Multimodal Physical Therapy Management Of A Patient With Unilateral Neglect Post-Stroke In An Outpatient Setting: A Case Report

Background and Purpose: Unilateral neglect (ULN) syndrome negatively affects recovery post-stroke and is often associated with falls, longer stays in rehabilitation, and the need for more assistance at discharge. Typical physical therapy treatments include voluntary trunk rotation, visual scanning exercises, mirror therapy, hemispheric activation, sensory awareness training, and lower extremity loading but the efficacy of these treatments is still unclear. The purpose of this case report is to describe multimodal physical therapy (PT) management that includes common PT interventions to alleviate symptoms of ULN and report upon the outcomes of the various treatment methods for rehabilitation of neglect during functional mobility. Case Description: 65 year-old male referred to outpatient PT following diagnosis of right hemispheric basal ganglia bleed presenting with impaired functional mobility primarily due to significant ULN. The patient was treated with the following interventions for 26 visits over 10 weeks: functional training, increased weight bearing activities, hemispheric activation, voluntary trunk rotation, visual scanning, mirror therapy, sensory awareness training, and gait training. Data collection included: 6 Minute Walk Test (6MW Test), gait speed, manual muscle testing (MMT), and level of assistance during functional task analysis. Outcomes: Overall improvement in the patient’s level of assistance with bed mobility and transfers was noted. Patient improved in 6MW Test from 90 ft. preintervention to 185 ft. postintervention reflecting increased functional status and a small meaningful change. Patient also improved in gait speed from 0.25 ft/sec preintervention to 0.51 ft/sec postintervention. Discussion: Using multimodal physical therapy management and applying an assortment of interventions developed for the rehabilitation of ULN post-stroke appeared to be beneficial for the patient in increasing awareness of left hemi-side, functional mobility, and status. Manuscript word count: 2,642 A. BACKGROUND and PURPOSE: Stroke is a leading cause of long-term disability, which results from brain cell damage due to either an interruption of the blood supply to the brain or hemorrhage into the brain tissue. Although the relative risk of stroke death fell by 35.1% and the actual number of stroke deaths declined by 21.2% from 2001 to 2011, each year about 795,000 people continue to experience a new or recurrent stroke. A common behavioral syndrome of stroke is unilateral neglect (ULN) with an incidence varying widely from 10% to 82% following right-hemispheric stroke. ULN is defined as the failure to report, respond, or orient to stimuli presented contralateral to a brain lesion; if the failure to respond can be accounted for by either sensory or motor deficits, it is not considered to be neglect. According to the current literature, ULN has a negative influence on functional recovery and is associated with a poor functional outcome following a stroke, therefore several rehabilitative approaches have been proposed and implemented to decrease neglect and improve patient recovery. As reported by Pierce et al, the physical therapy (PT) interventions that have shown therapeutic effectiveness are hemispheric activation approaches and trunk rotation therapy. In addition, a few authors support visual scanning exercises and mirror therapy, as well as sensory awareness and spatial organization training. Due to current evidence showing ULN slows recovery of the ability to bear weight through the paretic lower extremity for symmetrical performance, findings suggest that paretic lower extremity loading may be an appropriate focus of intervention. Although many research articles have been published on ULN negatively affecting post-stroke functional mobility and recovery, there is a lack of information on the efficacy of PT interventions to decrease neglect symptoms. Due to the wide variety of clinical presentations and the complex nature of ULN syndrome in patients following stroke, the optimal PT interventions and treatment strategies is unclear. Thus, the purpose of this paper is to describe physical therapy management strategies used during an outpatient rehabilitation stay for a patient with ULN post-stroke. B. CASE DESCRIPTION: Patient History and Systems Review: The patient was a 65-year-old male admitted to a hospital-based outpatient physical therapy facility following a right basal ganglia hemorrhagic stroke, which occurred 9 weeks prior to outpatient PT admission. At onset of stroke, the patient was acutely admitted to the hospital where a computerized tomography (CT) scan and neurosurgical evaluation was conducted. The CT scan, CT angiogram, and magnetic resonance imaging (MRI) were positive for a large right basal ganglia bleed with a mild mass effect and negative for an aneurysm or arteriovenous malformation. The right basal ganglia bleed etiology was deemed to be due to hypertension. Prior to his outpatient PT admission, the patient received inpatient PT services for 5 days and home health PT services for 3 weeks. Related past medical history included: hyperlipidemia, hypertension, Type II diabetes, unoperated inguinal hernia, alcohol abuse, depression, and percutaneous endoscopic gastrostomy (PEG) tube placement for nutritional support due to impaired swallowing. See Table 1 for patient medications being taken at admission. Table 1. Medications at Admission Medication: Indication: Adverse Reaction: AmLODIPine Hypertension Fatigue, dizziness, nausea, peripheral edema Cholecalciferol Dietary supplement (Vitamin D) Weakness, nausea/vomiting, muscle/bone pain, polyuria, weight loss Doxazosin Hypertension Dizziness, headache, nausea, edema Insulin Aspart (Novolog FlexPen) Type II Diabetes Edema, hypoglycemia Labetalol Hypertension Dizziness, fatigue, hypotension, muscle cramps Lantus Type II Diabetes Hypoglycemia Lexapro Depression Insomnia, dizziness, fatigue, nausea, irritability, muscle cramping, dyspnea Simvastatin Hyperlipidemia Upper respiratory tract infections, headache, abdominal pain, constipation, nausea, myopathy TraMADol Pain, when necessary (PRN) Dizziness, drowsiness, headache, constipation, nausea, weakness UNE Drug Facts and Comparisons Database Prior to stroke, the patient worked full-time as a medical supply manufacturer and stated he enjoyed outdoor activities such as hiking and camping. The patient affirmed his willingness to participate in the physical therapy plan of care and in this case report. He indicated that he wanted to improve mobility of his left arm and leg, as well as walk independently. The findings of the system’s review are summarized in Table 2. Table 2. Systems Review Cardiovascular/Pulmonary Right Left Intact Slight edema of lateral ankle and hand (non-pitting)