1st CASE PRESENTATION

Tuesday, 14 July 2015

REHABILITATION OF PATIENT WITH RIGHT

HEMIPARESIS DUE TO INFARCTION STROKE DUE TO
PACS LEFT CAROTID SYSTEM SUBACUT PHASE WITH
MOBILIZATION DISTURBANCE AND ADL DISTURBANCE

Presented By:
Ardhita Resiani, dr.

Supervised by :
Novitri, dr., Sp.KFR
Marietta Shanti, dr., Sp.KFR

Physical Medicine and Rehabilitation Department

Faculty of Medicine Padjadjaran University

Dr. Hasan Sadikin Central Hospital

Bandung
2015

I. INTRODUCTION
Stroke is one leading cause of death and neurological disability inmost
countries. In consequence, it is necessarily to make effort of early and appropriate
prevention, treatment, and rehabilitation.1,2,3,4In advanced countries, stroke is the
third cause of death after heart disease and cancer.1,3The American Heart
Association (AHA) estimates 600,000 strokes annually; 500,000 newcases, and
100,000 recurrent cases.2,3In United States, approximately 4 million stroke
survivors, 5070% of them obtain functional independence, and about 1530%
remain permanently disabled.2,3
The overall mortality from stroke is declining, reflecting better risk-factor
reduction and hence lower incidence and better medical management of patients
during the acute phase. It should be noted that long-term survival poststroke is
improving, so that despite reduced incidence, prevalence of stroke in the
population has stayed the same or has increased.4
Most patients who experiencestroke can and do have improvement in
functional ability, butthe amount, rate, timing, pattern, type, and ultimate
outcomeof the improvements differ across patients and across situations. 1The
approach that is required for appropriate assessment andtreatment of stroke
patients therefore demands specializedknowledge, skills, and creativity.3The major
underlying theme of all rehabilitationinterventionsis to maximize quality of life
for patients with stroke. Itis quality of life, and not simply improved motor
control, functionalindependence, or community placement, that is the realgoal of
the rehabilitation program.3
II. DEFINITION
Stroke is a non traumatic brain injury, caused by occlusion or rupture of
cerebral blood vessel, that result in sudden neurologic deficit characterized by loss
of motor control, altered sensation,cognitive and language impairment,
disequillibrium, or coma.1

WHO defines stroke as one clinical manifestation of either local or global

cerebral function disorder which occurs abruptly and rapidly, for more than 24
hours or up to death due to disorder of brain circulatory system.
III. BRAIN BLOOD SUPPLY
The principal blood supply for the brain comes from two arterial systems
that receive blood from different systemic arteries: the anterior circulation, fed by
the internal carotid arteries, and the posterior circulation, which receives blood
from the vertebral arteries. The vertebral arteries join at the junction of the
medulla and pons (or pontomedullary junction) to form the basilar artery, which
lies unpaired along the midline. The anterior circulation is also called the carotid
circulation, and the posterior circulation, the vertebral-basilar circulation. 5
The anterior and posterior arterial systems connect at several locations. One
site of interconnection is on the ventral brain surface, where the communicating
arteries are located.Together the proximal portions of the cerebral arteries and the
communicating arteries form the circle of Willis. The posterior communicating
artery allows blood to flow between the middle and posterior cerebral arteries, and
the anterior communicating artery allows blood to flow between the anterior
cerebral arteries on both sides of the cerebral hemispheres.5
The anterior cerebral artery supplies the dorsal and medial portions of the
frontal and parietal lobes.Themiddle cerebral artery supplies blood to the lateral
convexity of the cortex.The posterior cerebral artery supplies the occipital lobe
and portions of the medial and inferior temporal lobes. 5

Figure 1. Circle of Willis

Figure 2. The arterial circulation of deep cerebral
structures illustrated in schematic horizontal section

IV. CLASSIFICATION

The clinical diagnosis of stroke is generally based on several categories,

including :
Based on clinical features and temporal profile:6
1. Improving Stroke( RIND = Reversible Ischemic Neurologic Deficit), i.e.,
when the neurologic deficit is totally cured in the period of 24 hours to 3
weeks.
2. Worsening Stroke( SIE = Stroke in Evolution ), i.e., when the neurologic
deficit becomes progressive severe, both quantitatively and qualitatively, and
both from anamnesis and followup.
3. Stable Stroke( Completed Stroke ), when neurological deficit goes on
completely with a very small changes in a given period.
Based on intracranial pathological features and it indicates type of stroke:2
Ischemic 85%
Embolic

Type

Thrombotic

Frequency
(%)
Factors
associated
with onset

35

30

Occurs
during sleep

Occurs
while awake

Major cause/

Perfusion
failure distal
to site of
severe
stenosis or
occlusion of
major vessels

Due mainly
to cardiac
source

Presentation

Slowly
(gradually)
progressive
deficit

Link with
TIA

50% with
preceding
TIA (50%
occurring
same
vascular
territory of
preceding
TIA)

Sudden,
immediate
deficit
(seizure
may occur)
Than in
thrombotic
11% with
preceding
TIA

Lacunar
20

Haemorrhagic 15%
Intracerebralhaemorrhage
Subarachnoid
haemorrhage
10
5
In 90% of cases occurs when
the patient is calm and
unstressed Blacks>whites

Small lesions
seen mainly :
-putamen
-pons
-thalamus
-caudate
-internal
capsule/corona
radiate
Abrupt or
gradual onset

23% with
preceding TIA

Hypertension

Occurs during
activity (often
strenuous
activity)
From ruptures
aneurysm

Gradual onset (over minutes

to days) or sudden onset of
local neurologic deficits

Sudden onset

8% with preceding TIA

7% with
preceding TIA

Based on the location of vascular lesion, the clinical symptoms of stroke

comprises :
1. Anterior Cerebral Artery Syndromes
The most common characteristic of ACA syndrome is contralateral
hemiparesis and sensory loss with greater involvement of the lower extremity
because the somatotropic organization of the medial aspect of the cortex includes
the functional area for the lower extremity.2
2. Middle Cerebral Artery Syndromes
The most common characteristic of MCA syndrome are contralateral
spastic hemiparesis and sensory loss of the face, upper extremity and lower
extremity, with the face and upper extremity more involved than the lower
extremity. left-side lesion (dominant hemisphere)global aphasia initially, then
turns intoBrocas aphasia (motor speech disorder.1,2 Lesions of the right parietal
lobe of the nondominant hemisphere (usually the right hemisphere) typically
produce perceptual deficit (e.g. unilateral neglect, anosognosia, apraxia, and
spatial disorganization).2 Homonymous hemianopsia ( a visual field defect) is also
common finding.
3. Internal Carotid Artery Syndromes
The clinical consequences of complete occlusion of an internal carotid
artery vary from no observable clinical deficit if there is good collateral
circulation to massive cerebral infarction in the distribution of the anterior and
middle cerebral arteries with rapid severe obtundation, with head and eyes turned
toward the side of the lesion and dense contralateral motor and sensory deficits. 4
Less extensive infarctions result in partial or total lesions in the
distribution of the middle cerebral artery. The anterior cerebral circulation may be
preserved through flow from the opposite side via the anterior communicating
artery. The first branch of the internal carotid artery is the ophthalmic, and if there
is inadequate collateral flow through the orbit from the external carotid artery,
there may be ipsilateral blindness from retinal ischemia on the side of the lesion
associated with contralateral hemiplegia.4

4. Posterior Cerebral Artery

Occlusion is often due to an embolus and most often causes a
homonymous

visual

field

defect,

usually

hemianoptic

or

quadrantanoptic.Additional problems, such as dyslexia and dyscalculia, occur due

to dominant hemisphere involvement.4Involvement of the non dominant
hemisphere may produce a parietal lobe syndrome. A hemisensory deficit may
occur with thalamic infarction and occasionally leads to a thalamic syndrome of
unremitting hemibody pain.4When both posterior cerebral arteries are occluded,
cortical blindness occurs andchanges in behavior are often seen.2
5. Vertebrobasilar system
Patients typically experience occipital headache, diplopia, progressive
quadriplegia, bulbar paralysis, coma, and frequently death. Locked-in syndrome
(LIS) results from ventral pontine lesions and is defined as quadriplegia and
anarthria with preserved consciousness and sensation. Thus the patient
cannotmove or speak but remains alert and oriented.Only one voluntary
movement, vertical gaze, remains. Communication can be established via vertical
eye movements.4
Other classificaton of subtypes cerebral infarction :7

V.RISK FACTORS1,2,4
Modifiable (treatable) risk factors:
Hypertension
The degree of risk increases with higher levels of pressure and becomes
particularly strong with levels higher than 160/95 mmHg. 1 In the
Framingham Study, a sevenfold increased risk of cerebral infarction was
observed in patients who were hypertensive.4
History of TIA/prior stroke (~ 5% of patients with TIA will develop a
completed stroke
within 1 month if untreated)
Cigarette smoking
Cigarette smoking is an important risk factor for cardiovascular disease,
but its negative influence on stroke was questioned for many years.
Community-based data from the Framingham Study have confirmed that
smoking

is

independently

associated

with

an

increased

risk

of

atherothrombotic stroke in both men and women. The relative risk of stroke
for heavy smokers (more than 40 cigarettes/day). Cessation of smoking
reverses risk to that of nonsmokers within 5 years after quitting.1
Hyperlipidemia
The role of elevated serum cholesterolhas not been epidemiologically
linked to increased strokeincidence, but its strong influence on the
developmentof coronary artery disease and atherosclerosis indicates
thathypercholesterolemia is at least an indirect risk factor for stroke.1
Diabetes Mellitus and Other Risk Factors
Diabetes mellitus increases the relative risk of ischemic stroke to 3 to 6
times that of

the general population. This risk can be partly attributed to

the higher prevalence of hypertension and heart disease among persons

with diabetes, but even after controlling for these factors, diabetes
independently doubles stroke risk. The prevalence of diabetes among
stroke survivors is 20%.1

Whether obesity is a risk factor for stroke has been challenged.

Hypertension and diabetes mellitus are more common in the obese and are
strong influences for stroke risk. Weight loss has a positive influence on
blood pressure and diabetic control, and probably has a risk-reducing
effect on stroke and cardiovascular diasease. Although obesity can
indirectly increase stroke risk, its independence as a risk factor remains
questionable.1
Heart disease, including electrocardiographic evidence of left
ventricular hypertrophy, cardiac failure, and nonvalvular atrial fibrilation,
increases stroke risk by 2 to 6 times normal. Control of hypertension,
cessation of smoking and reduction of serum cholesterol can reduce the
development of heart disease and prevent stroke.1
Nonmodifiable:
Agesingle most important risk factor for stroke worldwide; after age 55,
incidence
increases for both males and females. Risk more than doubles each decade
after age 55
Sex ( male> female)
Race ( African Americans 2 > whites > Asians)
Family history of stroke
VI. CLINICAL SYNDROMES

Motor Control and Strength

The primary motor area is located along the cortex of the
precentralgyrus anterior to the central sulcus of both hemispheres,and
extends from the paracentral lobule within the longitudinalfissure to the
frontal operculum within the Sylvian fissure. Theclassic 'motor
homunculus' is useful for visualizing the topographyof motor control along
the precentralgyrus.1

With hemiplegia, weakness and poor control of voluntary

movementare present initially, associated with reduced restingmuscle tone.
As voluntary movement returns, non-functionalmass flexion and extension
of the limbs are first noted Synergy patterns, or mass contraction of
multiple musclegroups, are seen. Later, movement patterns can be
independent of synergy.1

Motor Coordination and balance

Trunk control and stability, coordination of movement patterns,and
balance all involve complex extrapyramidal systems thatare frequently
disrupted by stroke. Extrapyramidal disorderscan be a major impediment
to functional recovery but are oftenamenable to therapeutic exercise.1

Spasticity
Spasticity is a velocity-dependent increase in resistance tomuscle
stretch that develops after an upper motor neuron injury within the central
nervous system. Loss of upper motorneuron control causes disinhibited
alpha and gamma motor neuron activity and heightened sensitivity to class
1a and 2muscle spindle afferents. Consequently, monosynaptic and
multisynaptic spinal reflexes become hyperactive.1,8
Spasticity develops shortly after completed stroke, and is
initiallymanifested as an increased phasic response to tendon tapand a
slight catch with passive ranging. Later, ranging can becomedifficult, and
the patient might show tonic positioning in flexionor extension. Often, as
voluntary motor activity returns, a reduction in tone and reflex response is
noted, but if recovery isincomplete, spasticity usually remains.1
Modified AsworthScale( taken from Bohannon and Smith, 1987)

0
1

No increase in muscle tone

Slight increase in muscle tone, manifested by catch and release or by minimal resistance at

1+

the end range of motions when the affected part(s) is moved in flexion or extension
Slight increase in muscle tone, manifested by catch followed by minimal resistance at the

end range of motions thoughout the remainder (less than half) of the ROM
More marked increase in muscle tone through most of the ROM, but the affected part(s) is
easily moved

3
4

VII.

Considerable increase in muscle tone, passive movement is difficult

Affected part(s) rigid in flexion or extension

TIME COURSE OF THE DISEASE

Based on Assessment of Physical Medicine and Rehabilitation and

functional writing code, the phases are distinguished as follows:9

Acute

Phase:

characterized

with

hemodynamic

and

neurologic conditions that have not been stabile (several days to two
weeks post stroke).

Subacute Phase (Recovery Phase) : characterized with

recovery and reorganization of nerve system (2 weeks to 6 months),
important to recover functionally.

Chronic Phase (Advanced Phase): characterized with

accomplishment of nerve system reorganization. The next recovery that is
still possible to continue is a functional recovery process based on
adaptation and compensation against the existing disability (>6 months).

VIII.RECOVERY FROM STROKES1,2,4

Recovery from Impairment
Hemiparesis and motor recovery have been the most studied of all stroke
impairments. As many as 88% of patients with an acute stroke have hemiparesis.
In a classic report, Twitchell described in detail the classic pattern of motor
recovery following stroke. In the majority of hemiparetic patients, the arm is more
involved than the leg, and the degree of functional motor recovery in the arm is
less than in the leg.
Another factor contributing to the discrepant outcomes between the upper
limb and the lower limb is the very distinct functional demands placed on the
upper versus the lower limb. The lower limb can be reasonably functional if it is
able to maintain an extended posture and have some gross volitional movements.
By contrast, the upper limb relies on the exquisitefine motor control of the hand

for functional tasks, and gross movements (as are often recovered in the proximal
portion ofthe upper limb) do not result in a substantial level of function.
The severity of arm weakness at onset and the timing of the return of
movement in the hand are both important predictors of eventual motor recovery in
the arm. The prognosis for return of useful hand function is poor when there is
complete arm paralysis at onset or no measurable grasp strength by 4 weeks.
However, even among those patients with severe arm weakness at onset, as many
as 11% may gain good recovery of hand function. Some other generalizations can
be made. For patients showing some motor recovery in the hand by 4 weeks, as
many as 70% will make a full or good recovery. Complete functional recovery,
when it occurs, is usually complete within 3 months of onset.
Bard and Hirschberg claim that if no initial motion is noticed during the
first 3 weeks, or if motion in one segment is not followed within a week by the
appearance of motion in a second segment, the prognosis for recovery of full
motion is poor.
Mechanisms of Neurologic Recovery
Neurological improvement begins immediately after the stroke and is
believed to result from a number of mechanisms. Improvements seen in the first
days to weeks after stroke appear to include recovery of function in portions of the
ischemic penumbra and resolution of edema and associated mass effect.
Specific Stroke Impairments and Their Rehabilitation: Motor Impairment
Strength, power (the speed with which force can be generated), motor control and
coordination, muscle tone, and balance may all be affected by stroke. Brunnstrom
adopted a different approach for assessment of motor function in hemiplegic
patients in which
movement patterns are evaluated and motor function is rated according to stages
of motor recovery. While this rating can be performed very quickly, the scale
defines recovery only in broad categories. Moreover, not all hemiparetic stroke

survivors progress through these stages sequentially, with some survivors

skipping stages during their recovery.
Brunnstrom Stages of Motor Recovery
Stage
Stage 1
Stage 2

Characteristics
No activation of the limb
Spasticity appears, and weak basic flexor and extensor synergies are

Stage 3

present
Spasticity is prominent; the patient voluntarily moves the limb, but muscle

Stage 4

activation is all within the synergy patterns

The patient begins to activate muscles selectively outside the flexor and

Stage 5

extensor synergies
Spasticity decreases; most muscle activation is selective and independent

Stage 6

from the limb synergies

Isolated movements are performed in a smooth, phasic, well-coordinated
manner

Spasticity
Critical to managing spasticity in patients with stroke is education on the benefits
and necessity of daily stretching, especially of the shoulder, wrist, fingers, hip,
and ankles. The use of static resting splints for hand and ankle can help prevent
contractures and reduce tone, but if spasticity is severe, splinting can result in pain
and skin breakdown under the orthosis. 1,10
Therapy for Motor Weakness
Early Phase and Supportive Care
In the early poststroke phase, the hemiparetic limb(s) may be completely
paralyzed and are at high risk for the development of contractures or nerve
pressure palsies. Therapy during this early phase should consist of proper
positioning of the patient in bed and support of the arm in a wheelchair trough
when sitting. Traction on the arm should be avoided when the patient is moved or
transferred to a wheelchair. All joints of the affected limbs should be passively
moved through a full range of motion at least once daily to prevent contractures.
If the limb(s) become quite spastic, frequent slow stretching can help to reduce
tone. Spasticity usually dominates in the flexors of the upper limb and may hold

the wrist and fingers in a constant position of excessive flexion. A static wristhand orthosis is often helpful in maintaining these joints in a functional position.
Motor Recovery
Motor recovery may become evident within hours to days after stroke. A
variety of approaches have been advocated to facilitate and enhance motor
recovery. Including traditional approaches, such as the neurodevelopmental
technique advocate by Bobath, Brunnstrom emphasized the synergistic pattern of
movement that develop during recovery from hemiplegia, Propioceptive
Neuromuscular Facilitation (PNF) was developed by Kabat and colleagues and
relies on quick stretching and manual resistance of muscle activation of the limbs
in functional directions and newer techniques such as Consraint-Induced
Movement Training (CIMT) and robot-aided exercise.

Therapy for Mobility

In the early phase after stroke, some induviduals will not have sufficient
trunk control and hemiparetic leg strength to maintain upright posture for walking.
These patients should receive initial therapy to develop gross trunk control and
training in pregait activities such as posture, balance and weight transfer to the
hemiparetic leg. As recovery progresses, stroke survivors usually develop better
gross motor skills and trunk balance and greater strength in the leg. Despite the
presence of spasticity and the inability to selectively activate individual muscles,
most stroke survivors will walk, although many will require an ankle-foot orthosis
and cane and will walk more slowly than previously.
IX. SHOULDER IN HEMIPLEGIC

During the flaccid stage, especially when there is sensory proprioceptive

impairment, the cuff muscles (especially the supraspinatus) can be elongated. The
seating function of the cuff muscles is lost and the head of the humerus glide
downward as well as laterally.In the early hemiplegic stage the scapula assumes a
depressed position. The lowering of the outer aspect of the scapula changes the
angulations of the glenoid fossa causing it to be malaligned for the humeral head.
With the usual functional scoliosis that occurs in the hemiplegic, that is, leaning
toward the hemiplegic side, the scapula is relatively depressed and rotated. This
changes the angulation of the glenoid fossa
Spasticity of the latissimusdorsi depresses the scapula and places traction
as well as internal rotation forces upon the humerus. Paresis of the serratus may
contribute to scapular angle change. Spasticity of the scapular muscles, such as
the rhomboids and/or levator scapula, can influence subluxation of the
glenohumeral joint by depressing and rotating the scapula downward. Brachial
plexus injury complicating the hemiparesis can cause paresis that impairs cuff
muscles and scapular muscles with potential subluxation.
Careful positioning of the shoulder serves to minimize subluxation and
later contractures as well as possibly promote recovery, while poor positioning
may adversely affect symmetry, balance and body image. Bender and McKenna
(2001) noted that the recommended position for the upper extremities is towards
abduction, external rotation and flexion of the shoulder.Educating patients to
avoid voluntarily dislocating the shoulder and to avoid positions of known
instability should be a part of the treatment program.
X. PROGNOSIS
Prognosis post stroke is divided into:4
1. Prognosis ad vitam: depends on stroke type, site and size brain lesion,
risk factor, comorbid disease or condition and complication.
The 30-day survival for patients with infarction is 85% but for patients
with haemorrhage, survival is reported to be 20-52%. Coma following a
stroke onset indicates a poor prognosis. With large vessel infarctions, due
either to thrombosis or embolism, prognosis is related to the volume of the

lesion. Outcome is poorest when the lesion involves more than10% of

intracranial volume.Medical complications such as pulmonary aspiration,
pneumonia, malnutrition, vein thromboembolism may affect the prognosis.
2. Prognosis ad sanationam: recurrences.
The probability of stroke recurrence is highest in the post acute stroke
period. For survival of an initial stroke, the annual risk of a second stroke
is approximately 5%, with a 5 year cumulative risk of recurrence of
around 25%, although may be high as 42%. Risk factors for initial stroke
also increase the risk of recurrence, especially hypertension, heart disease,
diabetes mellitus and obstructive sleep apnea.
3. Prognosis ad functionam, depends on:

Onset post-stroke
Most improvement is noted in the first 6 months, although as many as
5% of patients show continued measurable improvement to 12 months
post-onset.

Site and size of neuroanatomical lesion.

Comorbid diseases or conditions.

Complications

The motivation and support of the patients family.

The available facilities and professional labours of rehabilitation.

REFERENCES
1. Harvey RL., Roth EJ., Yu David. Rehabilitation in Stroke Syndromes. In
Braddom. Physical Medicine and Rehabilitation.4thedition. USA: WB
Saunders Company; 2011. Page 1177-1222
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Cuccurulo.

Physical

Medicine

and

Rehabilitation

and

Board

Review.2ndedition.USA : Demos Publishing company;2010. Page 1-48

3. Malory BS. Stroke. In Cooper. Essential Physical Medicine and
Rehabilitation. USA :Humana Press Inc;2002. Page 45-69
4. Brandstater ME. Stroke Rehabilitation. In DeLisa. Physical Medicine &
Rehabilitation: Principles and Practice.5th

edition. USA : Lippincott

Williams & Wilkins;2010. Page 551-574

5. Martin,

John H. Vasculature of the Central Nervous System and the

Cerebrospinal Fluid. In Neuroanatomy Text and Atlas.3rd Edition. McGraw

and Hill. New York; 2003. Page 159-73.
6. Whisnant, PT et all. Classification of cerebrovascular disease III. In :
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Association; 1990 : 638 58
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KW.,

Bone

Ian.

Clinical

Syndromes-Large

Vessel

Oclusion,Classification of Cerebral infarction, Cerebral Infarction,

Intracerebralhaemorrhage. In Lindsay,Bone,Callander. Nuerology and
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8. Anderson T.P. Rehabilitation of
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Patient

with Complete Stroke . In

Physical Medicine and Rehabilitation.4th

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9. PERDOSRI, KonsensusNasionalRehabilitasi Stroke, Jakarta .2004.
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Case Report
Mr S, 53 years old, right handed, married, moslem, lives in Cicendo, Bandung. He
was consulted from Neurology Department of Hasan Sadikin Hospital during his
hospitalization on 27 March 2015 - 5 April 2015 with diagnosis stroke ec infark
atherotrombotic right carotid system risk factor hypertension, hypertension stage
II, dyslipidemia.

ANAMNESIS (10 April 2015)

Chief Complain:
Weakness of his right limbs
History of Present Illness:
Two weeks ago (27 March 2015), Mr. S felt sudden weakness of his right
limbs upon go home from his work. He couldnt raise nor move his right arm and
leg at all. He felt that his right arm is as weak as his right leg. He felt difficult
speech and mouth deviation to the left. He also felt numbness on his right leg. He
didnt complain about vomiting, dizziness, double vision, choking, tinnitus,
seizure, nor blackout. He didnt lose consciousness, but his family said that he
looked confused and didnt recognize his family for a while. His family brought
him to Emergency Room of KebonJati Hospital. His blood pressure was 170/110.
He was referred to HasanSadikin Hospital because there was no neurologist
doctor when at that time. The attending doctor diagnosed him of having a stroke
attack due to blocking in brain vessels and advised him to be hospitalized. He was
hospitalized for 9 days.
On the 4rd day of his hospitalization, he was consulted to PMR department.
He was only able to move his right limbs on his hip and knee on full range of
motion, although still cannot go against gravity. Defecation and urination
disturbances were denied. The program given was proper bed positioning, turning/

2 hour, passive range of motion exercise for his right limbs and active range of
motion exercise for his left limbs.During hospitalization, he felt some progresses.
His difficult of speech decreased, people could understand him better.He could
raise his right arm, full range of motion , and he could against gravity but he
could against minimal resistance. He could move his right foot and fingers
although not fully when put in against gravity nor gravity eliminated position. He
could sidelie and sit independently. He could also stand with support, but still
unable to walk independently. His numbness on his right leg has decreased. Most
of his basic activity of daily living was helped by his family. His wife helped him
ate his meals and change his clothes. After 9 days of hospitalization, he was
allowed to go home. His rehabilitation program was to stand by his bed with
support and then walk around the house with support as he can. Passive range of
motion exercise for his right limbs and active range of motion exercise for his left
limbs are still continued 3 times/ day. He got some medications that need to be
continued: Acetosal 1x 80mg, Amlodipin 1x5mg, Simvastatin 1x10mg.
One week after discharge, his speech was still slurred but people can still
understand him better. He could already walk by walker around the house and to
his neighborhood as far as +- 300 meters with a couple resting time, but he had
not been able to climb and down stairs. He didnt feel numbness anymore on his
right leg. He could brush his teeth, ate, & drank independently. His wife still
helped him bathing by picking up the dipper and washed him. Grooming,
toileting, and dressing still helped his wife and his son and daughter.He regularly
exercises his limbs with his wife 3 times/ day. No complains of pain on limbs
movement.
History of past illness:
1.

History of hypertension (+), known since 7 months ago with the

highest blood pressure 160/100. He did routinely control or take regular
medication at klinik near his home.

2. History of dyslipidemia (+), known since 7 months ago.

3. History of diabetes mellitus (+) known since 7 months ago

4. History of prior stroke was denied
History of Familial Diseases
1.

History of familial hypertension, diabetes mellitus, and heart disease is

denied

History of Habits:
-

Smoking (+) 6 packs/ day since 1985, stopped after stroke

Eating fatty food (+)

Doing sport or exercise (-)

Psychosocial and Economic History :

He graduated from junior high school. He is married to his wife and has 3
children (2 sons & 1 daughter). He lives in his house with his wife, his 2childs, his
1 grandchild . The house has 2 floors, sized 3x6 meters, 2 bedrooms, and filled
with 5 persons.
He uses squatting toilet and doesnt find difficulty in using it. The toilet
has ceramic floor with good ventilation and lighting. The bathroom has water sink
and ceramic floor with enough lighting, but less ventilation. His bed is in the first
floor in the living room. His house has enough lighting, but less ventilation. It is 5
meters away from toilet. There are stairs in the house, but he doesn't need to go
upstairs.
After the sickness, he often feelssad because he didnt work and activity
again. He gets angry easily although he knows that the person he angry with
doesnt mean any harm. He knows to his wifes recover his work when he illness.
He is very motivated so that he often exercises with his wife and takes a walk
around the house. He has good relationship with his families and neighbors. His
family always gives him support.

His monthly budget for daily living until date is covered by his savings.
He made 1 million a month on average before his sickness. His wife does not
work. He uses BPJS PBI for medical insurance.
History of Vocational and Avocational :
Before the illness, he works as a entrepreneur since 5 years ago. He have
small shop in front of alleys home.He often works overnight and often stay up.
The other job, he also work as a taxi driver, but he was already stop since 1 years
ago.

After the illness, he has not work ever since. He hopes that he can work
again soon. He can pray 5 times/day, but he prays in sitting position because he
has not been able to endure rukuh and sujud position. He can rise from sitting
to standing without help. His leisure time is filled with walking around in
neighborhood and watch television.PHYSICAL EXAMINATION (10 April
2015)
Consciousness

: compos mentis

Contact

: adequate

Nutritional status

: Body Weight : 65 kg, Height : 158 cm

BMI =26,6 kg/m2 (overweight)

Communication

: Dysarthria (+) on /r/, /l/

Receptive

: good

Expressive

: Naming

: good

Repetition

: good

Fluency

: good

Comprehensive

: good

MMSE = 22/30 (mild impairment cognitive function) -> impaired in attention &
calculation, recall, language(see attachment 2)
Vital signs
Blood Pressure

: 130/90 mmHg

Heart Rate

: 84 x/min

Respiratory Rate

: 20 x/min

Temperature

: 36.4 C

Mobilization
Side lying

: independent

Rolling

: independent

Lying to sitting

: independent

Sitting to lying

: independent

Sitting to standing

:partial independent

Standing to walking : dependent

Balance
Standing : Static: Romberg: good (with opened and closed eyes)
Poor with closed eyes (falls to the right side)
Dynamic: Tandem walking: unable to conduct
Berg Balance Scale = can not examine

Internal Status
Head

: deformity (-)
Pale palpebra conjunctiva -/-, icteric sclera -/-

Chest

: symmetrical shape and movement of both hemithorax

Heart

: Normal heart sounds (S1-S2), murmur (-), gallop (-)

Lung

: VBS right = left, ronchi -/-, wheezing -/-, slem -/-

Abdomen

: flat, supple, normal bowel sound

Extremities

: edema -/-, cyanosis -/-

Neurologic Status
Cranial Nerves

normal smelling sensation for both nostrils

II

normal vision , normal visual field for both eyes

III

Ptosis -/Round and equal size of pupils, 3 mm/3 mm

Direct/indirect light reflexes +/+
Eyeball movement: good/good

IV&VI
V

Eyeball movement : good/good

Face sensibility : V1 : normal / normal
V2 : normal / normal
V3 : normal / normal
Masseter muscles strength : normal/normal
Temporal muscles strength : normal/normal
Jaw reflex (-)
Mandible at midline

VII

VIII

Facial asymmetry (+):

Eyebrows raising : symmetric

Eyes closing: symmetric

Nasolabial fold: slight paresis of the right side

Smilling: slight paresis on the right side

Sensory of 2/3 anterior tongue: normal

Hearing : normal/ normal

Schwabach:
Air Conduction (AC) : normal/ normal
Bone Conduction (BC) : normal/ normal
Rinne :
Right ear : + (AC > BC)
Left ear : - (BC > AC)
Weber : no lateralize
normal

IX & X

Dysfonia (-)
Gag reflex (-)
Palatal arch symmetric
Uvula in the midline

XI

Paresis sternocleidomastoideus muscle -/Paresis upper trapezius muscle -/-

XII

Tongue fasciculation (-), tremor (-), atrophy (-)

Tongue deviation (+) slightly to the right

Physiological Reflexes

UE

Biceps : +++/++
Triceps : +++/++
Brachioradialis: ++/++

LE

KPR : +++/++
APR : +++/++

Pathological Reflexes

Sensibility

UE

Hoffman Tromner: -/-

LE

Babinski: +/-

UE

Sensibility

: normal / normal

Proprioceptive : good / good

LE

Sensibility

: normal / normal

Proprioceptive : good / good

Coordination

Tone

Clonus

Musculoskeletal Status
Head and Neck

UE

good / good (finger to nose test)

LE

good / good (heel to shin test)

UE

Spasticity: 1 / 0 (Modified Asworth Scale)

LE

Spasticity: 0 / 0 (Modified Asworth Scale)

LE

-/-

Deformity

-/-

Inflammation sign

-/-

Edema

-/-

Oromotor Status:

Drooling

Lip seal

Good

Tongue movement

Jaw movement

Pa/ ta/ ka

Good
Good
Pa/ ta : good
Ka : good

Range of Motion

Full

Pain in movement

MMT

Trunk
Posture

Normal, straight alignment

Occiput to wall distance

1 cm

Shoulder height

Right = Left

Scapular prominence

-/-

Hump

-/-

Arm distance

Right = left

Pelvic obliquity

Right = Left

ROM

Flexion = 4 cm(Modified Schoeber Test)

Extension = 1,5 cm (Modified Schoeber Test)

Lateral flexion = 20 O-20 O
Rotation = 40O-40O
MMT

Flexion = 4
Extension = 4
Rotation = 4

Upper Extremities
Inspection

Flexor synergy pattern -/-

Deformity

Glenohumeral joint subluxation -/-

Inflammation sign

-/-

Edema

-/-

Range of Motion

Full / Full

Pain in movement

- /-

MMT

4444/5555

Hand Prehension

Power Grip
Fist/ palmar

: good/ good

Cylindrical

: good/ good

Spherical

: good/ good

Hook

: good/ good

Precision Grip
Tip-to-tip

: good/ good

Three-prongchuck: good/ good

Lateral pinch

: good/ good

Lower extremities
Inspection

Extensor synergy pattern -/-

Deformity

-/-

Inflammation sign

-/-

Edema

-/-

Range of Motion

Full /full

Pain in movement

-/-

MMT

2543/5555

Vegetative status
Bowel and bladder functions normally

FUNCTIONAL ASSESSMENT
1. Cognitive : (ICD-9CM : 89.13)(see attachment 2)
MMSE = 22/30 (mild impairment cognitive function) -> impaired in
attention & calculation, recall, language

2. Communication : (ICD-9CM : 89.15)(see attachment 3)

Naming (pictures) in word level = 5
Mention names in a semantic category = 5
Conclusion : no language disorder

3. Activity of Daily Living : (ICD-9CM : 93.09)

Barthel Index = 11/20 (moderate disability) -> impaired in feeding,

bathing, grooming, dressing, toileting, climbing stairs(see attachment
6)

SUPPORTING EXAMINATION
Chest X-Ray (8 March 2014)
Kardiomegali tanpa bendungan paru

Head CT Scan (8 March 2014)

Infark serebri di subcortical lobus parietalis kiri

Tidak tampak perdarahan intra serebri

Laboratory findings :
Lab darah

28 Maret 2015

Hb
Ht
Leukosit
Trombosit
Na
Kalium
Ureum
Kreatinin
GDS

12,8
40
12.400
406.000
140
4,1
36
0,78
160

30 maret 2015
Kolesterol total
HDL
LDL
Trigliserida
HbA1c
GDP
AsamUrat
GD2PP

231
41
160
270
6,5
89
4,5
103

DIAGNOSIS :
Clinical Diagnosis

Infarction Stroke due to Partial Anterior Circulation

Syndromes Left Carotid System Subacute Phase
(G.46.1)

with mobilization disturbance (Z 74.0), ADL disturbance (Z 74.1) due to left

hemiparesis
- Hypertension grade I (I.11)
- Diabetes Mellitus type II (E.12)
- Dyslipidemia (E.78.0)
Etiological Diagnosis

Cerebral infarction , with risk factor hypertension,

diabetes mellitus, Dyslipidemia, smoking

Location Diagnosis

Neuromuscular system, musculoskeletal system,

metabolic system

Functional Diagnosis

Impairment

Right hemiparesis
Right central VII & XII nerve
paresis

Disability

ADL & IADL

Mobilization

Handicap

PROGNOSIS :

Vocational &Avocational

Quo ad vitam

: ad bonam

Quo ad sanationam

: dubiaad bonam

Quo ad functionam

: dubiaad bonam

PROBLEM
M1

: Stroke

M2

: Hypertension

M3

: Dyslipidemia

R1

: Mobilization

R2

: ADL and IADL

R3

: Vocational &Avocational

REHABILITATION GOAL :
Short term :

Maintain ROM to maintain flexibility

Improve muscle strength of right side hemiparesis

Improve balance

ADL independently

Long term :

Prevent recurrent stroke by controlling hypertension, dyslipidemia, stop

smoking

Improve cardiopulmonary endurance

Regain optimal gait pattern

Back to work

MEDICAL PROGRAM :
1. Stroke
S : Right side limbs weakness
O : Right side upper and lower limb weakness
Spasticity (MAS) grade 1 for right upper& lower limb
Right central VII & XII nerve paresis
Head CT scan: Infarkcerebri in subcortical sinistra parietalis lobe

Low risk of fall

MMSE = 22/30 (mild impairment cognitive function) -> impaired in
attention & calculation, recall, language
G : Prevent recurrent stroke
Improve functional capability
P : Educate the patient and family about stroke, risk factors, time course, and
recovery of stroke
Assess psychological status in the next meeting

2. Hypertension
S : History of hypertension
O : Blood pressure 170/110 mmHg on Amlodipin 1x5mg

G : Control regularly and reduce risk factor

P: Educate the patient to control to Neurology Department and take the
medicine regularly (Amlodipin 1x5mg)
Consult to nutrisionist for low salt diet

3. Dyslipidemia
S : History of dyslipidemia known since hospitalized
O :Total Cholesterol
HDL Cholesterol

: 231 mg/dL
: 41 mg/dL

LDL Cholesterol

: 160 mg/dL

Trigliseride

: 270 mg/dl

G : Control regularly and reduce risk factor

P : Educate the patient to control to Neurology Department and take the
medicine regularly (Simvastatin 1x10mg)
Consult to nutrisionist for low fat diet

REHABILITATION PROGRAM :
1. Mobilization
S : Patient walks with abnormal gait and tires easily
O : Weakness of right lower limb(MMT 2543)
Proprioceptive: impaired for right lower limb
Hemiparetic gait
G : Short term :Maintain ROM to maintain flexibility
Improve muscle strength of right side hemiparesis
Improve balance
Long term : Improve cardiopulmonary endurance
Regain optimal gait pattern
P : Short term : Active Assistive ROM exercise for lower limbs
Exercise testing with ergocycle
Ergocycle for endurance & strengthening exercise
Long term : gait training

2. Activities of Daily Living

S:Patient cant brushes his teeth, eating, & drinking using his left hand, still
needs help to pick up the dipper and wash himself while bathing, cant
climb & down stairs, grooming, toileting, and dressing can be done
independently if the patient mainly uses his left hand

O :Barthel Index = 11/20 (moderate disability) -> impaired in feeding,

bathing, grooming, dressing, toileting, climbing stairs (see attachment 6)
Weakness of the right upper limb (MMT 4444)
Trunk weakness (MMT: flexion = 4, extension = 4, rotation = 4)
Weakness of right lower limb(MMT 2543)
Hemiparetic gait
G :Independence in activities of daily living
P: Active Assistive ROM exercise for upper limbs
Passive ROM exercise for lower limbs

3. Vocational &Avocational
S: patient hopes to be able to get back to work
O: Weakness of the right upper limb (MMT 4444)
Impaired right hand prehension and dexterity
Trunk weakness (MMT: flexion = 4, extension = 4, rotation = 4)
Weakness of right lower limb(MMT 2543)
Proprioceptive: impaired for right lower limb
Hemiparetic gait
G : Assign patient for work
P : Active Assistive ROM exercise for upper limbs
Passive ROM exercise for lower limbs

DISCUSSION
From anamnesis, the patient felt sudden weakness of his right limbs upon
go home from his work. He couldnt raise nor move his right arm and leg at all.
His blood pressure at Emergency Room was 170/110. From physical examination
there were right hemiparesis and right central paresis of VII & XII nerve, increase
of physiologic reflex, presence of pathologic reflex and spasticity. The anamnesis
and physical examination suggested a infark stroke.
This patient has contralateral hemiparesis and contralateral cranial nerve
paralysis. It is suggesting a carotid system circulation stroke. The risk factor for
stroke found in this patient is smoking, hypertension, and dyslipidemia. The time
course of this case is 3 months.It is a subacute phase stroke.
Impairment in this patient are right hemiparesis, right central VII &XII
nerve paralysis,that makes him disable in mobilization, ADL, and IADL. He feels
sad because of his sickness. He also becomes easier to be angry. Considering the
condition of this patient, rehabilitation program is emphasized on optimalizing
neurological recovery while preventing complications so that his recovery
progress is facilitated well to achieve optimal functional capability possible.
Prognosis ad vitam in this patient is ad bonam because the vital signs are
stable and the risk factors has already been controlled. Prognosis sanationam is
dubiaadbonam, because the patients compliance in control to neurologist for his
hypertension & dyslipidemia, consume the medications regularly, and diet
modificationis questionable. Prognosis ad functionam is dubia adbonam because
he has good motivation to do exercises. By these 3 months, the recovery progress
of his limbs weakness is still positively progressing.

CASE ANALYSIS
Smoking

Hypertension

Dyslipidemia

Infark stroke subacute phase

Paralysis of VII and XII cranial nerve

Lower limb weakness

Feels sad

ADL & IADL disturbance

Vocational &Avocational

Dysarthria

FOLLOW UP
20 June 2015
1.
SUBJECTIVE

MOBILIZATION

Patient claims that he could walk around his house twice further than the last meeting with
less frequent rests.

OBJECTIVE
Physical examination
Lower extremities
ROM
MMT
Spasticity
Proprioception

Full/ Full (See attachment 1 for further details)

(See attachment 1)
Flexion = 0 (Modified Asworth Scale)
Extension = 0 (Modified Asworth Scale)
Good/good

Functional Assessment
Cardiopulmonary
Endurance Test (ICD-6MWT-> failed to conduct because condition of the patient is not possible
9CM : 93.09)
ASSESSMENT

Mobilization disorder due to right side hemiparesis (R26.8, G81.9)

GOAL

Short term :
Maintain ROM to maintain flexibility
Improve muscle strength of right side hemiparesis
Long term :
Improve cardiopulmonary endurance
Regain optimal gait pattern
Short term : Active ROM exercise for lower limbs
Strengthening exercise right lower limbs
Plan : 6MWT
Long term : gait training

PROGRAM

2.
SUBJECTIVE
OBJECTIVE

DYSPHAGIA

He feels difficult swallowing. He complaint about the tonsils is swollen. He feels like as
chocked.
TOR BSST : (see attachment
Tonsils : T2/T2

ASSESSMENT

Swallowing disorder due to paralysis n XII ddtonsilitis

GOAL

Improve capability swallowing

PROGRAM

Consult THT

3.
SUBJECTIVE

DEPRESSION

He still gets sad and depresses when he is lonely. He gets angry easily, but also resolves
quickly. He is still highly motivated to exercise because he wants to recover well from his
sickness.

OBJECTIVE
Functional Assessment
Psychological
status:
(ICD-9CM : 93.94)

Depression Anxiety Stress Scale (DASS) : (see attachment 8)

Depression = (mild depression), Anxiety = 0 (normal), Stress = 6 (normal)
Hamilton Depression Scale (HAM-D) = (mild depression) (see attachment 9)

ASSESSMENT

Mild depression (F06.3)

GOAL

Alleviate depression

PROGRAM

Consult psychiatrist

Attachment 1
Range of Motion and Manual Muscle Testing
Cervical
Cervical flexion
Cervical extension
Cervical lateral flexion
Cervical rotation
Trunk
Flexion
Extension
Lateral flexion
Rotation
Upper extremity
Shoulder flexion
Shoulder extension
Shoulder abduction
Shoulder adduction
Shoulder internal rotation
Shoulder external rotation
Elbow flexion
Elbow extension
Elbow supination
Elbow pronation
Wrist flexion
Wrist extension
Wrist ulnar deviation
Wrist radial deviation
Thumb abduction
Thumb adduction
Thumb flexion MCP
Thumb flexion IP
Thumb extension MCP
Thumb extension IP
Other fingers abduction
Other fingers adduction
Other fingers flexion MCP
Other fingers flexion PIP
Other fingers flexion DIP
Otherfingersextension MCP
Lower extremity
Hip flexion
Hip extension
Hip abduction

Range Of Motion
Right
Left
0 -40
0 -50
0 -20
0 -20
0 -50
0 -50
Range Of Motion
4 cm (Modified Schoeber Test)
1,5 cm (Modified Schoeber Test)
250 - 200
400 - 400
Range Of Motion
Right
Left
0 - 1800
0 - 1800
0 - 500
0 - 500
0 - 1800
0 - 1800
0
0 - 40
0 - 400
0
0 - 70
0 - 700
0 - 900
0 - 900
0
0 - 130
0 - 1300
0
0
00
0
0 - 80
0 - 800
0 - 800
0 -800
0
0 - 80
0 - 800
0
0 - 70
0 - 700
0 - 300
0 - 300
0
0 - 20
0 - 200
0
0 - 70
0 - 700
0
0
00
0 - 500
0 - 500
0
0 - 80
0 - 800
0
0 - 15
0 - 150
0 - 200
0 - 200
0
0 - 20
0 - 200
0
0
00
0
0 - 90
0 - 900
0 - 1000
0 - 1000
0
0 - 70
0-700
0
0 - 20
0 - 200
Range Of Motion
Right
Left
0 - 1100
0 - 1100
0 - 200
0 - 200
0 - 400
0 - 400

MMT
Right

Left
5
5

5
5

5
5
MMT
4
4
4
MMT

Right
4
4
4
4
4
4
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5

Left
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
MMT

Right
4
4
4

Left
5
5
5

Hip adduction
Hip internal rotation
Hip external rotation
Knee flexion
Knee extension
Ankle dorsoflexion
Ankle plantarflexion
Ankle inversion
Ankle eversion
Hallux flexion MTP
Hallux flexion IP
Hallux extension MTP
Other fingers flexion MTP
Other fingers flexion PIP
Other fingers flexion DIP
Other fingersextension MTP

0 - 200
0 - 400
0 450
0 - 1500
00
0
0 - 150
0 - 500
0 - 300
0-100
0 - 300
0 - 300
0 - 500
0 - 100
0 - 300
0 - 300
0 - 300

0 - 200
0 - 400
0 - 450
0 - 1500
00
0 - 200
0 - 500
0 - 300
0 - 100
0 - 300
0 - 300
0 - 500
0 - 100
0 - 300
0 - 300
0 - 300

4
4
4
5
5
5
5
Not done
Not done
5
5
5
5
5
5
5

5
5
5
5
5
5
5
Not done
Not done
5
5
5
5
5
5
5

Attachment 2
MINI MENTAL STATE EXAMINATION (MMSE)
Instructions: Score one point for each correct response within each question or activity.

Question
ORIENTATION "What is the year? Season? Date? Day of the week?
Month?"
"Where are we now: state? Country? Town/city?
Hospital? Floor?"
REGISTRATIO The examiner names three unrelated objects clearly
N

Max 10/4 20/6

5

and slowly, then asks the patient to name all three of

them. The patient's response is used to scoring. The
examiner repeat them until patient learn of them, if

possible. Number of trials:............

ATTENTION & "I would like you to count backward from 100 by
CALCULATION sevens" (93,86,79,72,65,...........) stop after the
RECALL

answer.
"Earlier I told you the names of three things. Can

you tell me what those were?"

LANGUAGE Show the patient two simple objects, such as a
wristwatch and a pencil, and ask the patient to name
them.
"Repeat the phrase : "No ifs, ands, or buts."
"Take the paper in your right hand, fold it in half,
and put it on the floor." (the examiner gives the
patient a piece of paper).
"Please read this and do what I says". (Written
instruction is "Close your eyes".)
"Make up and write a sentence about anything". (this
sentence must contain a noun and a verb).

Please copy this picture. (the examiner gives the

30

22

27

patient a blank piece of paper and asks him/her to

draw the symbol elow. All 10 angles must be present
and two must intersect).

TOTAL

Interpretation of the MMSE:

Method
Single Cutoff
Range
Education

Severity

Score
25-30

Degree of
impairment
Questionably
significant

20-25

Mild

10-20

Moderate

0-10

Severe

Source:

Score
<24
<21
>25
21
<23
<24
24-30
18-23
0-17

Interpretation
Abnormal
Increased odds of dementia
Decreased odds of dementia
Abnormal for 8th grade education
Abnormal for high school education
Abnormal for college education
No cognitive impairment
Mild cognitive impairment
Severe cognitive impairment
Formal Psychometric
Day-to-Day Functioning
Assessment
If clinical signs of cognitive
May have clinically significant
impairment are present, formal
but mild deficits. Likely to
assessment of cognition may be affect only most demanding
valuable
activities of daily living.
Formal assessment may be
Significant effect. May require
helpful to better determine
some supervision, support and
pattern and extent of deficits.
assistance.
Formal assessment may be
Clear impairment. May require
helpful if there are specific
24-hour supervision.
clinical indications
Patient not likely to be testable.
Marked impairment. Likely to
require 24-hour supervision
and assistance with ADL.

Folstein MF, Folstein SE, McHugh PR: Mini-mental state: A practical method for grading
the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189198.Attachment 3
PETUNJUK ASESMEN PENEGAKAN DIAGNOSIS AFASIA
Pasien: Tn.Y
Tanggal : 5 April 2014
Untukmenegakkan
afasiadiperlukanevaluasikemampuanpasienmenyebutdanmenamaitingkat kata
JENIS REGISTRASI

SKOR
AFASIA

Menamai-tingkat kata
Menyebut

diagnosis

14
14

NORMAL
5
5

Diagnosis afasia ditegakkan bila skor pasien (1 4)pada kedua subtes.Jika salah satu
subtes menghasilkan skor 5 (normal) berarti pasien tidak mengalami afasia. Yang perlu
diperhatikan, gangguan bicara dapat terjadi oleh penyebab lain seperti disartria atau
apraksia verbal. Bila pasien dapat menamai secara tertulis (subtes menulis tingkat
kata) dengan baik sedangkan menamai secara lisan tidak, maka pasien tidak menderita
afasia tetapi apraksia verbal.
1. MENAMAI TINGKAT KATA (Leksiko semantik)
Tujuan :Menilai kemampuan menamai gambar
Bahan :Kartu stimulus 1 dan 2
Instruksipadakartu1 :Pasien diminta menyebutkan satu-persatu nama gambar pada
kartu 1. Bila pasien tidak dapat menamai item 1 (gelas) dan 2 (payung), tanyakan apakah
bias menunjukkan gerakannya atau menyebutkan apa fungsi alat tersebut.
Kartu 1

Instruksi pada kartu2 :Pasien diminta menyebutkan warna dan angka sesuai gambar
berikut :
Kartu 2

Tabel 1.Poin stimulus

No
1.
2.
3.
4.
5.
6.
7.
8.

Stimulus
Gelas
Payung
Panah
Segitiga
Biru
Kuning
Sembilan
Tujuhbelas

Poin 1-1/2-0
1
1
1
1
1
1
1
1

TOTAL POIN = 8
SKOR = 5

Tabel 2.HasilPemeriksaan
Poin
Arti

1
Langsung
menjawab
benar

1/2
Menjawab
benar
setelah 5
detik

0
Hanya
sebagian
benar atau
tidak benar

Tabel 3.Skor
Total
poin
0
1-2
3-5 1/2
6-7 1/2
8

Skor
1
2
3
4
5

Skor :untuk menentukan skor, dihitung terlebih dahulu jumlah total poin ( lihattabel 1),
kemudian dicocokkan dengan standar pencapaian skor untuk mendapatkan skor akhir .
2. MENYEBUT
Tujuan:Menilai kemampuan menyebut contoh nama-nama dalam satu kategori semantic
tertentu.
Bahan:Formulir Registrasi
Instruksi:Pasien diminta menyebutkan nama-nama binatang sebanyak mungkin dalam
waktu satu menit. Bisa menyebut binatang jinak, binatang buas atau jenis-jenis
burung.Ulangi instruksi bila perlu.

Skor :Hitung jumlah nama binatang yang disebut dalam waktu satu menit. Pengulangan
tidak dihitung.Nama yang diucapkan tidak perlu sempurna, asalkan dapat dikenal.
Menyebut nama binatang dalam 1 menit
1. kucing
2.tikus
3.anjing
4.jerapah
5.gajah
6.kuda
7.nyamuk
8.semut
9. kecoak
10.kambing
Jumlahtotal :10

11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

Selanjutnya, dicocokkan dengan standar pencapaian skor untuk mendapatkan skor akhir,
menurut tolak ukur di bawah ini :
Jumlahnamabinatang
yang dapatdisebutkan
0
1-2
3-4
5-9
10
SKOR = 5

Skor
1
2
3
4
5

Conclusion = NormalAttachment 4

TOR-BSST (Toronto Bedside Swallowing Screening Test)

A. Sebelum masukan cairan: (Tandai abnormal atau normal untuk setiap tugas)
1. Minta pasien menyebutkan ah dan nilai kualitassuara
Abnormal

Normal
V

2. Minta pasien menjulurkan keluar lidahnya dan kemudian menggerakkannya dari

satu sisi kesisi lain
Abnormal

Normal
V

B. Masukancairan:
Batuk
selama/setelah
menelan

Perubahan
suara
setelah
menelan

Meneteskan
air liur
selama/setelah
menelan

Normal

Menelan 1

Menelan 2

Menelan 3

Menelan 4

Menelan 5

Menelan 6

Menelan 7

Menelan 8

Menelan 9

Menelan 10

Minumdengancangki
r

V
V
C. Setelah masukan cairan: (dilakukan setidaknya satu menit setelah Anda
menyelesaikan bagian B)
1. Minta pasien menyebutkan ah kembali dan tentukan kualitas suara
Abnormal

Normal
V

Attachment5
BERG BALANCE SCALE
The Berg Balance Scale (BBS) was developed to measure balance among older people
with
impairment in balance function by assessing the performance of functional tasks. It is a
valid
instrument used for evaluation of the effectiveness of interventions and for quantitative
descriptions of function in clinical practice and research. The BBS has been evaluated in
several reliability studies. A recent study of the BBS, which was completed in Finland,
indicates that a change of eight (8) BBS points is required to reveal a genuine change in
function between two assessments among older people who are dependent in ADL and
living in residential care facilities.
Description:
14-item scale designed to measure balance of the older adult in a clinical setting.
Equipment needed: Ruler, two standard chairs (one with arm rests, one without),
Footstool or step, stopwatch or wristwatch, 15 ft walkway
Completion:
Time: 15-20 minutes
Scoring:
A five-point scale, ranging from 0-4. 0 indicates the lowest levelof function and 4 the
highest level of function. Total Score = 56
Interpretation:
41-56 = low fall risk
21-40 = medium fall risk
0 20 = high fall risk
A change of 8 points is required to reveal a genuine change in function between 2
assessments.

Berg Balance Scale

Name: Mr. S
Rater: dr. Esi
ITEM DESCRIPTION SCORE (0-4)
Sitting to standing
Standing unsupported
Sitting unsupported
Standing to sitting
Transfers
Standing with eyes closed
Standing with feet together
Reaching forward with outstretched arm
Retrieving object from floor
Turning to look behind
Turning 360 degrees
Placing alternate foot on stool
Standing with one foot in front
Standing on one foot
Total

Date: 5 April 2014

________4
________4
________4
________4
________4
________4
________4
________4
________4
________4
________4
________0
________4
________0
________48/ 56

CONCLUSION = LOW FALL RISK

GENERAL INSTRUCTIONS
Please document each task and/or give instructions as written. When scoring, please
record the lowest response category that applies for each item.
In most items, the subject is asked to maintain a given position for a specific time.
Progressively more points are deducted if:
the time or distance requirements are not met
the subjects performance warrants supervision
the subject touches an external support or receives assistance from the examiner
Subject should understand that they must maintain their balance while attempting the
tasks. The choices of which leg to stand on or how far to reach are left to the subject. Poor
judgment will adversely influence the performance and the scoring.

Equipment required for testing is a stopwatch or watch with a second hand, and a ruler or
other indicator of 2, 5, and 10 inches. Chairs used during testing should be a reasonable
height. Either a step or a stool of average step height may be used for item # 12. BERG
BALANCE SCALE
SITTING TO STANDING
INSTRUCTIONS: Please stand up. Try not to use your hand for support.
(V) 4 able to stand without using hands and stabilize independently
( ) 3 able to stand independently using hands
( ) 2 able to stand using hands after several tries
( ) 1 needs minimal aid to stand or stabilize
( ) 0 needs moderate or maximal assist to stand
STANDING UNSUPPORTED
INSTRUCTIONS: Please stand for two minutes without holding on.
(V) 4 able to stand safely for 2 minutes
( ) 3 able to stand 2 minutes with supervision
( ) 2 able to stand 30 seconds unsupported
( ) 1 needs several tries to stand 30 seconds unsupported
( ) 0 unable to stand 30 seconds unsupported
If a subject is able to stand 2 minutes unsupported, score full points for sitting
unsupported. Proceed to item #4.
SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR
ON A STOOL
INSTRUCTIONS: Please sit with arms folded for 2 minutes.
(V) 4 able to sit safely and securely for 2 minutes
( ) 3 able to sit 2 minutes under supervision
( ) 2 able to able to sit 30 seconds
( ) 1 able to sit 10 seconds
( ) 0 unable to sit without support 10 seconds
STANDING TO SITTING
INSTRUCTIONS: Please sit down.
(V) 4 sits safely with minimal use of hands
( ) 3 controls descent by using hands
( ) 2 uses back of legs against chair to control descent
( ) 1 sits independently but has uncontrolled descent
( ) 0 needs assist to sit
TRANSFERS
INSTRUCTIONS: Arrange chair(s) for pivot transfer. Ask subject to transfer one way
toward a seat with armrests and one way toward a seat without armrests. You may use
two chairs (one with and one without armrests) or a bed and a chair.
(V) 4 able to transfer safely with minor use of hands
( ) 3 able to transfer safely definite need of hands
( ) 2 able to transfer with verbal cuing and/or supervision
( ) 1 needs one person to assist
( ) 0 needs two people to assist or supervise to be safe

STANDING UNSUPPORTED WITH EYES CLOSED

INSTRUCTIONS: Please close your eyes and stand still for 10 seconds.
(V) 4 able to stand 10 seconds safely
( ) 3 able to stand 10 seconds with supervision
( ) 2 able to stand 3 seconds
( ) 1 unable to keep eyes closed 3 seconds but stays safely
( ) 0 needs help to keep from falling
STANDING UNSUPPORTED WITH FEET TOGETHER
INSTRUCTIONS: Place your feet together and stand without holding on.
(V) 4 able to place feet together independently and stand 1 minute safely
( ) 3 able to place feet together independently and stand 1 minute with supervision
( ) 2 able to place feet together independently but unable to hold for 30 seconds
( ) 1 needs help to attain position but able to stand 15 seconds feet together
( ) 0 needs help to attain position and unable to hold for 15 seconds
REACHING FORWARD WITH OUTSTRETCHED ARM WHILE STANDING
INSTRUCTIONS: Lift arm to 90 degrees. Stretch out your fingers and reach forward as
far as you can. (Examiner places a ruler at the end of fingertips when arm is at 90
degrees. Fingers should not touch the ruler while reaching forward. The recorded measure
is the distance forward that the fingers reach while the subject is in the most forward lean
position. When possible, ask subject to use both arms when reaching to avoid rotation of
the trunk.)
(V) 4 can reach forward confidently 25 cm (10 inches)
( ) 3 can reach forward 12 cm (5 inches)
( ) 2 can reach forward 5 cm (2 inches)
( ) 1 reaches forward but needs supervision
( ) 0 loses balance while trying/requires external support
PICK UP OBJECT FROM THE FLOOR FROM A STANDING POSITION
INSTRUCTIONS: Pick up the shoe/slipper, which is in front of your feet.
(V) 4 able to pick up slipper safely and easily
( ) 3 able to pick up slipper but needs supervision
( ) 2 unable to pick up but reaches 2-5 cm(1-2 inches) from slipper and keeps balance
independently
( ) 1 unable to pick up and needs supervision while trying
( ) 0 unable to try/needs assist to keep from losing balance or falling
TURNING TO LOOK BEHIND OVER LEFT AND RIGHT SHOULDERS WHILE
STANDING
INSTRUCTIONS: Turn to look directly behind you over toward the left shoulder. Repeat
to the right. (Examiner may pick an object to look at directly behind the subject to
encourage a better twist turn.)
(V) 4 looks behind from both sides and weight shifts well
( ) 3 looks behind one side only other side shows less weight shift
( ) 2 turns sideways only but maintains balance
( ) 1 needs supervision when turning
( ) 0 needs assist to keep from losing balance or falling

TURN 360 DEGREES

INSTRUCTIONS: Turn completely around in a full circle. Pause. Then turn a full circle
in the other direction.
(V) 4 able to turn 360 degrees safely in 4 seconds or less
( ) 3 able to turn 360 degrees safely one side only 4 seconds or less
( ) 2 able to turn 360 degrees safely but slowly
( ) 1 needs close supervision or verbal cuing
( ) 0 needs assistance while turning
PLACE ALTERNATE FOOT ON STEP OR STOOL WHILE STANDING
UNSUPPORTED
INSTRUCTIONS: Place each foot alternately on the step/stool. Continue until each foot
has touched the step/stool four times.
( ) 4 able to stand independently and safely and complete 8 steps in 20 seconds
( ) 3 able to stand independently and complete 8 steps in > 20 seconds
( ) 2 able to complete 4 steps without aid with supervision
( ) 1 able to complete > 2 steps needs minimal assist
(V) 0 needs assistance to keep from falling/unable to try
STANDING UNSUPPORTED ONE FOOT IN FRONT
INSTRUCTIONS: (DEMONSTRATE TO SUBJECT) Place one foot directly in front of
the other. If you feel that you cannot place your foot directly in front, try to step far
enough ahead that the heel of your forward foot is ahead of the toes of the other foot. (To
score 3 points, the length of the step should exceed the length of the other foot and the
width of the stance should approximate the subjects normal stride width.)
(V) 4 able to place foot tandem independently and hold 30 seconds
( ) 3 able to place foot ahead independently and hold 30 seconds
( ) 2 able to take small step independently and hold 30 seconds
( ) 1 needs help to step but can hold 15 seconds
( ) 0 loses balance while stepping or standing
STANDING ON ONE LEG
INSTRUCTIONS: Stand on one leg as long as you can without holding on.
( ) 4 able to lift leg independently and hold > 10 seconds
( ) 3 able to lift leg independently and hold 5-10 seconds
( ) 2 able to lift leg independently and hold L 3 seconds
( ) 1 tries to lift leg unable to hold 3 seconds but remains standing independently.
(V) 0 unable to try of needs assist to prevent fall
(48) TOTAL SCORE (Maximum = 56)

Attachment 6
THE BARTHEL INDEX

FEEDING
0 = unable
1 = needs help cutting, spreading butter, etc., or requires modified diet
2 = independent
BATHING
0 = dependent
1 = independent (or in shower)
GROOMING
0 = needs to help with personal care
1 = independent face/hair/teeth/shaving (implements provided)
DRESSING
0 = dependent
1 = needs help but can do about half unaided
2 = independent (including buttons, zips, laces, etc.)
BOWELS
0 = incontinent (or needs to be given enemas)
1 = occasional accident
2 = continent
BLADDER
0 = incontinent, or catheterized and unable to manage alone
1 = occasional accident
2 = continent
TOILET USE
0 = dependent
1 = needs some help, but can do something alone
2 = independent (on and off, dressing, wiping)
TRANSFERS (BED TO CHAIR AND BACK)
0 = unable, no sitting balance
1 = major help (one or two people, physical), can sit
2 = minor help (verbal or physical)
3 = independent
MOBILITY (ON LEVEL SURFACES)
0 = immobile or < 50 yards
1 = wheelchair independent, including corners, > 50 yards
2 = walks with help of one person (verbal or physical) > 50 yards
3 = independent (but may use any aid; for example, stick) > 50 yards

10/4
2

20/6
2

STAIRS
0 = unable
1 = needs help (verbal, physical, carrying aid)
2 = independent
TOTAL (0-20):
Interpretation:
0-4

: very severe disability

5-9

: severe disability

10-14 : moderate disability

15-19 : mild disability

11

20

20

: independent in ADLAttachment7
INSTRUMENTAL ACTIVITIES OF DAILY LIVING SCALE (IADL)
M.P. Lawton & E.M. Brody

A. Ability to use telephone

1. Operates telephone on own initiative;
looks up and dials numbers, etc.
2. Dials a few well-known numbers
3. Answers telephone but does not dial
4. Does not use telephone at all.

E. Laundry
1. Does personal laundry completely
2. Launders small items; rinses stockings, etc.
3. All laundry must be done by others.

1
1
0

B. Shopping
1. Takes care of all shopping needs
1
independently
2. Shops independently for small purchases
0
3. Needs to be accompanied on any shopping trip 0
4. Completely unable to shop.
0
C. Food Preparation
1. Plans, prepares and serves adequate meals
independently
2. Prepares adequate meals if supplied with
ingredients
3. Heats, serves and prepares meals or prepares
meals but does not maintain adequate diet.
4. Needs to have meals prepared and served.

1
0
0
0

D. Housekeeping
1. Maintains house alone or with occasional
1
assistance (e.g. heavy work domestic help)
2. Performs light daily tasks such as dishwashing, 1
bed making
3. Performs light daily tasks but cannot maintain 1
acceptable level of cleanliness.
4. Needs help with all home maintenance tasks.
1
5. Does not participate in any housekeeping tasks. 0

F. Mode of Transportation
1. Travels independently on public
transportation or drives own car.
2. Arranges own travel via taxi, but does not
otherwise use public transportation.
3. Travels on public transportation when
accompanied by another.
4. Travel limited to taxi or automobile with
assistance of another.
5. Does not travel at all.
G. Responsibility for own medications
1. Is responsible for taking medication in
correct dosages at correct time.
2. Takes responsibility if medication is
prepared in advance in separate dosage.
3. Is not capable of dispensing own
medication.
H. Ability to Handle Finances
1. Manages financial matters independently
(budgets, writes checks, pays rent, bills goes to
bank), collects and keeps track of income.
2. Manages day-to-day purchases, but needs
help with banking, major purchases, etc.
3. Incapable if handling money.
0

1
1
0

1
1
1
0
0

1
0
0

Score = 0

Source: Lawton, M.P., and Brody, E.M. "Assessment of older people: Self-maintaining and
instrumental activities of daily living." Gerontologist 9:179-186, (1969).
Copyright (c) The Gerontological Society of America. Used by permission of the Publisher.

Attachment 8
Depression Anxiety and Stress Scale (DASS)
The DASS is a 42-item questionnaire which includes three self-report scales designed to
measure the negative emotional states of depression, anxiety and stress. Each of the three
scales contains 14 items, divided into subscales of 2-5 items with similar content. The
Depression scale assesses dysphoria, hopelessness, devaluation of life, self-deprecation,
lack of interest/involvement, anhedonia, and inertia. The Anxiety scale assesses
autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience
of anxious affect. The Stress scale (items) is sensitive to levels of chronic non-specific
arousal. It assesses difficulty relaxing, nervous arousal, and being easily upset/agitated,
irritable/over-reactive and impatient. Respondents are asked to use 4-point
severity/frequency scales to rate the extent to which they have experienced each state
over the past week.
Scoring:
Scores of Depression, Anxiety and Stress are calculated by summing the scores for the
relevant items. The depression scale items are 3, 5, 10, 13, 16, 17, 21, 24, 26, 31, 34, 37,
38, 42. The anxiety scale items are 2, 4, 7, 9, 15, 19, 20, 23, 25, 28, 30, 36, 40, 41. The
stress scale items are 1, 6, 8, 11, 12, 14, 18, 22, 27, 29, 32, 33, 35, 39. To use the Scoring
Template (below) print on to a plastic overhead. The score for each of the respondents
over each of the sub-scales, are then evaluated as per the severity-rating index below.
Normal
Mild
Moderate
Severe
Extremely Severe

Depression
09
10 13
14 20
21 27
28+

Anxiety
0-7
89
10 14
15 19
20+

Stress
0 14
15 18
19 25
26 33
34 +

Norms: Normative data are available on a number of Australian samples. From a

sample of 2914 adults the means (and standard deviations) were 6.34 (6.97), 4.7
(4.91), and 10.11 (7.91) for the depression, anxiety, and stress scales, respectively. A
clincical sample reported means (and standard deviations) of 10.65 (9.3), 10.90 (8.12),
and 21.1 (11.15) for the three measures.
Source: www.psy.unsw.edu.au/groups
Reference :Lovibond, S.H. &Lovibond, P.f. (1995). Manual for the Depression anxiety
Stress Scales. (2nd Ed) Sydney: Psychology Foundation.

Depression
Anxiety

= 10 (mild depression)
= 0 (normal)

Stress

= 6 (normal)Attachment9

The Hamilton Rating Scale for Depression

(to
be
administered
by
a

health

care

professional)

To rate the severity of depression in patients who are already diagnosed as depressed,
administer this questionnaire. The higher the score, the more severe the depression.For
each item, write the correct number on the line next to the item. (Only one response per
item)
1. DEPRESSED
MOOD
(Sadness,
hopeless,
helpless,
worthless)
0= Absent
1=
These
feeling
states
indicated
only
on
questioning
2= These feeling states spontaneously reported verbally
3= Communicates feeling states non-verballyi.e., through facial expression, posture
voice, and tendency to weep
4= Patient reports VIRTUALLY ONLY these feeling states in his spontaneous
verbal and non-verbal communication
2. FEELINGS OF GUILT
0= Absent
1= Self reproach, feels he has let people down
2= Ideas of guilt or rumination over past errors or sinful deeds
3= Present illness is a punishment. Delusions of guilt
4= Hears accusatory or denunciatory voices and/or experiences threatening
visualhallucinations
3. SUICIDE
0= Absent
1= Feels life is not worth living
2= Wishes he were dead or any thoughts of possible death to self
3= Suicidal ideas or gesture
4= Attempts at suicide (any serious attempt rates 4)
4. INSOMNIA EARLY
0= No difficulty falling asleep
1= Complains of occasional difficulty falling asleepi.e..more than 1/2 hour
2= Complains of nightly difficulty falling asleep
5. INSOMNIA MIDDLE
0= No difficulty
1= Patient complains of being restless and disturbed during the night
2= Waking during the nightany getting out of bed rates 2 (except for purposes of
voiding)
6.INSOMNIA LATE
0= No difficulty
1 = Waking in early hours of the morning but goes back to sleep
2= Unable to fall asleep again if he gets out of bed

7. WORK AND ACTIVITIES

0= No difficulty
1= Thoughts and feelings of incapacity, fatigue or weakness related to activities;
work orhobbies
2= Loss of interest in activity; hobbies or workeither directly reported by patient,
orindirect in listlessness, indecision and vacillation (feels he has to push self to
work oractivities)
3= Decrease in actual time spent in activities or decrease in productivity
4= Stopped working because of present illness
8. RETARDATION: PSYCHOMOTOR (Slowness of thought and speech; impaired
abilityto concentrate; decreased motor activity)
0= Normal speech and thought
1= Slight retardation at interview
2= Obvious retardation at interview
3= Interview difficult
4= Complete stupor
9. AGITATION
0= None
1= Fidgetiness
2= Playing with hands, hair. etc.
3= Moving about, can't sit still
4= Hand wringing, nail biting, hair-pulling, biting of lips
10. ANXIETY (PSYCHOLOGICAL)
0= No difficulty
1= Subjective tension and irritability
2= Worrying about minor matters
3= Apprehensive attitude apparent in face or speech
4= Fears expressed without questioning
11.ANXIETY SOMATIC: Physiological concomitants of anxiety, (i.e. effects of
autonomicoveractivity, 'butterflies." indigestion, stomach cramps, belching, diarrhea,
palpitations,hyperventilation, paresthesia, sweating, flushing, tremor, headache,
urinary frequency).Avoid asking about possible medication side effects (i.e. dry
mouth, constipation)
0= Absent
1= Mild
2= Moderate
3= Severe
4= Incapacitating
12. SOMATIC SYMPTOMS (GASTROINTESTINAL)
0= None
1= Loss of appetite but eating without encouragement from others. Food intake
about normal
2= Difficulty eating without urging from others. Marked reduction of appetite andfood
intake

13. SOMATIC SYMPTOMS GENERAL

0= None
1= Heaviness in limbs, back or head. Backaches, headache, muscle aches. Loss of
energyand fatigability
2= Any clear-cut symptom rates 2
14.GENITAL SYMPTOMS (Symptoms such as: loss of libido, impaired sexual
performance, menstrual disturbances)
0= Absent
1= Mild
2= Severe
15.HYPOCHONDRIASIS
0= Not present
1= Self-absorption (bodily)
2= Preoccupation with health
3= Frequent complaints, requests for help. etc.
4= Hypochondriacal delusions
16.LOSS OF WEIGHT
A.
When
rating
by
0= No weight los
1=
Probably
weight
loss
associated
with
2=
Definite
(according
to
patient)
3= Not assessed

history:
present
weight

illness
loss

17.INSIGHT
0= Acknowledges being depressed and ill
1= Acknowledges illness but attributes cause to bad food, climate, overwork, virus,
needfor rest. etc.
2= Denies being ill at all
18.DIURNAL VARIATION
A. Note whether symptoms are worse in morning or evening. If NO diurnal variation,
mark none
0= No variation
1= Worse in A.M.
2= Worse in P.M.
B. When present, mark the severity of the variation. Mark "None" if NO variation
0= None
1= Mild
2= Severe
19. DEPERSONALIZATION AND DEREALIZATION (Such as: Feelings of unreality,
nihilistic ideas)
0=
Absent
1=
Mild
2=
Moderate
3=
Severe
4= Incapacitating

20.PARANOID SYMPTOMS
0= None
1= Suspicious
2= Ideas of reference
3= Delusions of reference and persecution
21.OBSESSIONAL AND COMPULSIVE SYMPTOMS
0=
1
=
2= Severe
Total Score 10 (mild depression)
Severity Classification:
0-7
= No depression
8-16 = Mild depression
17-23 = Moderate depression
24 = Severe depression

Absent
Mild