Physiotherapy Rehabilitation in Cerebellar Stroke: A Case Study

Introduction

This is a case of a 61- year- old man with a diagnosis of posterior circulation ischaemic stroke who was referred to our physiotherapy outpatient unit in a major tertiary hospital in Nigeria about two years ago. Prior to that time he was on admission at the acute stroke unit (ASU) of the same hospital for 7 days and had 4 sessions of physiotherapy.

Presenting Complaint

Difficulty with speech, fine tremors of the neck and shoulders (titubation), inability to stand and walk independently.

Objective Assessment

• Head and Neck - Marked titubation (tremor of head, neck and shoulder); mild facial palsy and expressive aphasia; no neck tenderness or rigidity, and no visual impairment.

• Trunk and abdomen - Trunk ataxia, fair trunk control, poor balance and coordination, poor vestibulochochlea function; no bladder or bowel dysfunction
• Upper Limbs - Muscle Power (Right- Oxford grade 4, Left 5), Deep and light sensation - Intact Proprioception – Impaired Tone- slightly decreased Deep Tendon Reflexes - hyporeflexia
• Lower Limbs - Muscle power apparently normal on both sides Sensation - Intact Proprioception – Impaired Tone- slightly decreased Deep Tendon Reflexes - hyporeflexia Ankle Clonus - Not present
• Postural test-Romberg’s sign was positive
• Gait- Only possible with close support and ataxic

Functional Assessment

Patient could not sit up from lying, nor stand or walk independently. Visible and palpable tremors were observed in the entire body but more pronounced in the head, neck and shoulders. Patient could not perform self-care activities; there was difficulty with speech, language and communication.

Problem Analysis

Poor motor and postural control; poor muscle tone, balance and coordination; titubation, vestibulochochlea dysfunction and facial asymmetry.

Plan of Treatment

To promote titubation control, functional capacity, cardiopulmonary efficiency, postural balance and coordination, improve facial muscle function and symmetry, train ambulation, prevent falls and integrate caregivers in the rehabilitation, as well as home programme. Goals were generated with mutual understanding of both the patient and his caregivers (careers) as follows: Short Term Goals

1. Patient would be able to use cervical collar regularly for 4 weeks, except when bathing or experiencing discomfort, in an attempt to control, reduce or treat titubation
2. Patient would be able to perform prehensile functions, including writing skills, using culturally familiar objects at therapy sessions with targets of achievement for 4 weeks
3. Patient would be able to perform both localized and generalized breathing exercises with short intervals of rest for 5 minutes in supine and sitting positions.
4. Patient would be able to undergo rhythmic stabilization exercises in lying, sitting and standing for 5 minutes.
5. Patient would be able to use finger-to nose and opposition exercise, as well as heel-to- knee exercise for both upper and lower limbs respectively for a total time of 10 minutes to enhance motor coordination and control
6. Patient would be able to carry out facial exercises in front of a mirror for 5 minutes daily
7. Patient would be able to walk within the parallel bars and exercise on a wobble board for 10 minutes at each treatment session
8. Patient would be able to carry graded weights to improve tone and power of the musculature of both upper and lower limbs.

Results

At the time of concluding this case study which was approximately 2 years since treatment began the patient had made unprecedented improvements to the satisfaction of him and his caregivers, as well as us the physiotherapists. He could sit, stand, and walk independently without falls. His posture too had improved and he had good motor power. He could carry out all activities of daily living independently with a score of 100 on the Barthel Index [1]. Tables 1 and Table 2 show improvements in coordination and proprioception of the upper and lower limbs. Romberg’s sign became negative and titubation had completely disappeared. However, his speech still lacked fluency.

Discussion

Cerebellar stroke is a challenging task for rehabilitation. The length of time, interdisciplinary team work and complex interventions used in this study have proved this fact. This case study has shown that physiotherapy plays a great role in controlling sequelae, improving functional task performance and quality of life for patients. Physiotherapists routinely use exercises to promote motor functions, and exercise has been reported to be paramount in promoting neuroplasticity [2] which is the neurophysiological concept that underlies the great improvement for this patient. The length of time taken to treat this patient as well as the consistency in keeping appointment are assumed to have impact on motor learning as a component of motor behaviour. A very innovative and interesting aspect of this study was the use of cervical collar in managing titubation. A search of literature showed this had never been used before. Our using cervical collar was premised on the assertion that head control is a prerequisite for motor function of other parts of the body in neuromotor development of the infants [3]. Early application of cervical collar seemed to have considerably contributed to the great results seen because at about one and half year into the study another patient with cerebellar stroke and titubation who had the dysfunction 5 years earlier was referred to the authors. This patient was younger, had never been able to walk independently, and had been managed only on medications and never had been referred for physiotherapy. After 6 months of treatment using cervical collar titubation was reduced but still had not been able to walk independently.

The study has revealed that cerebellar lesions typically impair several aspects of motor function, because the cerebellum is responsible for fine motor coordination and body movement, posture, and balance [4] In this study the authors have taken this fact into consideration in their strategic approach to management which differed from managing a typical upper motor neurone lesion such as the corticospinal tract lesion.

Conclusion

Physiotherapy a most vital role in the management of people with cerebellar stroke. Early referral and intervention, as well as consistency, is crucial in achieving results. Physiotherapists must take responsibility in developing innovative strategy that works.