Fictional Case Study using Constraint Induced Therapy and Visual Scanning in R MCA stroke with L hemineglect

Abstract

The purpose of the case is to present the effects of constraint induced therapy (CIT) in combination with visual scanning training and task-oriented training in a 65 year old female who presented with profound left visual and spatial neglect and motor and sensory deficits in the upper limb following a right middle cerebral artery stroke. This patient was referred to an inpatient rehabilitation unit 2 weeks post stroke and presented with left sided neglect, L hemiparesis of the upper extremity, difficulty ambulating, impulsiveness, and mild sensory deficits.  Following a 6-week intensive rehab program involving the above-mentioned interventions, the patient was able to return home independently, and experienced significant improvements in functional mobility, upper arm motor control and strength, and ability to implement appropriate strategies to manage her neglect.

Introduction

The following case presents an individual with profound left visual and spatial neglect and left side motor and sensory deficits in the upper limb following stroke. The purpose of this case study is to create an effective rehabilitation program utilizing a combination of constraint induced therapy (CIT), visuospatial training methods, and task-oriented rehabilitation to encourage optimal rehabilitation and return to independence. Individuals with spatial neglect following stroke present greater challenges in regaining motor function of the paretic limbs. leading to impaired motor and functional recovery, increased risk for falls, increased hospitalizations, and a lower likelihood of home discharge and community reintegration.

There are several methods used to treat spatial neglect such as prism training, mirror therapy, and neck muscle vibration, but a 2015 review revealed visual scanning training (VST) had the most positive impact on occupational performance. Furthermore, VST has been found to improve grip strength of the paretic limb vs. controls. The major stroke treatment guidelines conflict somewhat on the use of VST in cases of neglect. The 2015 Canadian Stroke Best Practice Guidelines (CSBPG) says that visual scanning techniques can be used in patients with neglect, although the evidence is not high quality (Evidence Level C) (Hebert et al, 2015, p. 475).  The Evidence-Based Stroke Rehab Clinician’s Handbook (EBSR) states that there is strong evidence for visual scanning, however the two RCTs they cite are rather dated (p. 21, EBSR, 2016). Finally, Stroke Engine states that there is conflicting evidence on visual scanning techniques for use in treatment of neglect (Canadian Partnership for Stroke Recovery, 2019).

As far as CIT, it is considered effective in promoting the use of the paretic limb and regaining motor function. Both the EBSR and the CSPBG recommend the use of CIT rehabilitation of the affected upper limb (Evidence Level A), provided the patient demonstrates at least 20 degrees of active wrist flexion and 10 degrees of active finger extension and has minimal sensory or cognitive deficits (p.7, EBSR, 2016; p.470, Hebert et al, 2015). It should be noted that our patient does have 20 degrees of wrist extension, however she also has marked sensory and cognitive deficits due to the hemineglect. Stroke Engine recommends CIT in the hemiparetic upper limb, and states that there is not enough evidence on the use of CIT in neglect patients to comment either way on its effectiveness (Canadian Partnership for Stroke Recovery, 2019). One of the goals of this case study is to examine the potential for the use of CIT in patients with hemineglect who have the recommended motor ability.

Therefore, our aim is to harness the known benefits of CIT for individuals with hemiparesis and use them in combination with VST and task-oriented training to improve the outcomes for a patient with combined upper extremity hemiparesis and visual and spatial neglect.  With this approach, we hope to maximize overall functional recovery, decrease the risk of falls, and improve the patient’s chances of returning home independently and being able to fully participate in her usual ADLs and IADLs.

Client Characteristics

Wendy is a 65 year old retired primary school teacher who suffered a right sided MCA stroke 2 weeks ago. She was referred to an inpatient stroke rehabilitation unit at the hospital. Wendy presents with left sided neglect, L hemiparesis of the upper extremity, difficulty ambulating, impulsiveness, and L sensory deficits. She has hypertension and Gastroesophageal Reflux Disease (GERD), and is overweight. Wendy’s husband passed away 2 years ago and she lives on her own in a bungalow. She has no children.

Examination Findings

Subjective:

In the subjective interview, Wendy reports that she has been experiencing weakness and decreased sensation in the left arm. She is oriented x 3, and understands that she experienced a major stroke recently. Prior to her admission, she had been very active (gardening, walking) and participated in many social activities such as weekly book club meetings and bingo at the community centre. She wants to return home and get back into her daily routine. She is apprehensive about standing and walking without falling and fears she will never regain her independence.

Objective:

As this case study is focused on treatment of the upper extremity as well as the pt.’s hemineglect, the details listed below include observation of functional mobility such as transfers and gait with a focus on deficits associated with neglect, outcome measures such as the CMSA, BBS, FIM, and BIT-C, and a more focused examination of the affected upper limb.  All details listed below were gathered in the first week of the patient’s stay.

The patient’s scores were 67 on the FIM, 24/42 on the CMSA Impairment Inventory, 44/105 on CMSA Activity Inventory, 26/56 on the BBS and 110/146 on the BIT-C.  PROM was within normal limits (WNL) in both upper extremities, while AROM on the left (affected) side was decreased in all directions. Of note, the patient did have 20 degrees of active wrist extension on the L, indicating she would be a good candidate for CIT of the upper extremity.  MMT revealed scores of 3-3+ at the shoulder, 2+ at the elbow and wrist, and 2- at the fingers. Sensation testing revealed decreased sensation and proprioception in the left upper extremity, with the greatest deficits distal to the elbow. The pt. also exhibited marked tactile extinction on the left, correctly identifying “both” during simultaneous stimulation 0/5 times.

As far as transfers and gait, the patient was independent with bed mobility, but required occasional cueing to ensure safe positioning of the affected extremities. She required only supervision and cueing with supine <-> sit, and minimum assistance with sit <->stand and bed<-> wheelchair transfers when leading with her unaffected side, but did demonstrate impulsivity, lack of awareness of safe positioning of her left side, and inattention to details such as the brakes on the wheelchair and her seatbelt.  If leading with her affected side, pt. required minimum to moderate assist with all transfers.

Pt. ambulated ~15m with 2ww and min assist X 2 initially. Pt. was able to grasp 2ww with assistance/cueing on L, and was able to maintain grasp independently during ambulation.  She utilized a mild circumduction strategy with her L lower extremity due to decreased knee flexion and ankle dorsiflexion, and due to external rotation of her L LE and the inattention to positioning she repeatedly caught it on the side of the 2ww. Pt.’s trunk remained rotated to the R throughout ambulation, and she did not notice objects or people on her left while ambulating.  When given control of the 2ww, pt. gradually steered to the left and would likely collide with the wall or other objects if PT and PTA had allowed her to.

Clinical Impression

Physiotherapy Diagnosis:

Pt. presents with L-side hemiparesis, with the upper extremity more affected than the lower extremity.  Sensation is intact bilaterally, although pt. exhibits decreased sensation and proprioception in L upper extremity, and tactile extinction during simultaneous stimulation of L and R sides. Overall, pt. demonstrates marked L sided neglect, with minimal spontaneous movement of L upper or lower extremities, lack of awareness of body position/objects/obstacles on L, and gaze deviation to the R. Pt.’s independence and functional mobility are significantly affected, and pt.’s score on the BBS indicate she is at high risk of falls. Pt. is currently unable to participate in her usual social roles,  as she requires supervision/assistance with transfers, gait, and most ADLs.

Problem list

• Visual and spatial neglect of the left side of her body
• Weakness and spasticity in L upper extremity
• Weakness in L lower extremity
• Decreased spontaneous use of the left upper and lower extremities due to hemineglect
• Tactile extinction due to hemineglect
• Impaired balance due to neglect/hemiparesis
• Unable to transfer/ambulate independently due to neglect/hemiparesis
• Kinesiophobia due to balance and gait deficits
• Increased risk of injury and falls due to weakness, neglect, and impulsiveness

Intervention:

Short term goals:

• Perform a reaching task with the left arm with minimal assistance/cueing within one week
• Perform a sit to stand with supervision within one week
• Independently position L upper and lower extremities appropriately during transfers with minimal cueing within one week
• Demonstrate appropriate use of visual scanning strategies during ambulation within 2 weeks
• Ambulate 50m with supervision using 2ww within 3 weeks
• Improve Berg Balance Scale score by a minimum of 7 points within 3 weeks (MCID)
• Improve CMSA activity and impairment scores by 8 points within 3 weeks (MCID)

Long term goals:

• Independent with visual scanning strategies within 6 weeks
• Independent with all transfers within 6 weeks
• Independent with ambulation with a quad cane within 6 weeks
• Able to return to reading, participate in book club meetings following discharge
• Able to return to cooking her own meals following discharge

Management program

The following is a 6 week rehab intervention created for Wendy, with a focus on improving motor activation and control of the affected upper extremity and targeting the hemineglect.  PT sessions will be focused on task-oriented activities with approximately half an hour per session devoted to the upper extremity 5x/week which has been demonstrated to improve hand function and activities of daily living in as little as 4 weeks. The other half hour will be devoted to functional mobility including balance, gait and transfers.  We will incorporate CIT and Visual Scanning strategies in all activities during the training sessions.

• Task-oriented upper extremity interventions:
  • Bingo-based reaching tasks in both standing and sitting
  • Gripping and weight-bearing activities with affected arm during gait and balance training
  • (OT will also work on cooking tasks and other functional activities as part of their sessions)
• CIT:
  • Patient will engage in 2hrs/day intensive practise with affected arm plus an additional 3hrs/day with the affected limb constrained for a total of 5hr/day of CIT. (in accordance with viaTherapy app parameters- Insert reference here, include mention that pt. meets requirements for active wrist and finger extension)
  • Both OT and PT will incorporate CIT into their sessions
• Visual Scanning:  (EBSR Stroke Rehabilitation Handbook recommends)
  • Integrated throughout PT session (roughly 1hr/day) and OT session (1hr/day). Scanning involves feedback following every attempt. Cues repetitively encourage the individual to attend to the L side.
  • Once pt. has some comfort with visual scanning during ambulation in a stable environment, PT will randomize environment to the left of pt. with inclusion of different obstacles and/or people that pt. must notice using visual scanning strategies and navigate around. (Kat will provide reference to this )
• Transfers: practice conducted throughout day with OT/PT and nursing staff
• Ambulation/Gait: At least 2x/day with 2ww and assistance initially, progressing as appropriate towards independence and a more mobile gait aid.

Outcome

Following a 6-week stay on the intensive stroke rehab unit, the patient exhibited marked improvement on a number of outcomes. Again, as this case study is focused on treatment of the upper extremity as well as the pt.’s hemineglect, the improvements listed below include those to do with functional mobility such as transfers and gait with a focus on features associated with neglect, outcome measures such as the CMSA, BBS, FIM, and BIT-C, and specific improvements associated with the affected upper limb.

Relevant outcome measures were assessed in the final week of the patient’s stay on the rehab unit.  The patient’s FIM score was 84 (up from 67 at admission), the CMSA Impairment Inventory was 32/42 (up from 24/42), the CMSA Activity Inventory was 55/105 (up from 44/105), the BBS was 34/56 (up from 26/56), and the BIT-C was 119/146 (up from 110/146). PROM remained WNL bilaterally, while AROM on the L improved in most directions.  Most notably, shoulder flexion improved to 110 degrees (from 70), and wrist extension improved to 30 degrees (from 20). MMT of left upper extremity showed significant improvements as well, with scores of 4 at the shoulder and elbow, and 3-3+ at the wrist and hand. Sensation testing revealed that patient was no longer reporting decreased sensation on the left, and that her proprioception in the L upper extremity had improved although still showed deficits.  Patient continued to exhibit tactile extinction on the left, reporting “both”only 2/5 times with simultaneous stimulation of left and right.

The patient’s functional mobility has also shown significant improvement over the course of the her stay. Patient is independent with all transfers at this time, demonstrating appropriate use of visual scanning strategies, safe positioning of her left extremities, and proper sequencing with brakes and seatbelt on the wheelchair. It is not recommended at this time that she engage in transfers leading with the affected side due to the continued evidence of neglect. Pt. ambulates ~50m independently with 2ww, and demonstrates appropriate visual scanning strategies to maintain position in centre of ward hallway, and to avoid people/obstacles on her L. She maintains her trunk and head in a neutral position during ambulation, grasps the 2ww with both hands, and maintains control of 2ww throughout ambulation independently.

Discussion

This case study presented an individual with R MCA stroke that resulted in L side hemiparesis of the upper extremity and L sided neglect. In an effort to address the L side motor impairments and the challenges of neglect, we employed a 6 week intervention that involved CIT and VST. CIT focused on constraining the unaffected limb for the duration of 5 hours per day with task-oriented activities such as bingo, gripping, and reaching activities performed during PT sessions for a minimum of 1 hour of the proposed 5 hours of CIT daily. VST involved the therapist directing the patient’s attention to their left as they participated in a task-oriented activity such as bingo with their unaffected limb constrained. CIT encourages the patient to use the affected limb to completed a task and VST is an important technique for encouraging attention to the neglected side.

Following the intervention, we noted improvements in several outcomes including visual and spatial attention, sensation, balance, ambulation, and transfers. Patient still exhibited tactile extinction but was able to manage due to the techniques employed. Currently, there is a lack of research that combine the effects of CIT and VST although past systematic reviews have alluded to the potential combined benefit of CIT and VST. Based on outcomes of this case study, research into combined use of CIT and VST when working with patients with both hemiparesis and hemineglect should be considered.

Self-study questions

1) Which of the following are treatment options for hemispatial neglect?

1. Prism training
2. Neck vibration training
3. Visual scanning
4. All of the above

2) Which outcome measures were included in Wendy’s case?

1. CMSA
2. Grip strength
3. Alpha-FIM
4. 6min walk test

3) What was the key intervention used in this Case Study

1. Visual scanning combined with neck-vibration therapy
2. Constraint induced therapy combine with prism training
3. Constraint induced therapy combine with visual scanning
4. Functional activity rehabilitation combine with neck vibration therapy

References