Category: Advancing Modules

Physical assessment findings

On assessment main findings were:

  • Abnormal muscle tone
  • Left sided weakness
  • Sensory loss
  • Left visual deficits
  • Hemiplegic shoulder pain
  • Compensations

Mr McTavish’s completed physiotherapy assessment findings form (PDF)

It is noted that patients like Mr McTavish may have other complications following stroke, not just physical. More information on other issues following stroke can be found in other advancing modules.

Glossary [PDF, 11KB]. It is suggested that you print this off for reference as you work through the above assessment findings

(Examples of blank full physical assessment forms that you can download and print: Physical Assessment Form [PDF]).

Overall Management Plan for Mr McTavish:

  1. Ongoing assessment and physical management
  2. Collaborative approach between the patient, their family and the MDT to be used
  3. Identification of appropriate goals. For more information on goal setting visit AM 7: Physical Rehabilitation
  4. Use base of support (BOS) and handling strategies to normalise tone
  5. Provide appropriate tactile sensory feedback
  6. Appropriate positioning to allow stimulation to either side
  7. Make frequent adjustments to posture/position to maintain comfort
  8. Ensure freedom of shoulder girdle/scapular mobility by passive movements of shoulder complex within anatomical range
  9. Minimise overuse of right side by creating adequate base of support (BOS), good seating/cushion choices and making appropriate functional demands (e.g. transfers using right side) for the stage of his recovery.
  10. Challenge orientation to the midline by encouraging dynamic weight shift
  11. Use appropriate equipment to assist transfers

The presenting features of a patient with TACS

A combination of:

  • New, higher cerebral dysfunction (such as aphasia, inattention, dyspraxia, agnosia)
  • Homonymous visuospatial field deficit
  • Weakness or sensory loss involving at least 2 of 3 parts of the body (face, arm, leg)

A brain scan that has a caption 'large area of low density due to infarction and oedema

This CT scan shows a large right hemisphere infarct which might result in a TACI clinical syndrome.

Predicted outcomes at 30 days post-TACI:

  • 40% of patients dead
  • 56% of patients dependent
  • 4% of patients independent

(Reference: Bamford, J., Sandercock, P., Dennis, M., Burn, J. and Warlow, C.1991. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet, 337 pp. 1521-1526.)

Mr McTavish was transferred to the stroke unit at his local hospital in Scotland, where the following physical assessment took place.

What is a Total Anterior Circulation Infarct?

The Oxford Community Stroke Project (OCSP) classification describes the clinical presentation of stroke and is useful in clinical practice and research.

Using this system, stroke patients are first classified as TACS (where ‘S’ denotes Syndrome), PACS, POCS or LACS until cerebral imaging allows the differentiation between infarction and haemorrhage.

Infarcts were subdivided according to clinical presentations when their symptoms were maximal. Stroke subtype were classified as follows:

Stroke Subtype Percentage (%) of infarcts
Total Anterior Circulation Infarcts (TACI) 17%
Partial Anterior Circulation Infarcts (PACI) 34%
Posterior Circulation Infarcts (POCI) 24%
Lacunar Infarcts (LACI) 25%

Case 1: Mr McTavish

photo portrait of Mr McTavishMr McTavish is 54 years old.

He had a right total anterior circulation infarct (TACI) whilst on a golfing holiday abroad. He was treated locally in a general medical ward but didn’t access stroke rehabilitation services. He was flown back to Scotland 3 weeks later. His transfer letter reported a severe weakness throughout the left side, with sensory loss. He had a homonymous hemianopia with visuospatial inattention.

He is 1.72m, and weighs 75 kg, he is married with 2 grown-up children and works as a self employed accountant. He drinks socially, smokes 10 cigarettes a day and exercises moderately playing golf twice a week. He has no other known medical conditions.

Common complications

Let’s find out more about the common physical complications which will be covered in this module.

NB: To return to the main interactive picture click on the arrow on the right hand side of the picture.

Learning points

On completion of this module you will be expected to have a critical understanding of the importance of the prevention and management of common physical complications following stroke.

You will learn:

  1. Which important common physical complications can occur following stroke
  2. How to recognise the clinical features of those common physical complications
  3. Strategies to prevent the development of common physical complications
  4. Individual assessment and treatment strategies for particular physical complications
  5. About establishing a regimen for maintaining a patient’s optimal physical condition to promote recovery
  6. The benefits of prompt interventions on patient outcomes with respect to physical complications

The following common physical complications will be covered in this module:

  • Hemiplegic shoulder pain
  • Abnormal muscle tone
  • Chest infection
  • Pressure ulceration
  • Deep vein thrombosis
  • Limb swelling (oedema)

Introduction

Introduction - Speech bubble

A nurse attending to a patient, who is lying in bed

On completion of this module you should have a critical understanding of the common physical complications which can occur following stroke and how these may be prevented. Where complications have arisen, you should understand the importance of early detection and appropriate management.

Module Authors

Introduction - Speech bubble

Module lead

Mark Smith, Consultant Physiotherapist & Strategic Lead, Allied Health Professionals,

Stroke Rehabilitation, NHS Lothian

 

Group members

Jane Shiels, Physiotherapy Rehabilitation Services Lead, NHS Lothian

Karis Georgeson, Occupational Therapist, NHS Shetland

Katherine Wilson, Specialist Physiotherapist, Stroke Rehabilitation, NHS Lothian

Dr Katie Thomson, Occupational Therapy Lecturer, Glasgow Caledonian University

Katrina McCormick, Clinical eLearning Project Manager, Chest Heart & Stroke Scotland

Lynsey McAlpine Clinical Specialist Physiotherapist, Stroke Rehabilitation, NHS Fife

Margo Martin, Chest Heart & Stroke Scotland Stroke Nurse, NHS Fife

Serena Battistoni, eLearning Interactive Content Developer, Chest Heart & Stroke Scotland

 

This module was originally developed by:

Group Lead: Mark Smith, Consultant Physiotherapist in Stroke, NHS Lothian

Group Members: Charlie Chung, Clinical Specialist Occupational Therapist in Stroke, NHS Fife
Therese Jackson, Consultant Occupational Therapist in Stroke, NHS Grampian
Peter Kerr, Clinical Nurse Specialist in Stroke, NHS Greater Glasgow & Clyde
Rhona McWhinney, Superintendent Physiotherapist, NHS Lanarkshire
Una Rutherford, Stroke Specialist Nurse, NHS Ayrshire & Arran

Critical Readers

Prof Martin Dennis, Professor of Stroke Medicine, University of Edinburgh
Pauline Halliday, Clinical Specialist Occupational Therapist, NHS Lothian
Pat Taylor, Charge Nurse, NHS Lothian
Lynn Reid, Lead Training Coordinator, CHSS
Clare Adams, Project Manager, CHSS

05: Management of physical complications following stroke

Introduction

On completion of this module you should have a critical understanding of the common physical complications which can occur following stroke and how these may be prevented. Where complications have arisen you should understand the importance of early detection and appropriate management.

The answers to all the test questions are contained within the module. This information may be provided in the ‘Additional Information’ boxes on some of the pages.