Case Study 5: Patient With Stroke: Constraint-Induced Movement Therapy

EXAMINATION

History

• Demographic Information:

  The patient is a 63-year-old African American man who sustained an ischemic cerebrovascular accident (CVA) 6 months previously, resulting in right-side hemiparesis.

• Social History:

  The patient is married and lives in a single-level home with his wife and daughter. He reports a history of smoking (quit more than 40 years ago) and drinks alcohol socially on occasion. He enjoyed carpentry, fishing, and hunting before his stroke.

• Employment:

  Patient is a retired steel mill worker.

• Medical History:

  The patient reports no previous surgeries or significant medical problems except for hypertension and type 2 diabetes; both are currently under control with lifestyle changes and medications.

• History of Present Illness:

  Patient sustained an ischemic CVA, resulting in right-side hemiparesis. Magnetic resonance imaging revealed a left pontine infarction. Cerebral angiography revealed severe stenosis of the right vertebral artery and proximal basilar artery. Before the stroke, the patient was right-handed.

• Chief Complaint:

  Patient complains he is unable to use his right arm and hand effectively. His goals are to use his right arm and hand well enough to perform household chores and return to his hobbies.

• Medications:

  Current medications include aspirin, Glucotrol, Glucophage, Coumadin, and warfarin.

Systems Review

• Communication/Language:

  • Patient exhibits mild dysarthria.

• Cognition/Affect:

  • There is no cognitive impairment as evidenced by his mini–mental state examination¹ score of 30.

  • No abnormalities in affect are noted.

• Cardiovascular/Pulmonary System:

  • Heart rate: 72 beats per minute and strong

  • Blood pressure: 110/80 mm Hg (sitting)

  • Respiratory rate: 16 breaths per minute, regular and unlabored

• Integumentary System:

  • No abnormalities are noted.

• Musculoskeletal System:

  • Height: 6 ft, 1 in. (1.9 m)

  • Weight: 205 lb (93 kg)

  • Passive range of motion is within normal limits (WNL) in all extremities, except for shoulder flexion, abduction, and external rotation in the right upper extremity (UE).

  • Gross strength is WNL in the left upper and lower extremities (LEs); patient demonstrates weak, active movement in the right UE and LEs.

• Neuromuscular System:

  • There is mild right facial droop (lower quadrant).

  • Hemiparesis is present in the right extremities.

  • Patient is able to actively extend his right wrist to 10 degrees past neutral and able to extend his second, third, and fourth digits (i.e., index, middle, and ring fingers, respectively) beyond 10 degrees at each finger joint. He is unable to extend his fifth digit.

• Learning Style:

  Patient reports that he likes to observe before learning a new movement skill.

Tests and Measures

• Tone:

  The examination results of tone in elbow flexors, forearm pronators, and wrist flexors from the Modified Ashworth Scale² for grading spasticity are presented in Table CS5.1.

• Range of Motion:

  UE range of motion (ROM) results are presented in Tables CS5.2 (passive ROM) and CS5.3 (active ROM).

• Balance:

  Balance was examined using the following:

  • The Established Populations for Epidemiologic Studies of the Elderly (EPESE)^3,4 short performance battery ...