor, good ventilation & lighting. The bathroom has water sink, ceramic floor, enough lighting, but less ventilation.His bedroom is in 1st floor, enough lighting, but less ventilation. Bed on the floor. His family removed the bed support because fear that he would fall from bed. It is 10 meters away from toilet. There are stairs in the house, but he doesn't need to go upstairsAfter the sickness, he often feels sad and sorry because he didnt have good habits before and didnt take his wifes advice. He doubts his boss will take him back to work. Wife occasionally finds him crying when he was alone. He is not interested in watching television as before, but he occasionally have preference to eat something. He gets angry easily although he knows that the person he angry with doesnt mean any harm. He resolves his anger quickly. He listens to his wifes advice now & very motivated so that he often exercises with his wife and takes a walk around the house. He has good relationship with families & neighbors. His family always gives support.He knows that his sickness is part of his bad habits.

that whats important is to recover from his illness and get rid of his bad habits. 24His monthly budget for daily living until date is covered by his savings. He made 1.5 2 million/ month before sickness. Wife doesnt work. He uses BPJS PBI for medical insurance.

House2-lane street

Living Room

BedroomBathroomToiletKitchenHistory of Vocational and Avocational Before the illness, he is a cloth screener in a garment workhouse since 1975. The job requires him to use both of his arms in standing position and to walk around a room. He often works overnight and doesnt eat regularly and properly because of strict dateline. The job depends on orders -> no regular income. He prays at mosque once a week. He occasionally played ping pong in his leisure time.After the illness, he has not work ever since. He has been told that his boss will take him back after his recovery, but he doubts it. He hopes that he can work again soon. He can now go to the mosque to pray once a week, but he prays sitting because he hasnt been able to endure rukuh and sujud. He can rise from sitting to standing w/o help. His leisure time is filled with walking around in neighborhood and watch television.PHYSICAL EXAMINATIONCognitive : (ICD-9CM : 89.13)MMSE = 25/30 (normal cognitive function) -> impaired in orientation, attention & calculation, recall, language

Communication : (ICD-9CM : 89.15)Naming (pictures) in word level = 5Mention names in a semantic category = 5Conclusion : no language disorder Feeding : (ICD-9CM : 89.15)TOR BSST = Before intake : normal sound, tongue movement slightly deviated to the rightIntake : no cough, no change of sound, no droolingAfter intake : normal soundSwallowing function = normal

Balance: (ICD-9CM : 89.15)Berg Balance Scale = 48/ 56 (low fall risk) -> impaired in placing alternate foot on bench/ stool while standing unsupported & standing on one leg

FUNCTIONAL ASSESSMENTGait Analysis: (ICD-9CM : 93.09)hemiparetic gait

Shorter step & stride lengthFUNCTIONAL ASSESSMENTArmTrunkPelvicHip jointKnee jointAnkle jointSagitalReduced right arm swing, flexor synergic pattern +Trunk bends anterior in the right leg late stance phaseReduced hip extension in late stance phaseReduced right knee flexion in swing phaseRight knee hyperextension in stance phaseNo heel strike of the right footNo push off of the right foot in late stance phaseReduced ankle dorsiflexion of the right foot in swing phaseCoronalNo hip hikingSlight right hip circumduction in swing phaseActivity of Daily Living : (ICD-9CM : 93.09)Barthel Index = 11/20 (moderate disability) -> impaired in feeding, bathing, grooming, dressing, toileting, climbing stairsIADL (Lawton & Brody) = 0 -> impaired in all aspects

FUNCTIONAL ASSESSMENTSUPPORTING EXAMINATIONChest X-Ray (7 March 2014)Tidak tampak TB paru aktifTidak tampak kardiomegaliHead CT scan (7 March 2014)Perdarahan intraserebral ganglia basalis sampai substansia alba periventrikel lateral kiri disertai lesi hipodens disekitarnya yang menyebaban midline shift sejauh 0,3 cm ke kanan. Hidrosefalus ringan

Laboratory findings8 March 2014Ureum: 32 mg/dlKreatinin: 0,9 mg/dlRandom blood sugar: 125 mg/dl

10 March 2014Total Cholesterol: 176 mg/dLHDL Cholesterol: 36 mg/dLLDL Cholesterol: 126 mg/dLTrigliseride: 101 mg/dlFasting blood sugar: 104 mg/dlUric Acid : 6,7 mg/dLClinical DiagnosisIntracerebral haemorraghic stroke subacute phase with mobilization, ADL & IADL disorders, and dysphagia due to right side hemiparesis, right central VII & XII nerve paresis (I62.9, R26.8, Z73.6, R13, G81.9, G52.7)Hypertension grade II on medication (I10)Dyslipidemia (E78.5)Right shoulder subluxation (M24.31)Conductive hearing loss of the left ear (H91.9)

Etiological DiagnosisIntracerebral haemorhage with risk factor: hypertension, dyslipidemia, smoking

Location DiagnosisNeuromuscular system, musculoskeletal system, metabolic system

Functional DiagnosisImpairmentRight hemiparesisRight central VII & XII nerve paresisDysphagiaRight shoulder subluxationDisabilityADL & IADLMobilizationHandicapVocational & AvocationalDIAGNOSISQuo ad Vitam: ad bonamQuo ad sanationam: dubia Quo ad functionam: dubia ad bonam

PROGNOSISM1: StrokeM2: HypertensionM3: DyslipidemiaM4: Right shoulder subluxationR1: MobilizationR2: ADL and IADLR3: DysphagiaR4: Vocational & AvocationalPROBLEMShort term :Maintain ROM to maintain flexibilityImprove muscle strength of right side hemiparesisImprove balanceADL independentlyPrevent shoulder subluxation complication

Long term :Prevent recurrent stroke by controlling hypertension, dyslipidemia, stop smokingImprove cardiopulmonary enduranceRegain optimal gait patternBack to workREHABILITATION GOALStrokeS : Right side limbs weakness O : Right side upper and lower limb weakness Spasticity (MAS) grade 1 for right upper & lower limbRight central VII & XII nerve paresisHead CT scan: Intracranial haemorrhage of basal gangliaLow risk of fallMMSE = 25/30 (normal cognitive function) -> impaired in orientation, attention & calculation, recall, languageG : Prevent recurrent strokeImprove functional capabilityP : - Educate the patient and family about stroke, risk factors, time course, and recovery of stroke- Assess psychological status in the next meetingMEDICAL PROGRAM MEDICAL PROGRAM Hypertension S : History of hypertensionO : Blood pressure 130/90 mmHg on Captopril 3x50 mg & Amlodipin 1x5mgG :Control regularly and reduce risk factorP : - Educate the patient to control to Neurology Department and take the medicine regularly (Captopril 3x50mg, Amlodipin 1x5mg)- Consult to nutrisionist for low salt dietDyslipidemiaS : History of dyslipidemia known since hospitalizedO : Total Cholesterol: 176 mg/dL HDL Cholesterol: 36 mg/dL LDL Cholesterol: 126 mg/dL Trigliseride: 101 mg/dl G : Control regularly and reduce risk factorP : - Educate the patient to control to Neurology Department and take the medicine regularly (Simvastatin 1x10mg)- Consult to nutrisionist for low fat diet

Shoulder subluxationS : No pain on limb movementO : Right shoulder subluxation (1 cm)G : Prevent right shoulder subluxation complicationP : - Educate caregiver & patient about Active Assistive ROM exercise movement- Shoulder sling at daylight or whenever active- Shoulder positioning at night or whenever at rest

MEDICAL PROGRAM MobilizationS : Patient walks with abnormal gait and tires easilyO : Weakness of right lower limb (MMT 3423) Proprioceptive: impaired for right lower limb Hemiparetic gaitG : Short term : Maintain ROM to maintain flexibility Improve muscle strength of right side hemiparesis Improve balanceLong term : Improve cardiopulmonary endurance Regain optimal gait pattern P : Short term : - Active Assistive ROM exercise for lower limbs - Exercise testing with ergocycle - Ergocycle for endurance & strengthening exercise Long term : gait training

REHABILITATION PROGRAM Activities of Daily LivingS : Patient brushes his teeth, eating, & drinking using his left hand, needs help to pick up the dipper and wash himself while bathing, cant climb & down stairs, grooming, toileting, and dressing can be done independently if mainly uses his left handO : Barthel Index = 11/20 (moderate disability) -> impaired in feeding, bathing, grooming, dressing, toileting, climbing stairsIADL (Lawton & Brody) = 0 -> impaired in all aspectsWeakness of the right upper limb (MMT 2311) Impaired right hand prehension and dexterity Trunk weakness (MMT: flexion = 4, extension = 4, rotation = 4) Weakness of right lower limb (MMT 3423) Proprioceptive: impaired for right lower limb Hemiparetic gaitG : Independence in activities of daily livingP : Active Assistive ROM exercise for upper limbsElectrical stimulation for right wrist & handREHABILITATION PROGRAM REHABILITATION PROGRAM DysphagiaS : Patient is choked when using straw to drink. He isnt choked when drinking directly from a glass nor when eating riceO : pa/ta = clear, ka/ = less clearTOR BSST: normalG : Eating and drinking without risk of aspirationP : Educate patient to drink directly from a glass or by spoon

Vocational & AvocationalS: patient hopes to be able to get back to workO: Weakness of the right upper limb (MMT 2311)Impaired right hand prehension and dexterityTrunk weakness (MMT: flexion = 4, extension = 4, rotation = 4)Weakness of right lower limb (MMT 3423)Proprioceptive: impaired for right lower limbHemiparetic gaitG : Assign patient for workP : - Active Assistive ROM exercise for upper limbs- Electrical stimulation for right wrist & handAnamnesis: sudden weakness of his right limbs upon waking up from sleep at night. He couldnt raise nor move his right arm and leg at all. BP at ER was 260/190. Physical examination: right hemiparesis and right central paresis of VII & XII nerve, increase of physiologic reflex, presence of pathologic reflex and spasticity. Anamnesis and physical examination -> haemorrhagic strokeThis patient has contralateral hemiparesis and contralateral cranial nerve paralysis -> carotid system circulation stroke. Risk factor : smoking, hypertension, and dyslipidemiaThe time course of this case is 2 months, it is a subacute phase stroke. DISCUSSIONImpairment : right hemiparesis, right central VII & XII nerve paralysis, dysphagia, right shoulder subluxation disable in mobilization, ADL, and IADL. He feels sad and depressed because of his sickness. He also becomes easier to be angryRehabilitation program is emphasized on optimalizing neurological recovery while preventing complications so that his recovery progress is facilitated well to achieve optimal functional capability possible. Prognosis ad vitam : ad bonam the vital signs are stable and the risk factors has already been controlledPrognosis sanationam : dubia the patients compliance in control to neurologist for his hypertension & dyslipidemia, consume the medications regularly, and diet modification is questionable, although ICH recurrence rate is relatively smallPrognosis ad functionam : dubia ad bonam he has good motivation to do exercises, although he sometimes ignores shoulder positioning. By these 2 months, the recovery progress of his limbs weakness is still positively progressing

CASE ANALYSIS

FOLLOW UP (20 April 2014)SUBJECTIVEMOBILIZATIONPatient claims that he could walk around his house twice further than the last meeting with less frequent rests.OBJECTIVEPELower extremitiesROMMMTSpasticityProprioceptionFunctional AssessmentCardiopulmonary Endurance Test (ICD-9CM : 93.09)Full/ Full (See attachment 1 for further details)(See attachment 1)Flexion = 0 (Modified Asworth Scale)Extension = 1 (Modified Asworth Scale)Good/goodExercise testing with ergocycle -> failed to conduct because patient has difficulty in maintaining balance on the ergocycleASSESSMENTMobilization disorder due to right side hemiparesis (R26.8, G81.9)GOALShort term : Maintain ROM to maintain flexibility Improve muscle strength of right side hemiparesis Improve balanceLong term : Improve cardiopulmonary endurance Regain optimal gait patternPROGRAMShort term : Active Assistive ROM exercise for lower limbs Strengthening exercise right lower limbs Plan : 6MWTLong term : gait trainingSUBJECTIVEACTIVITIES OF DAILY LIVINGHe feels that his right arm is a little stronger. He still needs his wife to wash him using dipper while bathing, but he can soap his body using his right hand better. However, he hasnt been able to spoon his meal nor take up a glass of water to his mouth by using his right hand.OBJECTIVEPEUpper extremitiesROMMMTSpasticityHand PrehensionLower extremitiesROMMMTSpasticityProprioceptionFull/ Full (See attachment 1 for further details)(See attachment 1)Flexion = 1+ (Modified Asworth Scale)Extension = 1 (Modified Asworth Scale)Power GripFist/ palmar: good / goodCylindrical: good / goodSpherical: poor / goodHook: fair/ goodPrecision GripTip-to-tip : poor / goodThree-prong chuck: poor / goodLateral pinch: poor / good

Full/ Full (See attachment 1 for further details)(See attachment 1)Flexion = 0 (Modified Asworth Scale)Extension = 1 (Modified Asworth Scale)Good/goodASSESSMENTADL disorder due to right side hemiparesis (Z73.6, G81.9)GOALIndependence in activities of daily livingPROGRAMADL exercise with right handActive Assistive ROM exercise for upper limbsSUBJECTIVEDEPRESSIONHe still gets sad and depresses when he is lonely. He gets angry easily, but also resolves quickly. He is still highly motivated to exercise because he wants to recover well from his sickness.OBJECTIVEFunctional AssessmentPsychological status: (ICD-9CM : 93.94)Depression Anxiety Stress Scale (DASS) :Depression = 10 (mild depression), Anxiety = 0 (normal), Stress = 6 (normal)Hamilton Depression Scale (HAM-D) = 10 (mild depression)ASSESSMENTMild depression (F06.3)GOALAlleviate depressionPROGRAMConsult psychiatristTHANK YOU