1st CASE PRESENTATION

Friday, 2 May 2014

REHABILITATION OF
INTRACEREBRAL HAEMORRHAGE
STROKE SUBACUTE PHASE
Presented By:
Erik Setiawan, dr
Supervised by :
Novitri, dr, Sp.KFR
Tertianto Prabowo, dr, Sp.KFR

INTRODUCTION
STROKE

Leading
cause of
death
Neurologica
l disability

Better risk
factor
reduction &
medical
management

long term
stroke
survival

Functional
independen
ce
Permanentl
y disabled

Rehabilitatio
n
intervention
to maximize
patient QOL

DEFINITION
WHO: rapidly developing clinical signs of
focal (or global) disturbance of cerebral
function, with symptoms lasting 24 hours
or longer or leading to death, with no
apparent cause other than of vascular
origin

Risk Factors

Modifiable
Risk
Factors

Hypertension
Smoking
Dyslipidemia
Diabetes Mellitus and Other Risk
Factors

Nonmodifia
ble Risk
Factors

Age
Sex
Race
Previous stroke

Brain Vascularisation

Brain Vascularisation

Brain Vascularisation

CLASSIFICATION

Based on clinical features and temporal

profile:
1. Improving Stroke ( RIND = Reversible
Ischemic Neurologic Deficit )
2. Worsening Stroke ( SIE = Stroke in
Evolution )
3. Stable Stroke ( Completed Stroke)

Thrombotic

Ischemic
Intracrani
al
pathology

Embolic

Lacunar

Haemorrha
gic

Intracerebr
al
Subarachno
id

Intracranial Hemorrhage
10% of all cases of stroke
Most common cause:
hypertension
Site of rupture : deep
perforating cerebral arteries,
but unlike lacunar strokes ->
doesnt obey anatomic
distribution of a vessel, but
dissects through tissue planes
Rupture of microaneurysms
(Charcot-Bouchard
aneurysms) -> pockets of
extravasated blood/
pseudoaneurysms, ->
previous microscopic ruptures
within the vascular wall ->
develop in hypertensive pts

Majority : putamen or
thalamus, 10% :
cerebellum
Clinical onset : dramatic
-> severe headache,
rapidly progressive
neurologic deficits.
Brain displacement ->
transtentorial herniation
& death (first few days)
Acute mortality >
infarction,
Survive : rapid neurologic
recovery (first 2-3
months) > infarction

CLINICAL SYMPTOMS

Motor Control and Strength

Motor Coordination and balance
Spasticity
Sensation

TIME COURSE OF THE

DISEASE
Acute Phase (several days to two weeks post
stroke).
Subacute Phase (Recovery Phase) : (2 weeks
to 6 months)
Chronic Phase (Advanced Phase): (>6
months).

REHABILITATION OF
STROKE

Brunnstrom Stages of Motor

Stag
Characteristics
Recovery
e
Stag No activation of the limb

e1
Stag Spasticity appears, and weak basic flexor and extensor
e 2 synergies are present
Stag Spasticity is prominent; the patient voluntarily moves the
e 3 limb, but muscle activation is all within the synergy patterns
Stag The patient begins to activate muscles selectively outside
e 4 the flexor and extensor synergies
Stag Spasticity decreases; most muscle activation is selective
e 5 and independent from the limb synergies
Stag Isolated movements are performed in a smooth, phasic,
e6

well-coordinated manner

 Spasticity
Daily stretching, especially of the shoulder, wrist,
fingers, hip, and ankles.

Depression and Psychosocial

Consideration
Sadness, grief, anxiety, depression, despair,
anger, frustration, and confusion
Depression : 30-60% poststroke -> limit
participation & outcome by inhibiting motivation

Shoulder Subluxation
Careful positioning of the shoulder serves to
minimize subluxation and later contractures

PROGNOSIS
Prognosis ad vitam: depends on stroke
type, site and size brain lesion, risk factor,
comorbid disease or condition and
complication.
Prognosis ad sanationam: The probability
of stroke recurrence is highest in the post
acute stroke period. Risk factors for initial
stroke also increase the risk of recurrence.

Prognosis ad functionam, depends on:

Onset post-stroke
Most improvement is noted in the first 6 months, although as
many as 5% of patients show continued measurable
improvement to 12 months post-onset.

Site and size of neuroanatomical lesion.

Comorbid diseases or conditions.
Complications
Patients motivation and family support
Availability of professional rehabilitation personnel &
facility

Case Report

ANAMNESIS (5 April 2014)

Mr Y, 52 years old, right handed, married, moslem,

lives in Kiaracondong, Bandung. He was consulted
from Neurology Department of Hasan Sadikin
Hospital during his hospitalization on 8-20 March
2014 with diagnosis intracerebral hemorrhage
stroke left carotid system risk factor hypertension,
hypertension stage II, dyslipidemia
Chief Complain:
Weakness on his right limb

him
Sudden Slurred
right speech
limbs , people understands
2
weeks
after
discharged
weakness better
upon waking
Speech
still drank
slurred but people

NGT
removed,
never
choked
when
up from sleep. Cant
understands him better
water
nor
ate
meals
with
rice
move right arm & leg at
hand,
Sometimes
choked
when drank

Could
raise
right
arm,
fingers,
foot,
all
water
straw
toes: not
full ROM in against
norusing
eliminated
Slurred speech
+, mouth
Walk
around
the
house
&
gravity
deviation to
left
neighborhood
w/o supporting device
Move
right
ROM in gravity
Numbness
on right
leg forearm: full nor
creeping on walls +- 300 m with
eliminated
Didnt
lose
afull
couple
rest
stops. Cant climb&

Move
right
hip
&
knee:
ROM
against
consciousness,
but
down stairs. Never falls.
gravity,
yield
resistance
looked confused for against
a
No numbness
right leg

Side
lie
&
sit
independently,
stand on
with
while
ER Pindadsupport
Hospital -> BP

Numbness
of right leg decreased
260/190
Wife
him ate and changed clothes
Referred
tohelped
Hasan
Sadikin
Hospital:
Could brush his teeth, ate & drank
ruptured
brain
blood
independently using left hand. Right
vessels & hospitalized 14
hand
help
2 weeks hospitalization
->cant
discharged
days
him bathing
by picking up
Program: stand by hisWife
bed helped
with support
&
3 days hospitalization
dipper & washing him. He could handle
walk
the
house
Able to move right hip
andaround
knee: full
ROM,
but with support as
soap using left hand & occasionally
tolerated
no against gravity, right
elbow: slight
right
hand
PROM right limbs & AROM
left
limbs 3x/d
movement
Grooming,
toileting,
dressing
Shoulderdisturbance
positioning
when lying supine,
No defecation nor urination
independently, mainly using left hand
standing,
walking
Program: proper bedsitting,
positioning,
turning/
2
Regularly
Medications:
Captopril
3x50mg, exercises
Amlodipinright limbs with
hr, PROM right limbs,
AROM left limbs,
wife 3x/d
1x5mg, Simvastatin 1x10mg
oromotor massage (NGT+)
No pain on movement
Controls to Pindad Hospital

History of past illness

History of hypertension (+) 3 years ago, highest
BP 180/? & average BP 160/110. No routine
control nor take regular medication.
History of dyslipidemia (+) known when
hospitalized -> Simvastatin 1x10 mg.
History of diabetes mellitus, cardiovascular
disease, high uric acid was denied
History of prior stroke was denied
History of hearing loss of left ear (+) 2 years ago.
Habit of cleaning ears with stick or match. Never
consulted to ENT doctor

History of Familial Diseases

History of familial hypertension, diabetes mellitus,
and heart disease is denied
History of Habits:
Smoking (+) 2 packs/ day since 1975, stopped after
stroke
Eating fatty food (+)
Doing sport or exercise (-)
Speech defect on pronouncing /r/ before stroke

Psychosocial History :
Graduated from senior high school.
Married to second wife and has 3 children (2 from his
first wife & 1 from the second). Two older children are
married & youngest child is still in junior high school.
Lives in mother-in-law house with his 2 nd wife, his
youngest child, his mother-in-law, his 2 nd wifes
siblings and their family.
House: 2 floors, sized 3x16 meters, 4 bedrooms, &
filled with 10 persons. Its facility from TNI-ABRI lent to
his late father-in-law & mother-in-law and will be taken
away after his mother-in-law pass away.
He hopes that he can work again soon to rent another
house.

 He uses squatting toilet and doesnt find difficulty. The

toilet has ceramic floor, good ventilation & lighting.
The bathroom has water sink, ceramic floor, enough
lighting, but less ventilation.
His bedroom is in 1st floor, enough lighting, but less
ventilation. Bed on the floor. His family removed the
bed support because fear that he would fall from bed.
It is 10 meters away from toilet.
There are stairs in the house, but he doesn't need to
go upstairs

 After the sickness, he often feels sad and sorry because

he didnt have good habits before and didnt take his
wifes advice.
He doubts his boss will take him back to work. Wife
occasionally finds him crying when he was alone. He is
not interested in watching television as before, but he
occasionally have preference to eat something.
He gets angry easily although he knows that the person
he angry with doesnt mean any harm. He resolves his
anger quickly.
He listens to his wifes advice now & very motivated so
that he often exercises with his wife and takes a walk
around the house.
He has good relationship with families & neighbors. His
family always gives support.

 His monthly budget for daily living until date

is covered by his savings. He made 1.5 2
million/ month before sickness. Wife doesnt
work.
He uses BPJS PBI for medical insurance.

House

2-lane
street

Living Room

Toilet

Bathroo
m

Kitche
n

Bedroom

History of Vocational and

Avocational
Before the illness, he is a cloth
screener in a garment
workhouse since 1975.
The job requires him to use both
of his arms in standing position
and to walk around a room.
He often works overnight and
doesnt eat regularly and
properly because of strict
dateline.
The job depends on orders -> no
regular income.
He prays at mosque once a
week.
He occasionally played ping
pong in his leisure time.

After the illness, he has not

work ever since.
He has been told that his boss
will take him back after his
recovery, but he doubts it. He
hopes that he can work again
soon.
He can now go to the mosque
to pray once a week, but he
prays sitting because he hasnt
been able to endure rukuh
and sujud. He can rise from
sitting to standing w/o help.
His leisure time is filled with
walking around in neighborhood
and watch television.

PHYSICAL
EXAMINATION

FUNCTIONAL ASSESSMENT
1. Cognitive : (ICD-9CM : 89.13)
MMSE = 25/30 (normal cognitive function) -> impaired in orientation, attention &
calculation, recall, language

2. Communication : (ICD-9CM : 89.15)

Naming (pictures) in word level = 5
Mention names in a semantic category = 5
Conclusion : no language disorder

3. Feeding : (ICD-9CM : 89.15)

TOR BSST =
Before intake : normal sound, tongue movement slightly deviated to the right
Intake : no cough, no change of sound, no drooling
After intake : normal sound
Swallowing function = normal

4. Balance: (ICD-9CM : 89.15)

Berg Balance Scale = 48/ 56 (low fall risk) -> impaired in placing alternate foot

FUNCTIONAL
ASSESSMENT
5. Gait Analysis: (ICD-9CM : 93.09)
hemiparetic gait

Arm
Reduced
right arm
swing,
flexor
synergic
Sagital pattern +

Coronal

Trunk
Pelvic
Trunk bends
anterior in
the right leg
late stance
phase

Hip joint
Reduced hip
extension in
late stance
phase

Slight right hip

circumduction
in swing phase

No hip
hiking

Shorter step & stride length

Knee joint
Reduced right
knee flexion in
swing phase

Right knee
hyperextension
in stance phase

Ankle joint
No heel strike of the
right foot

No push off of the

right foot in late
stance phase

Reduced ankle
dorsiflexion of the
right foot in swing
phase

FUNCTIONAL
ASSESSMENT
6. Activity of Daily Living : (ICD-9CM :
93.09)
Barthel Index = 11/20 (moderate disability)
-> impaired in feeding, bathing, grooming,
dressing, toileting, climbing stairs
IADL (Lawton & Brody) = 0 -> impaired in all
aspects

SUPPORTING
EXAMINATION
Chest X-Ray (7 March 2014)
Tidak tampak TB paru aktif
Tidak tampak kardiomegali

Head CT scan (7 March

2014)
Perdarahan intraserebral ganglia
basalis sampai substansia alba
periventrikel lateral kiri disertai
lesi hipodens disekitarnya yang
menyebaban midline shift sejauh
0,3 cm ke kanan. Hidrosefalus
ringan

Laboratory findings

8 March 2014
Ureum : 32 mg/dl
Kreatinin: 0,9 mg/dl
Random blood sugar
: 125 mg/dl

10 March 2014
Total Cholesterol: 176
mg/dL
HDL Cholesterol: 36
mg/dL
LDL Cholesterol: 126
mg/dL
Trigliseride : 101 mg/dl
Fasting blood sugar :
104 mg/dl
Uric Acid : 6,7 mg/dL

DIAGNOSIS
Clinical Diagnosis
Intracerebral haemorraghic stroke subacute phase with mobilization, ADL & IADL disorders, and
dysphagia due to right side hemiparesis, right central VII & XII nerve paresis (I62.9, R26.8,
Z73.6, R13, G81.9, G52.7)
Hypertension grade II on medication (I10)
Dyslipidemia (E78.5)
Right shoulder subluxation (M24.31)
Conductive hearing loss of the left ear (H91.9)
Etiological Diagnosis
Intracerebral haemorhage with risk factor: hypertension, dyslipidemia, smoking
Location Diagnosis

Neuromuscular system, musculoskeletal system, metabolic system

Functional Diagnosis
Impairment Right hemiparesis
Right central VII & XII nerve paresis
Dysphagia
Right shoulder subluxation
Disability ADL & IADL
Mobilization
Handicap Vocational & Avocational

PROGNOSIS
Quo ad Vitam
: ad bonam
Quo ad sanationam : dubia
Quo ad functionam : dubia ad bonam

PROBLEM

M1
M2
M3
M4
R1 :
R2 :
R3 :
R4 :

: Stroke
: Hypertension
: Dyslipidemia
: Right shoulder subluxation
Mobilization
ADL and IADL
Dysphagia
Vocational & Avocational

REHABILITATION GOAL
Short term :
Maintain ROM to maintain flexibility
Improve muscle strength of right side hemiparesis
Improve balance
ADL independently
Prevent shoulder subluxation complication
Long term :
Prevent recurrent stroke by controlling hypertension,
dyslipidemia, stop smoking
Improve cardiopulmonary endurance
Regain optimal gait pattern
Back to work

MEDICAL PROGRAM
1. Stroke
S:
O:

Right side limbs weakness

Right side upper and lower limb weakness
Spasticity (MAS) grade 1 for right upper & lower limb
Right central VII & XII nerve paresis
Head CT scan: Intracranial haemorrhage of basal ganglia
Low risk of fall
MMSE = 25/30 (normal cognitive function) -> impaired in
orientation, attention & calculation, recall, language
G:
Prevent recurrent stroke
Improve functional capability
P : - Educate the patient and family about stroke, risk
factors, time
course, and recovery of stroke
- Assess psychological status in the next meeting

MEDICAL PROGRAM
2. Hypertension
S:
History of
hypertension
O:
Blood pressure 130/90
mmHg on Captopril 3x50 mg
& Amlodipin 1x5mg
G : Control regularly and
reduce risk factor
P :
- Educate the patient
to control to Neurology
Department and take the
medicine regularly (Captopril
3x50mg, Amlodipin 1x5mg)
- Consult to nutrisionist for
low salt diet

3. Dyslipidemia
S : History of dyslipidemia
known since hospitalized
O:
Total Cholesterol
: 176
mg/dL
HDL Cholesterol : 36 mg/dL
LDL Cholesterol : 126 mg/dL
Trigliseride : 101 mg/dl
G:
Control regularly and
reduce risk factor
P : - Educate the patient to
control to Neurology
Department and take the
medicine regularly (Simvastatin
1x10mg)
- Consult to nutrisionist for low
fat diet

MEDICAL PROGRAM

4. Shoulder subluxation
S : No pain on limb movement
O:
Right shoulder subluxation (1 cm)
G:
Prevent right shoulder subluxation
complication
P : - Educate caregiver & patient about Active
Assistive ROM exercise movement
- Shoulder sling at daylight or whenever active
- Shoulder positioning at night or whenever at rest

REHABILITATION
PROGRAM
1. Mobilization
S : Patient walks with abnormal gait and tires easily
O:
Weakness of right lower limb (MMT 3423)
Proprioceptive: impaired for right lower limb
Hemiparetic gait
G:
Short term : Maintain ROM to maintain flexibility
Improve muscle strength of right side hemiparesis
Improve balance
Long term : Improve cardiopulmonary endurance
Regain optimal gait pattern
P : Short term : - Active Assistive ROM exercise for lower limbs
- Exercise testing with ergocycle
- Ergocycle for endurance & strengthening exercise
Long term : gait training

REHABILITATION
PROGRAM
2. Activities of Daily Living
S:
Patient brushes his teeth, eating, & drinking using his left hand,
needs
help to pick up the dipper and wash himself while bathing, cant
climb & down stairs, grooming, toileting, and dressing can be done
independently if mainly uses his left hand
O:
Barthel Index = 11/20 (moderate disability) -> impaired in feeding,
bathing, grooming, dressing, toileting, climbing stairs
IADL (Lawton & Brody) = 0 -> impaired in all aspects
Weakness of the right upper limb (MMT 2311)
Impaired right hand prehension and dexterity
Trunk weakness (MMT: flexion = 4, extension = 4, rotation = 4)
Weakness of right lower limb (MMT 3423)
Proprioceptive: impaired for right lower limb
Hemiparetic gait
G:
Independence in activities of daily living
P : Active Assistive ROM exercise for upper limbs
Electrical stimulation for right wrist & hand

REHABILITATION
PROGRAM
3. Dysphagia
S : Patient is choked when
using straw to drink. He
isnt choked when drinking
directly from a glass nor
when eating rice
O:
pa/ta = clear, ka/ =
less clear
TOR BSST: normal
G:
Eating and drinking
without risk of aspiration
P : Educate patient to drink
directly from a glass or by
spoon

4. Vocational & Avocational

S: patient hopes to be able to get back to
work
O: Weakness of the right upper
limb
(MMT 2311)
Impaired right hand
prehension and
dexterity
Trunk weakness (MMT: flexion = 4,
extension = 4, rotation = 4)
Weakness of right lower limb (MMT
3423)
Proprioceptive: impaired for right
lower limb
Hemiparetic gait
G:
Assign patient for work
P : - Active Assistive ROM exercise for
upper limbs
- Electrical stimulation for right wrist &
hand

DISCUSSION
Anamnesis: sudden weakness of his right limbs upon waking
up from sleep at night. He couldnt raise nor move his right
arm and leg at all. BP at ER was 260/190.
Physical examination: right hemiparesis and right central
paresis of VII & XII nerve, increase of physiologic reflex,
presence of pathologic reflex and spasticity.
Anamnesis and physical examination -> haemorrhagic stroke
This patient has contralateral hemiparesis and contralateral
cranial nerve paralysis -> carotid system circulation stroke.
Risk factor : smoking, hypertension, and dyslipidemia
The time course of this case is 2 months, it is a subacute
phase stroke.

 Impairment : right hemiparesis, right central VII & XII nerve

paralysis, dysphagia, right shoulder subluxation disable in
mobilization, ADL, and IADL.
He feels sad and depressed because of his sickness. He also
becomes easier to be angry
Rehabilitation program is emphasized on optimalizing neurological
recovery while preventing complications so that his recovery
progress is facilitated well to achieve optimal functional capability
possible.
Prognosis ad vitam : ad bonam the vital signs are stable and the
risk factors has already been controlled
Prognosis sanationam : dubia the patients compliance in control
to neurologist for his hypertension & dyslipidemia, consume the
medications regularly, and diet modification is questionable,
although ICH recurrence rate is relatively small
Prognosis ad functionam : dubia ad bonam he has good
motivation to do exercises, although he sometimes ignores shoulder
positioning. By these 2 months, the recovery progress of his limbs
weakness is still positively progressing

CASE ANALYSIS

FOLLOW UP (20 April 2014)

SUBJECTIVE

1.
MOBILIZATION

Patient claims that he could walk around his house

twice further than the last meeting with less frequent
rests.
OBJECTIVE

PE

Lower

extremities

ROM
Full/ Full (See attachment 1 for further details)
MMT
(See attachment 1)
Spasticity
Flexion = 0 (Modified Asworth Scale)

Extension = 1 (Modified Asworth Scale)

Proprioception Good/good

Functional

Assessment
Cardiopulmon Exercise testing with ergocycle -> failed to conduct
ary
because patient has difficulty in maintaining balance on
Endurance
the ergocycle
Test (ICD-9CM
: 93.09)

ASSESSMENT Mobilization disorder due to right side hemiparesis

(R26.8, G81.9)
GOAL
Short term :
Maintain ROM to maintain flexibility
Improve muscle strength of right side hemiparesis
Improve balance
Long term :
Improve cardiopulmonary endurance
Regain optimal gait pattern
PROGRAM
Short term : Active Assistive ROM exercise for lower
limbs
Strengthening exercise right lower limbs
Plan : 6MWT
Long term : gait training

SUBJECTIVE

OBJECTIVE
PE
Upper
extremities
ROM
MMT
Spasticity

Hand
Prehension

Lower
extremities
ROM
MMT
Spasticity

Proprioceptio
n
ASSESSMENT
GOAL
PROGRAM

2. ACTIVITIES OF DAILY LIVING

He feels that his right arm is a little stronger. He still

needs his wife to wash him using dipper while
bathing, but he can soap his body using his right
hand better. However, he hasnt been able to spoon
his meal nor take up a glass of water to his mouth by
using his right hand.

Full/ Full (See attachment 1 for further details)

(See attachment 1)
Flexion = 1+ (Modified Asworth Scale)
Extension = 1 (Modified Asworth Scale)
Power Grip
Fist/ palmar
: good / good
Cylindrical
: good / good
Spherical
: poor / good
Hook : fair/ good
Precision Grip
Tip-to-tip
: poor / good
Three-prong chuck: poor / good
Lateral pinch : poor / good

Full/ Full (See attachment 1 for further details)

(See attachment 1)
Flexion = 0 (Modified Asworth Scale)
Extension = 1 (Modified Asworth Scale)
Good/good

ADL disorder due to right side hemiparesis (Z73.6,

G81.9)
Independence in activities of daily living

ADL exercise with right hand

Active Assistive ROM exercise for upper limbs

SUBJECTIVE

3.
DEPRESSION

He still gets sad and depresses when he is lonely. He gets angry easily,
but also resolves quickly. He is still highly motivated to exercise because
he wants to recover well from his sickness.
OBJECTIVE

Functional

Assessment

Psychological
Depression Anxiety Stress Scale (DASS) :

status: (ICD-9CM :
Depression = 10 (mild depression), Anxiety = 0 (normal), Stress = 6
93.94)
(normal)

Hamilton Depression Scale (HAM-D) = 10 (mild depression)

ASSESSMENT
Mild depression (F06.3)

GOAL
Alleviate depression

PROGRAM
Consult psychiatrist

THANK YOU