The effect of a multifocal rehabilitation approach in a patient with a complicated left MCA cerebral vascular accident with a

Purpose: The purpose of this case report is to investigate physical therapy rehabilitation strategies in a patient with a complicated left middle cerebral artery (MCA) CVA with hemorrhagic transformation, including subarchanoid hemorrhage, through review of retrospective data from the patient’s therapy course at a Skilled Nursing Facility during the summer of 2009. Case Description: The patient (WM) is a 64 year old white male who sustained a large left middle cerebral artery(MCA) distribution CVA. WM underwent intrarterial thrombolysis with tPA followed by a mechanical thrombectomy. WM developed a hemorrhagic conversion of the CVA with a small intraventricular hemorrhage and a small subarachnoid hemorrhage with a 4 mm rightward midline shift. WM received PT, OT, and ST during hospital course with slow progress. Examination showed upper extremity passive range of motion (PROM) to be within functional limits bilaterally with passive range of motion. The lower extremities demonstrated decreased dorsiflexion bilaterally secondary to heel cord tightness, and decreased hip internal rotation lacking about 5 degrees from neutral bilaterally. Hip external rotation and knee flexion and extension were within functional limits bilaterally. Functional Independence Measure (FIM) scores were: one for bed transfers, zero for chair and wheelchair transfers, and zero for locomotion. Interventions: Interventions that were implemented include: Gait/pre gait training, therapeutic exercise such as PROM and strengthening activities when appropriate, and therapeutic activities such as transfer training and bed mobility. Neuromuscular re-education was also implemented to aid in the recovery of any sensory or motor deficits including proprioceptive neuromuscular facilitation (PNF) and electrical stimulation. Outcomes: At 6 weeks the patient progressed to minimal assist for rolling and transfers supine to sitting edge of bed, with stand by assist while seated edge of bed. Transfer training included minimum assistance for a stand pivot transfer to a w/c and for sit to stand transfers. Transfers from sit to stand additionally required bracing of the right knee to prevent buckling. Contact guard assist was required for static standing. In terms of ambulation, various distances were met although they were inconsistent in the parallel bars with contact guard assist ranging from 3' to 7' with a wheel chair follow and tactile and verbal cues. FIM scores improved for transfers to a four, for the walking portion of locomotion to a one, and remained at a 0 for the stair portion. Conclusion: The individual and combined roles of hemorrhagic transformation, subarachnoid hemorrhagic, hypertension, and hyperglycemia on functional outcome require further investigation to determine the proper treatment guidelines in the acute phases and rehabilitation course following ischemic stroke. The functional gains made throughout the 6 weeks of rehabilitation suggest the importance of physical therapy interventions specific to impairments. Overall this case highlights the importance of monitoring vitals and glucose levels in order to limit associated risks resulting in poor outcomes, and suggests the use of a recommended motor impairment assessment, such as the Fugel-Myer, when working with this population to best determine impairments and subsequent plan of care.