Case presentation on Hemiparesis

1. HEMIPARESIS
DARSHAN PARMAR

2. DEMOGRAPHIC DATA
Name : Bhavsangbhai Kyor
Age : 75 years
Gender : Male
Address : Matru Ashish, street no.2, Rameshwar nagar, Jamnagar
Occupation : Retired
Dominance : Right
Affected side : Right
Socioeconomic condition : Good
Height : 158cm Weight: 60kg BMI : 24 kg/m2

3. DEMOGRAPHIC DATA
Provisional Diagnosis : CVA Rt. Hemiplegia (ischemic)
Laboratory Reports :
Hb : 14 grams/dL
RBC count : 4.41 trillion cells/L
HCT : 41.2 %
WBC count : 14600 cells/L ↑
Platelet : 236000/mcL
Random Blood Sugar : 170 mg/dL ↑
VLDL Cholesterol : 40 mg/dL ↑
01/11/2021

4. VITALS
Blood Pressure : 138/72mmHg
Temperature : Normal
Heart Rate : 88 pulse/min.
Respiratory rate :22 breath/min.

5. CHIEF COMPLAIN
• On 04/11/2021
• Unable to lift his right arm
• Unable to lift his right leg
• Unable to walk independently
• Unable to maintain Balance
• Tingling and Numbness on right Upper and
Lower limb and Scalp.
• On 23/11/2021
• Unable to maintain balance while walking
• Tingling and Numbness on right sole of foot
and scalp area.

6. HISTORY
Present History : On 30/10/2021 at 7:00 am patient fell down and was unable to lift his Right arms
and leg. Patient had took bath with cold water in Cold environment before stroke at 5:00 am. Later
the patient was taken to the local clinic at Haridwar, during that period patient was fully conscious
and was able to communicate with his family, even he had asked his family member to take him to
the clinic by giving address. (this interpret that during the time of stroke patient was fully conscious
and his memory was intact).
Doctor at local clinic had referred the patient to the Hospital. So the patient was taken to
“Ramakrishna Mission Sevashrama, Kankhal” in the Emergency ward at Haridwar(Uttarakhand) on
same day. The attendant Doctor was Dr. Ashwani Chauhan over their. Patient was diagnosed with
DM and HTN at that time. Their was No H/o DM and HTN before the stroke. On Examination
patient was having Pulse: 100/min, BP: 190/100mmHg after 15 minutes it was reduced to
170/100mmHg, SpO2: 96% and RBS: 193mg/dl.

7. Patient had a complain of Rt hand and leg weakness and pain on both the leg (which could be
probably post-stoke pain*) during admission. Treatment given was
◦ Inj. Pantop 40 mg IV (Acid reflux)
◦ Inj. Emeset 10mg IV (Nausea & Vomiting)
◦ Inj. Nitroglycerin 1ml/hr (Angina)
◦ Inj. Lasix 2ml IV (High BP)
◦ Tab. Telma 40 (High BP)
◦ Cap. Ecosprin 150 (Anticoagulant)
◦ Tab. Atorva 40 (Cholesterol)
◦ Inj. Strocit 10mg in 100NS (psychostimulant)
Treatment for leg pain
Tab. PCM 50mg (pain relief)
Tab. Cyclopex (Antispasmodic)
Tab. Betasone (Allergy)
Tab. Ranitidine (Acid reflux)
Tab Nimesolide (pain relief)
Tab. Dexon (Anti-inflammatory)
Tab. Cetrizine (Allergy)
*Sullivan 6th edition pg:669

8. Family members were asked to admit the patient for 20 days, but he was not admitted. Later he
was taken to Jamnagar, where they consulted Dr. Amit Udani on 01/11/2021. Patient was advised
for Brain MRI and ECG. By the reports of MRI Dr. Amit Udani sir had advised for Physiotherapy and
the medication prescribed by him were
◦ Cap. Clopcare A 150 (Blood thinning)
◦ Cap. Atvast 40 (lower’s blood Cholesterol)
◦ Tab. Methron (for infection)
Patient had started Physiotherapy from 02/11/2021 by a Visiting Physiotherapist. The treatment
given by the Physiotherapist was Passive and Active-assisted Hip and knee ROM exercise, Ankle toe
movement.
On 04/11/2021 patient entered Neuro Department of GPTC on wheel chair with the complain of
unable to lift his right arm and leg. Patient was assessed thoroughly, accordingly exercise for
prescribed and he is taking treatment at GPTC till date.
10 days

9. Past History : Not Relevant
Personal History : Smoking since 50 years
Stopped consumption of Alcohol before 20 years (used to consume once a week)
Family History : H/o DM – wife and son (Not Relevant)
Surgical History : Removal of Kidney stone before 6 years through LASER.
Medical History : DM and HTN since 30/10/2021, Type 1 LV Diastolic Dysfunction.
30/10/2021 – BP : 170/100 mmHg, RBS : 193mg/dl
01/10/2021 – RBS : 170mg/dl
06/11/2021 – BP : 150/90 mmHg
10/11/2021 – RBS : 174mg/dl

10. Current Drug History :
Cap. Clopcare A (for blood thinning)
Cap. Atvast 40 (lower’s blood Cholesterol)
Tab. Elfolin Plus (Nutritional deficiency)
Tab. Olmetime (for HTN)
Tab. Glycomet (for DM)
Rehabilitation History :
• Stretching to Tight Muscle
• Passive movement for Rt Shoulder
• Active – assisted for Rt elbow, wrist, hip, knee, ankle
• Sit to stand
• Bridging, Curls up, Plantigrade positioning
• Hamstring curls with support
• Shoulder elevation, depression, retraction, protraction with Biofeedback
• Weight bearing on Rt hand and Reachouts
• Reachout in standing with Pelvis supported
• Marching by holding Parallel bars
• Gait Training in Parallel bars

11. INVESTIGATION
MRI BRAIN : (01/11/2021)
• Multiple small to medium sized acute non-haemorrhagic infarcts involving left high fronto-
parietal region and small similar infarct involving right high parietal region.
• Old lacunar infarcts involving left basal ganglia and pons.
• Age related atrophic changes.
• Few small vessel ischaemic changes.
• Moderate atherosclerotic changes involving left extracranial ICA origin causing 10 to 20%
narrowing.
• Moderate atherosclerotic 30 to 40 % narrowing involving left main stem MCA
• Mild atherosclerotic changes involving right carotid bulb and proximal ICA without significant
narrowing.

12. Frontal Lobe injury : Impairment of recent memory, inability to concentrate, behavior disorders,
difficulty in learning new information. Emotional lability, Contralateral plegia, paresis,
Expressive/Brocas/motor aphasia.*
Parietal Lobe Injury : Inability to discriminate between sensory stimuli, Inability to locate and
recognize parts of the body. Severe Injury: Inability to recognize self, Inability to write.*
Lacunar Infarct : Dysarthria, Ataxic hemiparesis, Dystonia, Deficit in consciousness, language, or
visual fields are not seen because higher cortical areas are preserved. A hypertensive
haemorrhage affecting the thalamus can also produce central stroke pain.**
Middle Cerebral Artery infarct : Contralateral Hemiparesis (UL>LL), Contralateral sensory loss,
Motor/sensory/global Aphasia, Ataxia, Pure motor hemiplegia (Lacunar stroke)**
Internal Carotid Artery infarct : ACA + MCA
Anterior Cerebral Artery infarct : Contralateral Hemiparesis (UL<LL), Contralateral sensory loss,
Urinary incontinence, problem in copying, absence of will power, slowness.**
*Minnesota Brain Injury Alliance; About Brain Injury: A Guide to Brain Anatomy
**Sullivan 6th edition pg:650-653

13. INVESTIGATION
ECG : (01/11/2021)
Type 1 LV Diastolic Dysfunction.

14. ON OBSERVATION
Built : Mesomorphic
Posture : Anterior View
Right shoulder depressed
Bow legs
Right leg external rotated

15. Posterior View :
Right shoulder depressed
Right leg external rotated

16. Lateral View :
Forward head posture

17. Anterior View :
Right shoulder depressed
Posterior View :
Right Shoulder depressed
Scapular Dyskinesia

18. Forward head poster
Right shoulder
Protracted.

19. GAIT
Anterior View :
Right leg moves in External Rotation
More weight bearing on sound leg
Arm swing reduced
Patient usually see downwards (due to loss of sensation on sole of foot due to DM)
Lateral View :
Arm swing reduced
Uneven steps to maintain Balance

20. ON OBSERVATION
Assistive device : Wheelchair (04/11/2021 to 10/11/2021)
Walker (10/11/2021 to 15/11/2021)
Swelling : Not Present
Tropic changes : Not Present
Involuntary Movement : Not Present
Muscle wasting : Not Present
Deformity : Not Present

21. ON PALPATION
Tenderness : Anterior joint line of right shoulder
Temperature : B/L symmetrical
Spasm : Not Present
Swelling : Not Present

22. ON EXAMINATION
Higher Function Examination :
Consciousness : Alert
Orientation : Oriented to Time, Place and Person
Memory : Immediate, Short term and Long term memory - all are intact
Attention : Alternating attention (Normal)
Behaviour : Cooperative
Speech : NAD
Reading : Non Fluent
Writing : Impaired

23. Cranial Nerve Examination :
1. Olfactory (S) : Intact
2. Optic (S) : Intact
3. Oculomotor (M) : Intact
4. Trochlear (M) : Intact
5. Trigeminal : Intact
6. Abducent (M) : Intact
7. Facial : Intact
8. Vestibulocochlear (S) : Intact
9. Glossopharyngeal : Intact
10. Vagus : Intact
11. Spinal Accessory (M) : Intact
12. Hypoglossal (M) : Intact

24. SENSORY EXAMINATION
Superficial Sensation :
◦ Fine Touch : Impaired on B/L sole of foot (300gm force)
◦ Crude Touch : intact
◦ Pin Prick : intact
◦ Pressure : intact
Deep Sensation :
◦ Proprioception : intact
◦ Kinaesthesia : intact
◦ Vibration : intact (impaired on Planter surface of
B/L Great Toe and Metatarsal joint)
Cortical Sensation :
◦ Stereognosis : intact
◦ Tactile localization : intact
◦ Barognosis : intact
◦ Graphesthesia : intact
*Predictor of Diabetic
Foot Ulcers : Pin-Prick
sensation, Vibration and
10g monofilament
pressure sensation at sole
of foot.
Loss of 10g monofilament
perception and reduced
vibration perception
predicts foot ulcer

25. PAIN ASSESSMENT
Site : Right Shoulder Joint
Onset : Gradual
Tenderness : Anterior joint line of right shoulder
Type : Dull aching
Aggravating factor : Activity (Shoulder flexion, abduction)
Relieving factor : Rest
NPRS : Activity : 3/10
Rest : 0/10

26. TONE
04/11/2021 25/11/2021
Shoulder Extensor 1
Elbow (Flexor/Extensor) 0 (Normal)
Wrist (Flexor/Extensor) 0 (Normal)
Hip (Flexor/Extensor/Abductor) 0 (Normal)
Knee (Flexor/Extensor) 0 (Normal)
Ankle (DF/PF) 0 (Normal)
Right Shoulder Flexor, Abductor, Extensor -
Hypotone

27. VOLUNTARY CONTROL
04/11/2021
Shoulder 0/6
Elbow 3/6
Wrist 3/6
Hip 4/6
Knee 6/6
Ankle 5/6
24/11/2021
Shoulder 3/6
Elbow 4/6
Wrist 3/6
Hip 4/6
Knee 6/6
Ankle 5/6

28. MMT
KNEE RIGHT LEFT
FLEXOR 4/5 4/5
EXTENSOR 5/5 5/5

29. Reflex : Left Right
23/11/2021 04/11/2021 04/11/2021 23/11/2021
2+ 2+ Biceps 2+ 2+
2+ 2+ Triceps 2+ 2+
2+ 2+ Knee jerk 2+ 2+
2+ 2+ Ankle jerk 2+ 2+
Synergy : Flexor Synergy in Right UL.
Tightness : B/L Hamstrings, Adductors
Extensor Response Babinski sign Extensor Response

30. LIMB LENGTH DISCREPANCY (LLD)
Right Apparent length Left
95 cm Umbilicus to medial malleolus 95 cm
Right True length Left
13 cm ASIS to GT 13 cm
39 cm GT to lateral Knee joint 39 cm
41 cm Medial knee joint to M.M. 41 cm

31. CO-ORDINATION TEST
NON EQUILIBRIUM :
Finger to finger test
Finger to nose test
Dysdiadochokinesia
Knee to heel test
EQUILIBRIUM :
Tandem walking : Severe Impairment : Able only to initiate activity without completion.
Walking sideways : Minimal Impairment : Able to accomplish activity, slightly less than normal speed.
Single leg standing : Severe Impairment : Able only to initiate activity without completion.
Minimal Impairment : Able to accomplish activity,
slightly less than normal speed.

32. BALANCE TEST
BERG BALANCE SCALE :
04/11/2021 : 32/56
Affected Component :
◦ Sit to stand – need assistance
◦ Standing unsupported – cannot maintain balance
◦ Standing unsupported with leg together – cannot maintain balance
◦ Reaching forward – cannot maintain balance
◦ Turn 360 – need supervision
◦ Alternate Step on stool/stepper, one leg standing, Tandem standing
25/11/2021 : 46/56
Affected Component :
◦ Sit to stand – need support of hand
◦ Turn 360 – slow
◦ One leg standing

33. GAIT EXAMINATION
Step length (Rt) (Rt Toe  Lt Toe) : 31cm
Step length (Lt) (Lt Toe  Rt Toe) : 34cm
Stride length (Rt) (Rt Toe  Rt Toe) : 63cm
Stride length (Lt) (Lt Toe  Lt Toe) : 66cm
Cadence : 62 steps/min.

34. FUNCTIONAL ASSESSMENT
Grooming : Independent
Dressing : Need Assistance
Bathing : Independent (need supervision)
Toileting : Independent (need supervision)
Transferring : Need Assistance
Ambulation : Need Assistance (cane – due to fear of fall)
Feeding : Independent (Modified – started to use Left hand to feed himself, before stroke he was
using right hand)

35. FUGL-MEYER ASSESSMENT SCALE
TOTAL UPPER LIMB SCORE : 48/66 (Affection : Flexor synergy, Coordination)
TOTAL LOWER LIMB SCORE : 32/34 (Affection : Coordination)
BALANCE TOTAL SCORE : 10/14 (Affection : one leg standing)
SENSATION TOTAL SCORE : 23/24 (Affection : sole of foot)
JOINT ROM TOTAL SCORE : 43/44 (Affection : Shoulder abduction)
PAIN TOTAL SCORE : 40/44 (Affection : Shoulder flexion, abduction and knee flexion)
TOTAL FUGL-MEYER SCORE : 196/226 (87%)

36. ICF*
Body Functional & Structural Impairment : B/L loss of sensation on sole of foot, Tingling and
numbness on Right foot and scalp, synergy in UL
Composite Impairment : Balance and Gait deficits
Activity Limitation : Dressing and walking independently
Participation Restriction : unable to attain social functions
Performance Qualifiers : moderate difficulty in locomotion  use of cane
Facilitator : Good Family support
Barriers : Fear of losing balance
*Sullivan 6th edition

37. CLINICAL DIAGNOSIS
Right side Hemiparesis

38. PROBLEM LIST
Impaired balance while walking
Needs the support of hand for standing from sitting
Needs assistance for Dressing
Upper limb synergy
Right Shoulder pain
Lack of coordination in upper limb
Tightness of B/L hamstrings and adductor

39. MANAGEMENT
SHORT TERM GOALS :
To improve Balance while Walking
Transfer Activity (Assistance to Independent Transfer)
Make Independent in ADLs
Break Upper Limb Synergy
Improve Co-ordination
Pain Management

40. To improve walking balance :
Strengthen Lower limb and core muscle  Improve Sitting Balance  Improve sit to stand 
Improve standing balance  Improve dynamic balance.*
1) Strengthening of Lower Limb :
◦ Active – Assisted exercise  Active exercise  Resisted Exercise.
◦ Ballster kicking (forward, backward and side ward) also improves balance.
◦ Hamstring curls with support  without support
2) Strengthening of Core Muscle :
◦ Bridging  One leg Bridging  Bridging with SLR**
◦ Curls ups
◦ Alternate arm and leg raise in Quadripod position
◦ Pelvic PNF (Anterior elevation and Posterior depression)***
◦ Trunk Rotation**
*Steps to Follow – Patricia
**E.Ko et al; The Additive effects of core muscle strengthening and Trunk NMES on Trunk Balance in Stroke patients, Ann Rehabil Med. 2016 Feb; 40(1): 142-151
***H. Patni; A Comparative study on the effects of Pelvic PNF exercise and Hip extensor strengthening exercises on Gait Parameters of Hemiplegic patients; Int J
Physiother Res 2019 Vol 7(4): 3150-56

41. 3) Improve Dynamic Sitting Balance :
Sitting on Vestibular ball  Perturbation while sitting on Vestibular ball.
4) Improve Sit to Stand :
Wall squats  Squatting  Sit to Stand from low stool
5) Improve standing balance :
Standing with wide base  narrow base  Tandem standing  Standing on one leg
Catching ball in standing (Task specific training)
Perturbation in standing
Reaching with Lower limb in Standing
6) Improve Dynamic Balance (Walking) :
Walking on foot prints
Tandem walking
Sidewards walking
Obstacle walking
LL-CIMT*
*E Oliveria et al; Effects of Lower Extremities Constraint Induced Movement Therapy on Gait and Balance of Chronic Hemiparetic Patients after Stroke:
Description of Study Protocol for RCT-Clinical Trial; Research square; July 19,2021

42. Transfer Activity (Assistance to Independent Transfer) :
◦ It gets improve by the previously mentioned exercise
◦ Initially when assistance is required  never lift the patient from Axilla
Break Upper Limb Synergy :
◦ Plantigrade Position
◦ D2 flexion for UL
◦ Scapular PNF (also improves scapular alignment)
Improve Co-ordination
◦ Finger to Finger
◦ Finger to Nose
◦ Finger to Therapist Finger
◦ Peg board activity in diagonal pattern
◦ Holding a glass of water and taking it towards mouth

43. Pain Management :
◦ Grade 1/2 Maitland Mobilisation
◦ Cryotherapy
◦ Table top polishing exercise* (reduces pain by improving shoulder integrity)
To improve Shoulder Stability :
◦ Scapular Strengthening Exercise (also improves scapular alignment)
◦ Scapular PNF (also improves scapular alignment)
◦ Shoulder Strengthening Exercise (Active-assisted  Active  Resisted exercise)
To improve Flexibility :
◦ Stretching of Tight muscle
To improve Cardio-Pulmonary function :
◦ Breathing Exercise (Diaphragmatic breathing, Segmental breathing, Spirometry)
◦ Marching
◦ Walking
*Sullivan 6th edition pg: 683

44. LONG TERM MANAGEMENT
Improve Flexibility (Stretching)
Improve Strength of Upper Limb (Resisted Training : Therabands, dumbells, Theratubes)
Improve Cardiac endurance (Walking, Cycling)

45. HOME ADVICE
Use of affected limb in daily activity.
Avoid stepping out of house without Foot wares.
Inspect the sole of foot regularly
Moisturise the feet
Walking (to improve circulation)
Yoga , Meditation
Focus on diet

46. THANK YOU