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Regaining Life After Stroke
Introduction
Stroke rehabilitation is one of the most challenging yet rewarding journeys in healthcare. Today, we share the inspiring story of a 65-year-old woman’s path to recovery following a severe cerebrovascular accident. This case study highlights the importance of comprehensive, multidisciplinary rehabilitation approaches and demonstrates how specialised care can significantly improve outcomes for stroke survivors, even in complex cases.
Understanding the Case
Initial Presentation
A 65-year-old female patient was hospitalised on October 11, 2024, with a history of altered sensorium for two days. She had been experiencing left-sided weakness and facial deviation for approximately two weeks, which gradually worsened over a week. On the day of admission, she developed right-sided weakness.
Due to a low Glasgow Coma Scale (GCS) score, indicating reduced consciousness, the patient required immediate intubation. MRI of the brain revealed multiple cerebral and cerebellar infarcts, with bilateral middle cerebral artery (MCA) territory involvement, indicating a severe and widespread stroke affecting both hemispheres of the brain.
Condition at Admission
Physical examination upon admission revealed the following clinical findings:
- Conscious but drowsy state
- GCS score of E4VTM5 (indicating moderate impairment)
- Tracheostomy performed on October 21, 2024, with 1 liter oxygen support
- Foley’s catheter and Percutaneous Endoscopic Gastrostomy (PEG) tube in place
- No signs of jaundice, cyanosis, clubbing, lymphadenopathy, or oedema
- Normal heart sounds without murmurs
- Bilateral air entry present with basal crackles in the lungs
- Soft, non-tender abdomen with normal bowel sounds
- Severe neurological deficits
- Upper limbs: Power 1/5 bilaterally (indicating severe weakness)
- Lower limbs: Power 0/5 bilaterally (indicating complete paralysis)
- Bedridden status
Rehabilitation Approach
Comprehensive Care Plan
Based on the discharge summary and clinical assessment, a holistic rehabilitation plan was implemented, focusing on the following key areas:
- Nutritional Support: PEG tube feeding provided as per a personalised diet plan developed by a clinical nutritionist.
- Respiratory Care: Ongoing tracheostomy care and oxygen administration as per medical guidance.
- Physical Rehabilitation: A customised physiotherapy program tailored to the patient’s functional abilities and neurological status.
- Preventive Care:
- Regular repositioning every 2 hours to prevent pressure ulcers
- Strict monitoring of fluid input and output
- Comprehensive oral, urogenital, and back care
- Strict adherence to infection control protocols
- Proper Foley’s catheter care with scheduled replacement
Rehabilitation Goals
The team established both short-term and long-term rehabilitation objectives:
Short-term Goals:
- Weaning from oxygen support
- Reducing respiratory complications
- Preventing secondary complications
Long-term Goals:
- Improving muscle strength
- Enhancing functional independence
- Facilitating communication
- Progressing toward mobility
Recovery Journey
Month 1: Initial Progress
During the first month, the patient remained drowsy with stable vital signs but experienced intermittent oxygen desaturation. Physical examination revealed:
- Bilateral limb weakness
- No response to stimuli
- Inability to move limbs
- Bilateral muscle wasting
- Bilateral calf muscle tightness
- Chest congestion
Management:
- Oxygen support was increased to 3 litres/minute as needed
- Regular suctioning performed due to increased secretions
- Antibiotics continued for 10 days as per discharge advice
- Foley’s catheter was changed to a silicone catheter on day 15
- Laboratory investigations were performed
- Treatment for urinary tract infection initiated based on positive culture results
Physiotherapy Interventions:
- Passive range of motion exercises for all limbs
- Passive chest physiotherapy
- Positioning for optimal drainage
- Proprioceptive Neuromuscular Facilitation (PNF) techniques
- Joint compression and distraction techniques
Outcomes:
- Improved sensorium
- Reduced oxygen demand, with complete weaning by day 12
- Resolution of fever
- Persistence of weakness
- Reduced chest congestion
- Development of slight movement in the left side
Month 2: Continued Rehabilitation
By the second month, notable improvements emerged:
- The patient became conscious and alert, though with global aphasia
- Bilateral limb weakness persisted
- Respiratory status improved with decreased tracheal secretions
- Muscle tone changed from wasting to hypertonic
- Calf muscle tightness remained
- Chest congestion continued
Management:
- Nebulisation therapy to reduce secretions
- Initiation of speech and swallow therapy
- Intensified physiotherapy program
Physiotherapy Advancements:
- Progression to an active-assisted range of motion exercises
- Continued chest physiotherapy
- Introduction of weight-bearing training on a tilt table
- Continued PNF techniques and joint mobilisation
Outcomes:
- Significant reduction in tracheal secretions
- Ability to swallow semi-solid foods
- Improved power in left upper limb (3/5)
- Resolution of neck stiffness
- Removal of urinary catheter
- Wheelchair mobilisation
- Development of eye contact
- Achievement of bed sitting with passive support
Month 3: Significant Gains
The third month marked substantial progress:
- The patient remained conscious and alert with improved weakness
- Expressive aphasia replaced global aphasia
- Bilateral lower limb weakness continued, but upper limb function improved
Management:
- Memory tasks to improve expressive aphasia
- Continued swallow therapy
- Planning for tracheostomy decannulation
Advanced Physiotherapy Interventions:
- Bed activities initiated
- Progression to bedside sitting
- Introduction of active and passive trainer machine at bedside
- Wheelchair mobilisation
- Weight-bearing training
- Standing with full support
Remarkable Outcomes:
- The patient began responding to verbal commands
- Significant reduction in joint stiffness
- Improved functional capacity
- Mobilisation to wheelchair achieved
- Transition to oral semi-solid diet
- GCS improved to E4VTM6
- Power improvements:
- Upper limbs: Right 2/5, Left 4/5
- Lower limbs: Right 1/5, Left 1/5
- Improving receptive aphasia
Communication Status
Throughout the rehabilitation journey, our team closely monitored communication abilities:
Initial Status:
- Completely nonverbal
- No observable gestures or consistent communicative behaviours due to bilateral weakness
Progress:
- Remained nonverbal but displayed emotional responsiveness
- Occasional responses using minimal eye movements or head gestures, though inconsistently
- Demonstrated emotional expressions such as tearfulness and smiling in response to social interaction
- Showed signs of emotional processing and social connection
Challenges:
- Persistent oro-motor weakness
- Severely restricted oral peripheral mechanisms
- Lack of clearly intentional communication
Conclusion
This case demonstrates the remarkable potential for recovery that exists even in severe stroke cases. Through diligent, multidisciplinary rehabilitation efforts, the patient progressed from a state of near-complete dependence to achieving significant functional gains.
While challenges remain—particularly in communication and mobility—the improvements witnessed over a three-month period offer both hope and a clear path for continued rehabilitation. The case underscores the importance of a comprehensive care plan that addresses physical, nutritional, respiratory, and communication needs in an integrated manner.
For individuals and families navigating the challenging path of stroke recovery, this journey illustrates that progress, although sometimes slow, is achievable through expert care, persistence, and a well-coordinated rehabilitation strategy. Early intervention and specialised care can significantly improve outcomes and enhance quality of life following a cerebrovascular event.