Lebanese University

Faculty of Public Health - section 4

Physiotherapy.

Training Report
Montada Al mokadin.

Presented by: Mariam Droubi.

Submitted to: Mrs. Chantal Rabay.

1. Collecting data:
1.1-

Personal information:

-Name: T.T.
-Age: 46 years old.
-Profession: furniture painter.
- Diagnosis: left CVA/ right hemiplegia
-Dominant side: Right side.
-Date of accident: /3/2013
-Date of starting physiotherapy: 1/10/2013
-Physiotherapist name: Mrs. Miriam Al Haber.

1.2-

History:

The patient has a history of blood hypertension. The patient had a first hemorrhagic stroke, this
lead to a case of right hemiplegic patient, he transferred to the hospital and still for 40 days in
Coma, then start with physiotherapy sessions.
1.3-

Risk factors:

-Hypertension.
- slightly obese.
Didnt make exercises.

2. Assessment plan:
2.1- General assessment
2.2- Pyramidal hypertonia
2.3-Assosciated problems
2.4- Neurologic assessment
2.5- Trophic assessment

2.6- Orthopedic and Articular assessment

2.7- Muscular assessment
2.8-functional assessment
2.9- Gait assessment

2.1- General assessment:

The patient entered the physiotherapy center using cane without any assistance.

2.2- Pyramidal hypertonia assessment:

Intensity of hypertonia
V1
Hip

knee
Ankle
Shoulder

Elbow
Forearm
Wrist
Fingers

Flexor
Internal Rotation
Adductor
flexor
Plantar flexor
Flexor
Adductor
Internal Rotation
flexor
Pronator
Flexor
flexor

2.3-Assosciated problems:
-No aphasia.
-Apraxia
-Agnosia
-Ataxia
-Balance impairement

I3
I2
I1
I3
I4
I4
I3
I4
I3
I3
I3
I3

Right side
V3
I3
I2
I2
I3
I4
I4
I4
I4
I3
I4
I3
I3

2.4- Neurologic assessment:

A- Sensory examination:
a- Superficial sensibility:
Normal results are indicated on the affected side in the lower limb.
There is a slight problem in the superficial sensitivity of the upper limb.
b- Deep sensibility:
No deep sensibility of position and movement is indicated in the upper limb, however it is
indicated in the lower limb.
B- Motricity examination:
a- Motor deficit: there is deficit in the shoulder abduction/ ER, Elbow supinaton, Wrist
and fingers Extension in the upper right limb.
In the Hip extension, ankle dorsiflexion, eversion of the right lower limb.
b- Movement slowness: Appear in testing the muscles of the right side of the body, upper
and lower limb.
C- Reflex:
-Babenski Sign : (+)
-patellar reflex: (+)
Conclusion:
-Normal superficial and deep sensibility in the lower limb.
-No superficial and deep sensitivity in the upper limb.
-Loss of motricity in the shoulder ER, forearm supination, wrist and fingers extension,
foot dorsiflexion and eversion.
-Slowness in movement.

2.5- Trophic assessment:

A-Cutaneous assessment:
There is slight edema in the right affected side comparative to the normal left side in the lower
limb.

B- Muscular assessment:
-There are no muscular contractures.
-Slight amyotrophic muscles appeared in the muscles of right shoulder and hand.
Conclusion:
-Normal cutaneous trophicity.
-Slight muscular amyotrophic.

2.6- Articular assessment:

a. Observation: (at rest)
IUpper limb scheme:
i. Shoulder internal rotation.
ii. Elbow flexion..
iii. Wrist and fingers flexion.
iv. Thumb adduction.
IILower limb scheme:
i. Hip slight adduction- external rotation.
ii. Slight ankle eversion with plantar flexion.
iii. Knee flexion.
b. Palpation:
There is no presence of any joint dislocation or deformities.
c. Mobilization:
There is limitation in the whole upper limb.
In the lower limb in active mobilization the patient can perform knee flexion but accompanied
with hip external rotation, while in passive mobilization there is no limitation except ankle
dorsiflextion and inversion.

2.7- Muscular assessment:

A- Analytic motor testing:
Joint
Shoulder
Elbow
Wrist
Fingers
Thumb
Hip
Knee
Ankle

Muscle group
E/F
Abd/Add
ER/IR
F/E
Sup/pro
F/E
F/E
Abd/Add
E/F
Abd/Add
IR/ER
F/E
Plantar/dorsi F
Inversion/Eversion

Grade(right)
0
0
0
0
0

1/0
1/0
1-/13/3
2/3
1/2
3/3
1/1
0/1

Grades: 0: no contraction
1: palpable contraction, no movement
2: contraction produces movement
3: movement against light resistance
4: movement against high resistance
5: normal movement
Conclusion:
There is general muscle weakness
B- Global testing:
Movement
Hand on mouth
Hand on the opposite shoulder
Elbow extension + shoulder abduction
Hand on the opposite knee
Knee E + plantar flexion

Grade
0
0
0
0
2

Grade(left)
4
4
4
4
4
4
4
4
4
4
4
4
4
4

Knee E + dorsi flexion

Knee F + plantar flexion
Knee F + dorsi flexion

2
2
2

* Grades: 0: no movement
1: rough of movement
2: partial movement
3: full amplitude
4: movement executed easily compared to unaffected limb
5: normal movement in repetition and speed.

2.8-Functional assessment:

Functional assessment:

Function
Hand on mouth (eat)
Hand on head (brushing hair)
Hand on back
Cross hands on chest
Rolling in bed/out of bed
Balance in sitting position
Balance in standing position
Walking ability
Go to the toilet
Go upstairs & downstairs

Able

Able with difficulty

Unable
+
+
+
+

+
+
with aid
With aid
With aid
with aid

2.9- Gait assessment:

In static position:
1. Trunk position: Slight trunk lateral flexion to the right side.
2. Upper limb: Add + IR + F (of elbow - wrist and hand) of the right side.
3. Lower limb: ER + plantar flexion.

 Type of walk: Fauchage gait.

- He cannot walk alone without using a technical aid.
- He cannot divided his body weight on his lower limb

Treatment
Objectives:
Short term:

Maintain good orthopedic state

Strength muscles of left side
Stretch retracted muscles
Accelerate motor recovery
Ameliorate ADL functions
Improve equilibrium and balance
Correction of gait

Long term:

Give maximum independence to the patient.

Attempt an autonomic correct gait.
Maintenance functional upper limb if possible.

Treatment application:
*Passive mobilization for all joints of right side especially external rotation , abduction and
flexion of shoulder , extension of elbow , supination of forearm , movements of thumb ,
extension of wrist and fingers , external rotation and abduction of hip , dorsiflexion of ankle
*Active ROM &Active resisted ROM:
-shoulder flex, ext, IR, ER, abd, add
-elbow flex, ext
-forearm pronation supination
-wrist ext, flex
-fingers flex, ext
-hip flex, ext, IR, ER, abd, add
-knee flex, ext
-ankle dorsiflexion, plantar flex, inversion, eversion
*Bridge exercise for strengthening hip extensors
*Put the patient in a posture of fingers ext, elbow ext, shoulder flexion and the patient to
stabilize his upper limb in this posture.
*In later stages he moves his arm actively to the posture.
-Bicycling.
-walking between parallel bars.