PTH-342

Physical Therapy for Neurological Disorder

Case study

 Patients name: Age: 24 years Occupation: Date of admit: 31 2551

Medical diagnosis: Subdural hematoma at

cerebral hemisphere Physical therapy diagnosis: Spastic diplegia

right

Chief complain:

 Present history 31 2551 craniotomy Subdural hematoma at right cerebral hemisphere

 5 2552 3 2554 shoulder subluxation

 Past history - 3 - - Family history - -

 Laboratory investigation - CT scan (31/10/51): Acute subdural hematoma at right cerebral hemisphere with brainstem compression - Lumbar puncture (31/10/51): CSF bleeding

- -

General observation Sthenic body build Not pale No jaundice No cyanosis Good consciousness Good orientation Good communication Ambulation by wheelchair

Functional movement (Gross motor function)

Functional movement Essential component Missing component Compensatory movement

Supine to Lt. side

(Independent)

- Neck rotation to Lt.

side - Rt. Arm cross midline - Lt. hip and knee slightly flexion

- Hip and knee slightly

flexion

- Lock rolling
- Trunk extension

Supine to Rt. Side (Independent)

- Neck rotation to Lt. side - Lt. Arm cross midline Rt. hip and knee slightly flexion

- Hip and knee slightly flexion

- Lock rolling - Trunk extension

Rt. side lying to sitting (Independent)

- Neck lateral flexion - Trunk lateral flexion - Hip and knee flexion

- Neck lateral flexion - Trunk lateral flexion - Hip and knee flexion

- Neck flexion - Trunk flexion in long sitting position

Motor system
Quality of movement Upper Extremities Right side: Good all direction of movement Left side: Good all direction of movement

Direction of movement Lower Extremities Hip flexion with knee flexion Hip Abduction Hip Adduction Knee Flexion Knee Extension Ankle dorsiflexion Ankle plantarflexion

Placing Right Poor Poor Poor Poor Poor Poor Poor Left Poor Poor Poor Poor Poor Poor Poor

Holding Right Zero Zero Zero Zero Zero Zero Zero Left Zero Zero Zero Zero Zero Zero Zero

Range of motion (PROM): Upper Extremities

Right side: PROM Full ROM all joints all direction

Left side: Limit ROM at inner range -Shoulder Flexion -Shoulder Abduction -Shoulder External rotation direction

: Lt. Shoulder subluxation 1.5 cm.

Range of motion (PROM): Lower Extremities

Right side: limit ROM at inner range - Hip Flexion - Hip Abduction - Hip Internal rotation direction

Left side: limit ROM at inner range - Hip Internal rotation - Ankle dorsiflexion direction

Muscle tone: Upper Extremities Right side: - Normal tone Left side: - Mild spasticity of Shoulder Flexor muscles, Shoulder Abductor muscles and Shoulder External rotator muscles

Muscle tone: Lower Extremities

Right side: - Severe spasticity of Hip Flexor muscles, Knee Flexor muscles and Intrinsic of foot muscles - Mild spasticity of Hip Abductor muscles and Hip Internal rotator muscles
Left side: - Severe spasticity of Hip Flexor muscles, Knee Flexor muscles and Intrinsic of foot muscles - Mild spasticity of Hip Abductor muscles, Hip Internal rotator muscles and Ankle Dorsiflexor muscles

Muscle length: Upper Extremities Right side: - Normal tone Left side: - Tightness of Shoulder Extensor muscles, Shoulder Adductor muscles and Shoulder Internal rotator muscles

Muscle length: Lower Extremities Right side: - Tightness of Hip Extensor muscles, Hip Adductor muscles, Hip External rotator muscles Left side: - Tightness of External rotator muscles and shortening of Ankle plantarflexor muscles

Deep tendon reflex

Pathological reflex
Pathological reflex Babinkis sign Clonus - Quadriceps - Ankle Clonus No Clonus No Clonus Clonus Right Extensor response Left Extensor response

Sensory system
Sensory system Superficial sensation - Light touch - Pinprick Right Left
- Intact Light touch of - Intact Light touch UE&LE UE&LE - Intact Pinprick - Intact Pinprick UE&LE UE&LE - Intact position sense of UE - Loss position sense of LE - Intact movement sense of UE - Loss movement sense of LE N/A - Intact position sense of UE - Loss position sense of LE - Intact movement sense of UE - Loss movement sense of LE N/A

Deep sensation - Position sense - Movement sense

Cortical sensation

Postural control and balance

Balance Sitting Static Dynamic Standing Static Dynamic

Result Good Fair Poor Zero

Right side
Phase Heel strike Foot flat Mid stance Terminal stance Acceleration Missing component Lack of ankle dorsiflexion Flat foot heel strike - Lack of pelvis forward rotation heel off and toe off - Lack of ankle dorsiflexion - Inadequate of hip flexion - Lack of pelvis forward rotation Lack of ankle dorsiflexion - Lack of ankle dorsiflexion - Inadequate of hip flexion Compensate/Abnormal movement Foot slap Foot slap - Trunk forward bending - Hip hiking - Hip hiking - - trunk lateral flexion - Trunk forward bending

Mid swing Deceleration

Left side
Phase Heel strike Foot flat Missing component Lack of ankle dorsiflexion Flat foot heel strike - Lack of pelvis forward rotation heel off and toe off - Lack of ankle dorsiflexion - Inadequate of hip flexion - Lack of pelvis forward rotation Lack of ankle dorsiflexion Compensate/Abnormal movement Foot slap Foot slap

Mid stance
Terminal stance Acceleration

- Trunk forward bending - Knee hyperextension

- Hip hiking - Hip hiking - - trunk lateral flexion -

Mid swing

Deceleration

- Lack of ankle dorsiflexion - Inadequate of hip flexion

- Trunk forward bending

Activity daily living (ADL)

Activity of Daily of Living(ADL) Bathing Result Independent

Dressing
Grooming Toileting Feeding

Independent
Independent Independent with moderate assistance Independent

Transfer

Independent with ambulation by wheel chair

Functional limitation 1.

Impairments Pathology - Spastic of trunk and LE muscles - Subdural hematoma at - Weakness of LE muscles right cerebral hemisphere - Shortening of Lt. plantarflexor muscle - Loss proprioception of LE

2. - Spastic of trunk and LE muscles - Subdural hematoma - Weakness of LE muscles right cerebral hemisphere - Shortening of Lt. plantarflexor muscle - Loss proprioception of LE

Functional limitation

Impairments

Pathology

3. - Spastic of trunk and LE muscles - Subdural hematoma - Weakness of LE muscles right cerebral hemisphere - Shortening of Lt. plantarflexor muscle - Loss proprioception of LE 4. - Tightness of Lt. shoulder flexor - Subdural hematoma muscles right cerebral hemisphere - Weakness of rotator cuff muscles - Lt. Shoulder sublaxation

 Decrease Spasticity
Shoulder flexor muscles Shoulder abductor muscles Shoulder internal rotator muscles of Left side Hip flexor muscles of both side Hip abductor muscles of both side Hip internal rotator muscles of both side Knee flexor of both side Intrinsic of foot muscles of both side

Duration: 2 weeks

 Increase Muscle power

Hip flexor muscles Hip extensor muscles Hip abductor muscles Hip adductor muscles Hip internal rotator muscles Hip external rotator muscles Knee flexor muscles muscles Ankle dorsiflexor muscles Ankle plantarflexor of both side

Duration: 4 weeks

 Increase ROM
Shoulder flexion Shoulder abduction Shoulder external rotation of Left side Hip flexion Hip abduction of Left side Hip internal rotation of both side Lt. Ankle dorsiflexion

Duration: 3 weeks

 Strengthening of rotator cuff muscle Duration: 4 weeks


Duration: 4 weeks (walker) Duration: 1 years

 Decrease spasticity Technique: - Rhythmic rotation - Ball rolling - Rhythmic rotation - Prolong passive stretch (standing) - Releasing intrinsic muscles in foot

Individual strengthening exercise

 Increase ROM Increase ROM Technique: Prolonged passive stretching Stretching exercise

Strengthening of rotator cuff muscle

Technique: - Individual strengthening exercise - ES

 Technique: - Balance training - Co-contraction of trunk muscle, Quadriceps and Hamstring

(walker) Technique: - Gait training - Pelvis control

Discussion