72 yo with significant CVA

1. 72 yo with significant CVA Cathy Ciolek, PT, DPT, GCS

2. Initial Evaluation • Subjective information • 72 yo female • Cva July 09 with probable 2nd cva in same time frame • family brought her to PT via paratransit in wheelchair • What else do you want to know?

3. Subjective • Home Situation • Has reclining wheelchair for mobility • Uses paratransit for doctors appts • W/C accessible house • Hoyer lift for transfers • Lives with husband but has 9 children, several local who assist • Prior Medical History • Heart disease • Mitral valve (rep 2000) • Seizure immed p cva • Diabetes • Arthritis • Right Hand Dominant • Native of Jamaica

4. Subjective (cont) • At eval- getting outpt OT and ST • Able to do some self feeding with cup, no swallowing issues (or thickened liquids required) • Tracheotomy and Peg tube scheduled for removal, able to speak but does rarely • Minimal to no active use of right arm and leg • Uses left arm to self feed • Minimal to no sitting without support at home • Out of bed to wheelchair ~3-4 hours per day

5. Subjective (cont) • Meds • Keppra • Baclofen , • Coumadin • Zocor • Digitalis • PT History • Minimal PT immediately post cva(s) • Minimal PT since • Somewhat questionable - Family Goals: for her to be able to walk, transfer

6. Question #1 • Based on her past medical history and medications- her stroke(s) was most likely a result of: • Brain bleed/ hemorrhage • Blood clot • Brain bleed and clot • None of the above

7. Initial Examination • Where do you start your examination?

8. Initial Evaluation • Vital Signs- BP: 115/65, HR: 80 bpm, SpO2: 98% • Observation- seated in high back wheelchair, utilizing full support- patient head position never looked beyond central locations to the right, generally attentive to left sided activities and head resting tilted and rotated left • ROM- not specifically measured, limited dorsiflexion (neutral left, less than neutral right) , minimally diminished knee extension on right (seated) (UE not assessed at eval) • Sensory- ?- responded to left UE correctly, not right UE or really either LE accurately • Motor- observed moving left hand to mouth/nose voluntarily but not on command, no volitional movement in right arm.

9. Initial Evaluation (cont) • Special tests- no clonus noted, no tremors noted • Tone- some increased tone noted right LE/UE and left LE • Transfers • Wheelchair to mat- dependent x 3 via transfer/sliding board • Supine to/from sit- dependent x 3 • Sit to stand- dependent x 3 (2 seconds standing)

10. Initial Evaluation • Sitting: Patient able to extend L knee, palpable anterior tibilais contraction when asked to DF L, did not actively move other LE joints and no palpable contraction B. Supine: Patient was not able to actively move either LE (No palpable muscle response for desired motions), therefore unable to determine if synergy is present. • Sitting Balance- dependent to sit upright • Off center to right side or posterior with decreased weight on left buttocks • Sitting Tolerance- unable to assess as not sitting without support

11. Question # 2 • Pusher syndrome is characterized by the patient • Actively pushing towards the contralateral side from the brain lesion • Actively pushing towards the ipsalateral side of the brain lesion • Believing their body is “upright” when tilted to the side • A and C • B and C

12. Question # 3 • Neglect of one side after stroke is often associated with all of the following except: • Visual field cut • Decreased sensory feedback • Pain in impaired arm/leg • Decreased motor activity and proprioceptive feedback

13. Assessment/Evaluation • What are her major impairments? • What is her prognosis? • What goals would you set for this patient? • What psychosocial issues would play a factor for this patient?

14. Assessment • Impairments we decided to intervene with: • Impaired endurance • Impaired sitting balance/sitting tolerance • Impaired muscle function limiting use of bilateral UE/LE • Prognosis we determined: good for goals as established • Good family support • Set goals fairly low

15. Goals for PT • Short Term Goals: • Goal is to evaluate and assess participation/ tolerance for standing frame in 2-3 visits. • Patient will be able to maintain upright sitting posture without support for 3-5’ to allow some active participation in personal hygiene. • Patient will tolerate standing (with support from traditional stander) for 5’ to increase weight bearing and upright endurance for progression towards family goal of standing. • Long Term Goals: • Patient will be able to maintain upright sitting posture without support for 10’ to allow some active participation in personal dressing. • Patient will tolerate standing (with support from traditional stander) for 10’ to increase weight bearing and upright endurance for progression towards family goal of standing

16. Plan of Care • What frequency and duration would you choose? • What interventions would you use to accomplish your goals? • What other factors do you need to keep in mind?

17. Plan of Care • Skilled PT 3x’s/week for 12 weeks • Interventions to Include: • Therapeutic Exercise • Neuromuscular Re-education • Transfer Training • Patient/Family Education • Psychosocial Issues/Complicating Factors • Decreased attention span • Decreased awareness right side(neglect), probably visual field cut • Aphasia (expressive and receptive? Unsure) • Family goals are completely unrealistic!

18. Psychosocial Issues • Family has completely unrealistic goals • Family dynamics • Over course of PT met 2 daughters and 1 son, each who provide some care • Primary caregiver during week is daughter who mostly attends PT • Weekend caregivers reportedly not following same schedule (staying in bed more of the day) • Family generally ignores patients wishes* • Patient learning abilities • Patient comprehension • Patient motivation

19. Typical Session • Vital Signs • Transfer to mat • Work on sitting balance/reaching • Moving from support to no support • Changing surface (rocker board, swiss disc) • Reaching activities with left arm (marbles, clothes pins, folding towels, making dough, rolling dough) • Work on facilitated motor control • Kicking with left and right LE • Abd/add with left and right LE • Right UE • Work on standing (if able)

20. Question # 4 Before we started any substantial standing (beyond transfers) we contacted the physician for clearance- what do you think was the key reason for this contact? A. Vital signs aren’t stable enough to stand B. This intervention was not listed on the prescription C. Concern for bone health/osteoporosis D. Concern for cardiac history- stress of standing

21. Care Management • Contacted primary care physician several times • Clearance for standing/bone integrity • Irregular heart rate noted • Requested assessment for anti-depressant • Contacted several DME reps regarding possible home standing unit

22. Outcomes/Results • Re-evaluation after ~90 Days • Patient sitting for 50 minutes without support on mat table • Utilizing left UE for reaching in PT, self feeding all the time at home and starting to search out right hand and try to use it for activities • Family dresses her while lying down- she helps occasionally • Standing frame attained >10 minutes- working on home unit as option • Transfers at home with 2 people OR with hoyer if 2 people not available • Problems • Family does not allow her to sit unsupported at home • Still not engaging beyond midline- limited cervical ROM, tone and pusher • Participation in PT and at home varies • Family allowing her to be passive

23. Question # 5 • During today’s treatment session therapy included the following interventions: • 10 min transfer to/from mat • 35 min balance activities while sitting on the mat • 10 min facilitating use of right and left UE motor control • The Most appropriate billling if this patient was Medicare (and no other Medicare pts were being treated simultaneously) would be? • 1 unit 97110(Ther Ex), 1 unit 97530 Inc Fnct Perf, 1 Unit 97112 Neuromuscular Re-education • 1 unit 97530 Increase Fnct Perf, 3 units 97112 Neuro musc Re-ed • 4 units 97110 Ther Ex • 3 units 97110 Ther Ex