Effect of Early Proprioceptive Neuromuscular Facilitation on a Hemiplegic Patient Post- Hemorrhagic Stroke: A Case Report

Background: Stroke is the sudden loss of neurological function caused by an interruption of blood flow to the brain. Hemorrhagic stroke occurs when a blood artery ruptures in the brain, causing bleeding into the brain leading to hemiplegia. Hemiplegia is a paralysis of the face, arm, and leg on one side. Aim: To study the effect of early Proprioceptive Neuromuscular Facilitation on a post-Hemorrhagic stroke hemiplegic patient Presentation of case: In the present case report, a 75-year-old male was admitted into the hospital with a history of dizziness and weakness of the right upper limb and lower limb along with slurring of speech. After doing CT scan, left Intraparenchymal bleed in the Corona Radiata were present and based on his symptoms and investigatory findings he was diagnosed as a case of right hemiparesis. He was under medical and physiotherapy management. Goal seeking limb was provided to the patient in the ICU and was continued in the ward. The early physiotherapeutic intervention proved to be effective for the positive outcome of the patient. After 20 days of treatment, there was a enormous improvement in the bed mobility of the patient. Speech therapy was also provided to the patient. Case Study Sheikh et al.; JPRI, 33(60B): 2494-2499, 2021; Article no.JPRI.76694 2495 Discussion: Early physiotherapy rehabilitation will increase the decreased ranges of movement of all joints, help in improving the daily living activity of the patient, thus enhancing the confidence of the patient. Conclusion: Thus, we conclude by this case report that early rehabilitation enhances the condition and later on the quality of life of the patient.


INTRODUCTION
Stroke is the sudden loss of neurological function caused by an interruption of blood flow to the brain. Strokes can be either ischemic or hemorrhagic. When the blood supply to a portion of the brain is cut off, an ischemic stroke develops. Hemorrhagic stroke occurs when a blood artery ruptures in the brain, causing bleeding into the brain. Intracerebral hemorrhage (ICH) and subarachnoid hemorrhage are two types of hemorrhagic stroke (subarachnoid hemorrhage) [1]. Hemorrhagic stroke accounts for the largest number of deaths with 37%to 38% in a month. Every year, 13.7 million people worldwide suffer from a hemorrhagic stroke. There are 1.8 million persons in India who had a stroke. In India, the rate of stroke in the general population is 154 per 100,000 [2]. Hemorrhagic stroke causes neurological symptoms such as weakness on one side of the body (hemiparesis), arm or leg paralysis (hemiplegia), sometimes it also causes facial palsy (facial palsy) in the early stages of muscular weakness. The most essential element in minimizing the risk of stroke and cardiovascular disease is hypertension treatment [3]. Hemiparesis describes a moderate loss of strength or paralysis on one side of the body, whereas Hemiplegia describes a complete loss of strength or paralysis on one side of the body. Shoulder subluxation, loss of functional capacity in the hands, foot drop, and psychological stress are all complications of neurological injury [3,4].

PATIENT INFORMATION
The 75-year-old male patient with right-hand dominance was apparently alright till 12 th October. Then on 13th October around 11 a.m., he went to the bathroom and fell there. After that, he panicked and started taking high breaths. His daughter-in-law saw him and with the help of other family members, picked him and took him to bed, and consulted their family doctor. The patient was a known case of hypertension for 10 years and was on regular medication. On examination, he had weakness of the right upper limb and lower limb and slurred speech. Immediately, he was taken to Sewagram hospital where a CT scan was done and the patient was admitted. Later on, the patient was brought to Acharya Vinobha Bhave Rural Hospital for further management on the evening of the same day. Here again, the CT scan was done and the patient was admitted to the neurology ICU.

Clinical Findings
The patient was mesomorphic built, conscious, cooperative, and well oriented to time, place, the Mini-mental state examination (MMSE) score was 25/30. On observation attitude of the right limb in the supine position, was shoulder and elbow extended forearm supinated and rested on side of body, hip in extension, knee extended, and externally rotated with the ankle in plantarflexion. The left side was in a neutral position. On examination, cranial nerves were intact, and the special sense of speech was slurring (global aphasia) hearing and vision were normal. Tonal examination of the right side was hypotonic for the upper limb and lower limb while for the left side it was normal. Muscle power was reduced on the right upper limb (Medical Research Council grade 1) and lower limb (Medical Research Council grade 2). Balance was impaired as the patient was not able to sit independently.

Clinical Diagnosis
The routine blood reports and urine examination did not reveal any abnormality. The CT scan reports revealed there was a left intraparenchymal bleed in Corona Radiata leading to his clinical symptoms.

Physiotherapy Functional Assessment
Barthel Index was taken and it showed 20/100 score by which it was evident that the patient is dependent on daily functional activities.

Physiotherapeutic Interventions
During the ICU stay, the main focus was on promoting the mobility of the patient to prevent further complications. Positioning was given along with regular turning and breathing exercises. Range of motion exercises to maintain joint mobility were provided. Details of the treatment are shown in Table 2.

Follow-up and Outcomes
There was a tremendous improvement in the Barthel index, STREAM Score, and the WHO-Quality of life post-rehabilitation.

RESULTS
Early rehabilitation for patients with hemorrhagic stroke opens up a gate for early recovery poststroke. Basic bed mobility training improves mobility and joint integrity. The vitals were taken into account while targeting the best possible outcome of the patient. The Barthel score was improved to 50/100 during the hospital stay [5].

DISCUSSION
This case study is mainly focused on early rehabilitation and the prevention of complications. Studies are suggesting the effective physiotherapeutic intervention post hemorrhagic stroke but only a few focus on rehabilitation from the acute phase. Continued rehabilitation from the acute phase leads to better outcomes and prevention of complications that were needed to be dealt with in the subacute phase [6,7]. Rigorous inpatient rehabilitation prevents outpatient rehabilitation basis and regular visits to different centers [8,9]. In the research done by Park, D.; Bae, Y., they found that when the muscle strength was improved the range of motion was also improved [10]. Physiotherapy rehabilitation when was combined, with the conventional physiotherapy and virtual rehabilitation, it increases the functional gait more significantly as compared with only conventional physiotherapy given [11]. When PNF is applied in combination with conventional physiotherapy for training on ramps or steps, it was found that it improved the functional capacity of patients [12]. Many studies in patients who have used the PNF method during their rehabilitation treatments have shown a significant improvement in core stability and therefore in their gait as well as in their daily activities, both on the affected and the healthy side [13].

CONCLUSION
Early rehabilitation has proved to be effective to improve the patient's condition, thus providing a positive outcome, boosting the patient's confidence and mental status. These interventions provide further scope to start the rehabilitation from the ICU itself to get better results. Earlier the intervention provided, better is the result.

INFORMED CONSENT
A proper informed consent was taken from the patient prior.

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).