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

Abstract A narrative abstract includes a summary of the purpose, case presentation, intervention and outcomes. Should be written after you have completed the rest of the case.

Introduction The following case presents an individual with left spatial neglect and left side motor and sensory deficits following stroke. The purpose of this case study is to create an effective rehabilitation program utilizing constraint induced therapy (CIT) in combination with visuospatial training methods to encourage optimal rehabilitation. Individuals with spatial neglect following stroke present greater challenges in regaining motor function of the paretic limbs (Nijboer, Kollen, & Kwakkel, 2014) leading to impaired motor and functional recovery, increased risk for falls, increased hospitalizations, and a lower likelihood of home discharge and community reintegration (Chen et al., 2015). Although there are several methods used to treat spatial neglect such as prism training, mirror therapy, and neck muscle vibration, a 2015 review by Gillen et al. 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 (Barrett & Muzaffar, 2015). In terms of motor training, CIT is considered effective in promoting the use of the paretic limb and regaining motor function (Peurala et al., 2012). Therefore, our aim is to harness the benefits of CIT for individuals with spatial neglect through combined treatment with VST. In this manner, we hope to improve recovery time, decrease the risk of falls, and have the individual return to their activities of daily living.

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 two storey house. She has no children.

Examination Findings

Subjective:

In the subjective interview, Wendy reported that she has been experiencing left shoulder pain (3/10 on the VAS scale) 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:

Initial assessment in the first week of the pt.’s stay on the Rehab unit included assessments using the Chedoke McMaster Stroke Assessment and Berg Balance Scale as well as a functional mobility assessment looking at transfers and gait, and an overall assessment of strength, muscle tone, and sensation.

• FIM: 67 (assessed by acute care team day 3 post-stroke)
• CMSA:
  • Impairment Inventory: = 23/42
  • Activity Inventory: = 44‬/105 BBS: =‬ 26/56
• Transfers:
  • Bed Mobility: Independent with cueing for appropriate positioning of L upper extremity
  • Supine <-> Sit: Supervision/cueing needed to unaffected side, Min Assist x 1 needed to affected side
  • Sit <-> Stand: Min Assist x 1, pt. demonstrates impulsivity and lack of awareness of position of L extremities, needs cueing for appropriate positioning of 2ww
  • Bed <-> Wheelchair: Supervision/cueing needed if leading with unaffected side, Mod. Assist needed if leading with affected side. Pt. requires repeated cueing with brakes, seatbelt, and general wheelchair set-up.
• Posture:
  • In sitting: Upper trunk rotated to R, with gaze approximately ~25 degrees R of midline. L upper extremity resting on lap, adducted and supinated, with L elbow flexed to ~35 degrees, fingers and thumb flexed into loose fist. L lower extremity externally rotated and abducted, L foot slightly inverted and plantar flexed.
  • In standing: Trunk rotated to R, L upper extremity hanging loosely at side, fingers and thumb flexed into loose fist. Pt. leans to R with weight-bearing on R>L. L lower extremity externally rotated, L knee intermittently hyper-extended if pt. weight-shifts to L
• Gait: (with 2ww and Assist x 2): Pt. has short step length bilaterally, with R shorter than L, and increased stance time on R. L L/E is externally rotated, and pt. requires cueing/assistance to avoid catching foot on the 2ww. Pt. shuffles feet, although does have observable heel-toe pattern on R>L. Dorsiflexion to neutral on L with flat foot contact. Decreased knee flexion on L during swing phase, mild circumduction strategy used to advance L L/E. Hip flexion WNL on L. Trunk rotated moderately to R, and patient weight bearing on R>L. L shoulder lower than R. Pt. able to grasp 2ww with assistance/cueing on L, and able to maintain grasp independently during ambulation. Of note, pt. directs 2ww to the L if not assisted with propulsion, and will collide with the wall/other objects on the L if not cued to avoid them. With fatigue, L L/E begins to buckle.
• Modified Ashworth:
  • L Elbow flexors: 2
  • L Elbow extensors: 1+
  • L knee flexors: 0
  • L knee extensors: 1
• Sensation Testing:
  • Simultaneous Stimulation:
    • Upper extremities: Pt. identifies “both” 0/5 times with simultaneous stimulation of L and R.
    • Lower extremities: Pt. identifies “both” 0/5 times with simultaneous stimulation of L and R.
  • Localization:
    • Upper extremities: Pt. able to localize touch to R/L, medial/lateral, although mentions decreased sensation in L upper extremity.
    • Lower extremities: Pt. able to localize touch to R/L, medial/lateral.
  • Proprioception:
    • Upper extremities: R WNL; L - 2/5 2nd MCP, 3/5 wrist, 5/5 elbow
    • Lower extremities: R WNL; L 4/5 1st MTP, 5/5 ankle
  • Combined cortical testing performed by OT

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 is evident in both upper and lower extremities 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 extremity Tactile extinction Impaired balance Unable to transfer/ambulate independently Left shoulder pain Kinesiophobia 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 even weight distribution of the lower extremities with assistance within one week Decrease left shoulder pain to 2/10 on the VAS scale within one week Independently position L upper and lower extremities appropriately during transfers with minimal cueing within one week Ambulate to bathroom with supervision using 2ww within 2 weeks 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 all transfers within 6 weeks Independent with ambulation with a quad cane within 6 weeks Able to climb a flight of stairs using a quad cane upon discharge Able to return to reading, participate in book club meetings following discharge Able to manage shoulder pain with at home-exercises Able to return to cooking her own meals

Management Program: