Introductory

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This is a case study of Mr. C who I met on 20th Nov 2020 at my practical exam. I had the

opportunity to talk to him and find out about his background history of stroke and was

able to assess his abilities through examination. He is a middle-aged gentlemen who

suffered a left hemispheric ischemic stroke 4 years ago resulting in a right sided paresis. I

was able to evaluate how the stroke impacted Mr. C's health and life using the Stroke

Impact Scale (SIS) test. I also assessed the functional ability of his affected arm and hand

by performing tasks using The Chedoke Arm and Hand Activity Inventory test (CAHAI). In

addition to these assessments, I observed Mr. C's ability to raise and lower himself from

both chair and floor.

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Mr. C background

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Mr. C was diagnosed with an ischemic stroke in 2016. In the month leading up to his

diagnosis, he presented twice to the hospital with symptoms of weakness of his right

arm. After undergoing brain imaging scans he was discharged with no abnormality found.

Only on the third presentation an MRI was performed which led to the diagnosis of left

hemispheric ischemic stroke. He was previously fit and healthy, leading an active lifestyle

with regular trips to the golf course.

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Effects the stroke had on Mr. C

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Prior to his stroke Mr. C was living a regular life. After his stroke he had to adjust to new

norms. As he suffered weakness to the right site of his body, he had difficulty performing

some tasks unaided. For that reason he now frequently uses a walking stick for support

when walking longer distances. He also uses ankle-foot orthotics (AFO) as he has a right

sided drop foot. He is a walk short distances unaided but slowly and for short distances

only. He does find it somewhat difficult to walk around the block and climbing up and

down stairs. He is able to look after himself and perform most of the activities of daily

living (ADL's) but he does find some task, like cutting food with knife, dressing and

bathing very difficult.

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Report of Limitations/ Assessment of Abilities

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On assessment I found that has quite severe spasticity in his right arm. He is only able to

move very so slightly his index finger and thumb. He has no control over his middle finger,

ring finger and little finger. He has gait control problems because of his foot drop and

weakness of his hamstrings.

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During performing a CAHAI test he was unable to use the fine motor skills of his fingers in

his most affected hand (right) to hold objects but was able to use the weight of his whole

arm to hold them down to aid the tasks.

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During SIS questionnaire test Mr. C mentioned that he finds standing and walking

somewhat difficult without his walking aid due to poor balance.

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During the practical assessment Mr. C was able to raise and lower himself from a chair

without much difficulty. He managed to raise him self up and down from the floor with and

without use of a support/chair. His speech, vision and cognitive functions remained

unaffected by the stroke.

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Report of Lesson Plan carried out during Assessment

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On Friday 20th of November I met with Mr.C. After carrying out the initial assessments I

created the following lesson plan. We started with a warm up and some light stretches to

prepare him for the main work out.

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Warm up:

- Turn and twist

- Low and high

- Hip circle

- Hip circle with one foot forward

- Hand over

- Arm Circle

- Wrist up and down

- The tipster

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After the initial warm up I followed up with some lower body weight training, balance

training and gait control exercises.

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Main lower body exercises:

- Body weight chair squat

- Kneeling Marching

- Kneeling moving objects across your body

- In and out brushes

- Entering

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Mr.C and I then walked over to a table where I had prepared a task board. We did multiple

attempts of different exercises using the task board along with some other equipment. We

performed some simple stretches before and during this activity as the spasticity of his

right arm made it difficult for him to do some of the tasks.

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Main upper body exercises:

- Removing all the objects from the task board

- Removing some of those objects and placing them back in a different location

- Reorganising a stacking toy

- Push ups with wooden stick

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Case Study

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I have summarised Mr C's physical limitations in previous sections. I found that his gait

control, in particular his drop foot, has the biggest impact on his day to day life. His ability

to walk without aid, walk for an extended period of time and walk up and down stairs are

things that Mr C. struggles with the most. I strongly believe that focusing on increasing

strength, balance and control in his right ankle is what will give him most benefit from our

training sessions.

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The brain, for its function, needs a constant supply of oxygen and nutrients. These are

being delivered by blood through blood vessels. Stroke occurs when this supply is cut off

or compromised. In 2010 it was the fourth largest cause of death in the UK after cancer,

heart disease and respiratory disease, causing almost 50,000 deaths. It is the leading

cause of adult disability in the UK. Every year around 152 000 people are affected by

stroke and walking dysfunction affects approximately 80% of them.1*

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Drop foot is one of many physical effects of stroke. NICE provides this useful definition of

drop foot. "It is the inability to lift the foot and toes when walking. It can result from

conditions such as stroke, multiple sclerosis or spinal cord injury." 2* It is caused by

weakness or paralysis of tibialis anterior, the muscle that normally lifts the foot.

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Drop foot affects peoples ability to walk unaided. People with this condition struggle to

clear the foot while walking, often dragging it along the ground, compromising their gait

control and balance. People commonly compensate by adjusting how they walk by using

"Steppage gate" and "Circumduction gait". This way of walking can compromise their

progress in the long term as it requires lot more energy.3* It also results in slower walking

and fatigue that onset at shorter distances.

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Steppage gait is form of gait abnormality that helps stroke survivors suffering from drop

foot to walk without dragging their toes along the ground, by lifting the knee higher than is

necessarily to keep the foot with toes pointing down away from the ground.4*

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Another type of gait abnormality adopted by stroke survivors is the circumduction gait. To

keep the foot clear off the ground, patients swing their leg outwards in semi-circular

motion to attain adequate clearance.5*

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There is no treatment that can help the stroke survivor completely eliminate drop foot but

there are some interventions that are widely available and can help them to manage

better. The most common examples are using braces and orthotics, functional electrical

stimulation (FES), resistance training, balance training and gait training.

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Ankle-foot orthotics (AFO) are braces that can help with position of ankle while walking.

They are used to support the ankle and prevent it from dropping. There are different

types. Some are made of plastic or light metal, and cannot be moved and provide

complete support. Some have a hinge or are made from soft material and provide less

support and require the user to apply a bit of effort. A study from 2014 which looked at 21

ambulant stroke patients, supported the effect of an AFO on walking mobility in this

group. "The findings demonstrate that stroke patients wearing an AFO may ambulate with

greater speed and safety on level surfaces and stairs"6*

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Wearing ankle foot orthotics in the long run may hinder patient's progress as they can

become increasingly dependent on it. Which means that over time, the muscle

responsible for dorsiflexion will become even weaker. The trick is to gradually reduce use

and increase strength training and mobilisation. By doing so, the stroke patient may

gradually require less obstructive AFO.

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Functional electrical stimulation (FES) is another potential treatment for drop foot. It works

by placing electrodes directly onto the skin. These electrodes send small electrical signals

to stimulate specific nerves, causing the muscle contract. It has a battery the size of pack

of cards which can be easily worn on a belt, in the pocket or in a cuff below the knee. It

has been proven that it aids in dorsiflexion during the swinging phase of gait, therefore

improving gait speed, cadence, and stride length while walking.7*

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It is advisable to use FES as a short term solution. Using it long term is not advised as it

may encourage it's user to become dependent on it. However there is no evidence to

suggest that long term use decreases neuroplasticity, but some patients report that it

works well for about a year but then becomes less effective with this being due to

changes in gait.8*

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Stroke Association UK suggests that nearly three-quarters of stroke survivors in the UK

have leg weakness, and over three quarters are affected by arm weakness (Stroke

association website 2020).9* The strength of a muscle is defined by the maximum force

that unit can produce to work against resistance. Weakness is the decrease in strength in

one or more muscles that results in a slower production of force, quick onset of fatigue

and excessive sense of effort with producing force. Stroke survivors experience weakness

on one side of their body which affects their ability to carry out certain activities of daily

life (ADL). Some studies suggest that difference in muscular strength of dorsiflexion is

more than any other muscles when the affected and unaffected side are compared. On

average the difference is 45%.10*

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There seems to be direct correlation between weakness and impaired movement

function. Resistance training can be used to help improve impairment of musculoskeletal

function after stroke. When combined with aerobic training, it has been found to be

superior in terms of outcomes for gait speed and endurance. There is strong evidence to

suggest that improved strength improves ADL's therefore helps with overall rehabilitation.

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Since drop foot results in weakness in tibialis anterior muscle, resistance training that

specifically targets this muscle will increase the ability to lift the front of the foot when

walking.

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Resistance training is also very important in improving balance. Balance involves

coordination and stability of our body. Having good balance is important because it

increases patients confidence in their functional abilities and decreases the risk of falls. It

plays a fundamental role in our ability to carry out many activities of daily life ADL's, such

as mobilising and reaching for objects. To have normal balance, different parts of our

body need to work together in synergy. Our brain, eyes, limbs and deep inner core

muscles must communicate together. "Impaired postural control has been identified as a

key component of mobility problems post stroke arising from motor, sensory, and

cognitive impairments."11*

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With drop foot there is an inability to properly activate tibialis anterior muscle, therefore

the communication between the muscle and brain is compromised as the brain is not

getting enough feedback from the affected ankle. This in turn has a negative impact on

balance. Improving this feedback with effective balance training can have a positive

impact on a patient's ability to stand and walk unaided.

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Having drop foot increases the risk of falls and changes the way you walk, which in turn

negatively affects ADL's and quality of life. Gait training is therefore a greatly important

aspect of stroke rehabilitation. Resistance training and balance training improve speed,

balance and strength. We can utilise these methods and use them in gait training. To aid

the drop foot we can specifically focus on exercises that involve conscious activation of

tibialis anterior muscle.

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In conclusion drop foot caused by stroke is form of disability that cannot be eliminated

completely. However I strongly believe that strength training, balance training and gait

training can have positive affect on patient ability to gain some control over their ankle in

the affected limb. Ankle foot orthotics and functional electrical stimulus are key to help

people become more mobile. However they should not be relied on 100% of the time.

Stroke survivors should always aim to gradually reduce their use, and adopt physical

exercise training to optimise their rehabilitation and facilitate recovery.