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Stroke Rehabilitation

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Narrative Report - Left sided hemiparesis due to an ischemic stroke by Clifford Choi on Saturday, December 3, 2011 at 12:47am ·
I thank my mentors in neurology, integrative medicine, and my patient for his determination to overcome this. He is an atheist but believed in me and himself. The patient reports full recovery. Here is his letter 4 months later. He has given permission to publish the report. He is back to work, travelling, driving, and has no known deficits. 80% of ischemic strokes survive the stroke, but it is uncertain how many fully recover 100% function.
_________________________________________________
Dear Dr. Clifford Choi, I tried to call the number you once gave me, but they told at the hospital SEIMC that you were not working there anymore.
Anyway I just wanted to touch base and say hello to you and thank you and the colleagues you had at the hospital.
The recovery has been very amazing. I was last week at this intensive rehabilitation (or so it was called) session at the _________ University hospital. I was supposed to be there the whole week, but they said that I’m actually in too good shape to gain anything from this anymore, so I left Wednesday morning.
I’m allowed to drive now, and officially I will be back to work on August 26th. I can call you, if you want. But then I would need your phone number. The world is a small place, so maybe we some day run into each other. You never know.
Best regards, patient x
The report below was submitted to the insurance company in Finland. For some reason they did not think that rehabilitation in Shanghai was necessary so they did not pay the hospital at first. After receipt of this report full payment was received.

Shanghai East International Medical Center
Rehabilitation Department
Narrative report Patient name Mr. F
Date of birth 1963
Date of narrative 05/18/11
Date of initial exam 04/26/11
Doctor name Clifford Choi, DC
Title Rehabilitation Physician

History of chief complaint The patient presents with left sided hemiparesis due to a ischemic stroke. The patient and witnesses reported him falling during the time of the incident. He experienced sudden onset of neurological deficits after a syncopal incident saturday 04/23/11 at 830 pm at a dinner with friends. He denies radiating and referred pain and describes left sided weakness. An infarction of the right pontis was reported by the radiologist on the MRI.
He was admitted to Shanghai East International Medical Center Emergency Department about 30 minutes later after the stroke. He was admitted to the hospital for emergent treatment. The Chief resident on duty recommended an evaluation by Rehabilitation Specialist Dr. Clifford Choi on 04/26/11. Dr. Choi asked for a neurology consult and MRA to confirm the patient was stable enough for stroke rehabilitation. An MRA showed anterior cerebral artery A1 left narrowing and left medial cerebral artery atherosclerosis.
Social history
Mr. F is a Finnish national who works for ___________ as an engineer. He was on a business visit to Shanghai when this incident occured. He speaks English and Finnish. He does not smoke.
Review of systems
The patient present with a small laceration on his forehead and bruising on the left flank due to a fall. He presents with left sided facial droop. There are no apparent EENT, respiratory, skin, or GI problems. No nausea, vomiting, headache, seizures or altered mental status was reported. The patient was AOx3 and had no vision problems. He is not able to walk without aid due to left sided weakness. He does not describe vertigo or dizziness.
Physical examination
Upon physical examination the patient presented with left sided weakness of the entire body.
The patient appears cooperative, alert and oriented times three, and presents with slight distress. There are no apparent abnormalities, scars, and tenderness upon examination of the left leg.
The patient presented with soft tissue injury consistent with a fall. The patient also presented with a small laceration on his forehead and left hand swelling. He had decreased active range of motion in all left sided planes. Walking was problematic. His oxygen saturation was 95% on the right and 94% on the left. Dr. Choi order O2 saturation above 98%.
His skin is warm and has normal color and pigmentation without any other lesions or infections. Respiration was normal with no apparent wheezes, rhonchi, or crackles. Speech and behavior are normal and cooperative. Further cranial nerve assessment is not normal.
Upon neurological examination, the patient denied nausea, vomiting, and dizziness. He had no seizures or tremors. Left sided weakness was apparent. He presented with cranial nerve 7 paralysis and presented with facial droop on the left side. The patient also presented with C5, C6, C7, C8, L4, L5, and S1 - 2/5 myotome weakness. The patient was not able to wiggle his toes or articulate his hand - left handed grip weakness. Sensory nerves in the respective levels were intact. Dr. Choi ordered a neurologist consult pre-rehabilitation.
Radiographic exams
The MRI revealed an acute infaction of the right pontis with older multiple lucunar infarction of the basal ganglia. MRA revealed an anterior cerebral artery A1 segment and anterior cerebri media.
Medications
Mannitol, Aspirin, Lipitor, Plavix
Treatment plan
Dr. Choi recommended rehabilitation for 1 week. Once Dr. Choi clears Mr. F, Mr. F will be transported to Finland (country of origin) by International Emergency Medical Transporters (SOS). During the treatment the following was performed daily: neuroplasticity rehabilitation, neuromuscular reeducation, and mobilization by Dr. Choi. Dr. Choi ordered acupuncture with low level voltage on affected side.
Short term goals
The short term goals for this case are to prepare the patient for neuromuscular reeducation for gross motor control.
Long term goals
The long term goals for this case are to develop strength and fine motor control in the left arm, hand, grip, and leg.
Prognosis
The prognosis is above average as the patient has reached the short term goal gross motor control was regained. The rehabilitation has successfully regained 4/5 myotomes and the patient can walk without aid.
Follow up Mr. F has reported that he had been discharged from physical therapy in his home country as they "could not do anything more for him." He is able walk, talk, drive and work with no apparent deficits. Mr. F had followed all the suggestions Dr. Choi made and was determined to get well.
Pathophysiology of diagnosis
Pure Motor Hemiparesis
The most common type of hemiparesis is pure motor hemiparesis. Patients with pure motor hemiparesis have face, arm and leg weakness. It can affect these body parts equally, but in some cases it may affect one body part more than the other. Left-sided hemiparesis involves injury to the right side of the brain, which controls the process of how we learn, non-verbal communication and certain types of behavior. Damage to this area of the brain can also cause people to talk excessively, have memory problems and short attention spans. Damage to the lower part of the brain can affect the body’s ability to coordinate movement. This is called ataxia and can lead to problems with posture, walking and balance.
Discussion
Treatments & Rehabilitation
Rehabilitation can help hemiparetic patients learn new ways of using and moving their weak arms and legs. It is also possible with immediate therapy that people who suffer from hemiparesis may eventually regain movement.
Professional rehabilitation specialized in integrative neuromusculoskeletal treatments and established practices is ideally the one who will manage a stroke patient’s entire rehabilitative process. Treating disabilities related to large movement. They can assist with strength, endurance and range of motion problems. They can also help stroke survivors get back the use of weak arms and legs through coordination and balance skills exercises. They help survivors relearn the skills needed to perform everyday activities and fine motor skills, such as picking up a pencil . They also help survivors learn how to change their environment to meet their new needs.
Some promising new treatments for hemiparesis may also help stroke survivors improve movement in the stroke-affected arms and legs years after the initial stroke, and include:
Electrical stimulation has been used in the treatment of hemiparesis to strengthen the arm and improve its range of motion. This procedure consists of placing small electrodes on the weakened muscles of the arm. An electrical charge helps the muscles contract as the patient works to make it move. Many of these electrical stimulation devices are also now covered by insurance.
National Stroke Organization reports
Researchers are currently looking into a new procedure called cortical stimulation (electrical stimulation to the area of the brain known as the cortex), to see if this can improve arm and hand movement. The procedure is done by placing a tiny electrode on the tough membrane covering the brain (the dura). The electrode sends an electrical current to the brain while a patient undergoes rehabilitation exercises. Currently, this type of therapy is only targeted toward patients who have some movement in their wrists and fingers.
Many studies also show that certain treatments can be helpful in relaxing the muscles in people who have “tone” or what is sometimes called “spasticity.” In this condition, a certain body part on the affected side is hard to move and the muscles feel as if they are tightened up. Treatments such as the injection of botulinum toxin (Botox) and the use of baclofen can improve this condition.
When people imagine themselves using a certain body part, areas of the brain and muscles can be activated as if the person is actually doing the activity. Mental practice, sometimes called Motor Imagery (MI) helps people imagine or visualize their limbs moving. This practice may improve arm movement in people with hemiparesis. It has also been suggested that MI may be useful in helping people walk.
Modified constraint-induced therapy (mCIT) is a treatment where stroke patients with hemiparetic arms visit a therapist three times a week for a half hour during a 10-week period. During that time, as well as at home for several hours per day, they practice focused exercises using the weak arm. Research studies show that modified CIT increases use and movement in the affected arm. However, this type of therapy only works on patients who have some movement in their wrists and fingers. Respectfully submitted,
Dr. Clifford Choi
Rehabilitation Physician
Shanghai East International Medical Center
551 South Pudong Road, Shanghai 20012 China
In 2013, Dr. Clifford Choi, Doctor of Chiropractic is serving as a consultant for Private sector. He can be reached at www.linkedin.com/in/drcliffordchoi

Visiting Professor GZ Red Cross Hospital
Visiting Professor GZ Sports University
Visiting Professor Indonesian Red Cross

Copyright Dr. Cliff 2009-2013

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