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Chapter I

INTRODUCTION

Background of the study

According to the World Health Organization (2004), 15 million people

worldwide will suffer from stroke this year. Five million will die and another five

million will be permanently disabled.

Cerebrovascular Accident is a third leading cause of death in the United

States. About 750,000 Americans suffer strokes each year and approximately

160,000 deaths each year. And reported that there is 4,000,000 stroke survivors. It is

also a leading cause of adult disability, many strokes are preventable. (American

Heart Association, Inc. 2003)

In the Philippines, in 2008, stroke affects 486 out of 100,000 Filipinos or

roughly half a million Filipinos, according to Dr. Pia Navarro in his study published

in The Philippine Journal of Neurology. However, access to specialist care may be a

problem. It is one the leading cause of chronic disability in the Philippines and often

leaves victims a severely mentally and physically impaired (www.inquirer.net).

According to Department of Health (DOH), the mortality rate from disease

of the heart doubled in twenty six years from 33.4 per 100,000 in 1969 to 73.2 per

100,000 in 1995. Based on the 1995 report of the Phillipine health Statistics, Health

information Service, Department of Health, diseases of the hearth were the first and

those of the blood vessels the second leading cause of mortality rate in the country.

A stroke (cerebrovascular accident, CVA, cerebral vascular accident or brain

attack) occurs when a part of the brain is damaged or destroyed because it is

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deprived of blood. A stroke is a medical emergency and can cause permanent

neurological damage, complications, and lead to death.(myDr, UMB Medical, 2009)

Physical Therapy also called Physiotherapy is a conservative method of

treatment, prevention and healing of injuries and disorders in movement. It also

deals with fitness, body mechanics or ergonomic training in prevention and

education, it provides healing and treatment through mechanical as well as physical

means like heat, electric current, exercise and support. For most stroke patients,

physical therapy (PT) is the cornerstone of the rehabilitation process. A physical

therapist uses training, exercises, and physical manipulation of the stroke patient's

body with the intent of restoring movement, balance, and coordination. The aim of

PT is to have the stroke patient relearn simple motor activities such as walking,

sitting, standing, lying down, and the process of switching from one type of

movement to another. (www.SHU.edu).

This case study will be conducted on the premise that, nowadays stroke is

one the leading cause of disabling the persons suffering with this condition. Many of

the patients cannot regain their complete functions and activities. This study aims to

provide the patients knowledge on the desired effects of physical therapy and its

benefit towards recovery.

Statement of the problem

This study sought to determine the efficacy of Physical Therapy in Patients

recovering with Cerebrovascular Accident.

Specifically it will answer the following question:

1. What is the profile of the respondent in terms of:

a. Age
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b. Gender

c. Occupation

d. Types of infarction

e. Length of time of Physical Therapy

2. How effective is the Physical Therapy on patients recovering with

Cerebrovascular Accident when classified as to:

a. Age

b. Gender

c. Types of Infarction

d. Length of Time Therapy

3. Is there a significant difference on the effect of Physical Therapy in patients

rate of recovery as to:

a. Age

b. Gender

c. Types of Infarction

d. Length of Time of Therapy

Hypothesis

Ho; There is no significant difference in the effect of Physical Therapy and

rate of recovery when classified as to age, gender, types of Infarction and length of

time of therapy.

Scope and delimitation

This study will focus in the case study of 3 patients diagnosed with

Cerebrovascular Accident who undergo Physical Therapy. The underlying cause of

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Cerebrovascular Accident is Hypertension and Diabetes Mellitus. Cerebrovascular

Accident caused by other underlying cause such as a family history of stroke, High

cholesterol, Smoking cigarettes, Obesity and overweight, Cardiovascular disease, a

previous stroke or transient ischemic attack (TIA), High levels of homocysteine (an

amino acid in blood) Birth control use or other hormone therapy, Cocaine use,

Heavy use of alcohol. The effects of maintenance drugs given to the patient and

other special areas of therapies such as Occupational and Speech Therapy are not

included.The age varies, as well as, gender, types of Infarction, occupation, and

length of time of physical therapy. The respondents recently residing at Tacurong

City. It will be conducted in the summer of school year 2010-2011 in Tacurong City.

Significance of the study

This study will determine the effects of Physical Therapy in patients

recovering with Cerebrovascular Accident.

To the community, information on the effects of Physical Therapy on the

recovery of patients who have had stroke may be gained from this study. As the

awareness of Physical Therapy and its effect is improved, quality of life and health

may be attained.

To the Nursing Professions, this study aims to help the professionals to

identify whether the Physical Therapy is effective to the patients recovering with

Cerebrovascular Accident. And also to gain knowledge on how to assess, provide

specific nursing diagnosis, plan appropriate intervention, and how to evaluate the

outcomes of nursing care. Collaborative care within Physical Therapists will be

strengthened.
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To the Physical Therapists, it will motivated the Physical Therapists to

continue the therapy. It can provide inspiration to better their services to their

patients.

To the patients, it will motivated to cooperate with the therapy. They will be

motivated to comply with therapies that would promote health and sense of well

being.

To the hospital and rehabilitation centers, this study will give the hospital and

rehabilitation appropriate knowledge about the efficiency of Physical Therapy with

Cerebrovascular Accident. And they can render appropriate program, exercise, and

care to specific type of infarction for the fast recovery of those patient.

To the families, it will provide essential information about how Physical

Therapy is helpful to the fast recovery of patients with Cerebrovascular Accident. As

the result of this study, they will support financially, spiritually and in all other

aspects their family member who had experienced Cerebrovascular Accident as a

major illness to undergo Physical Therapy for rehabilitation.

Future Researchers, it will give the future researchers initial information and

data about the effectiveness of Physical Therapy in patients recovering with

Cerebrovascular Accident. To be more observant in current issues and encouraged

them to continue the research and provide additional information.

Definition of terms

To give the readers a clear and better understanding of the terms used in the

study, the following terms are conceptually and operationally defined:

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Cerebrovascular Accident. This term refers to the sudden development of

injury to brain cause by destruction of the blood flow. In this study, it is the disease

diagnosed to be experienced by the respondents.

Patients. It refers to the treatment of injuries and physical condition by a

trained person under the supervision of specialists in Physical medicine. These are

the respondents of the study. They are patients diagnosed with Cerebrovascular

Accident and is undergoing Physical Therapy for rehabilitation.

Effectiveness. According to Websters dictionary, it refer to produce result,

especially the desired or indented result. In our study, it shows the possible outcome

of the study that connotes the positive result.

Age. This term refers to the length of time that somebody or something has

existed, usually express in years. The respondents age in this study varies, it is also

refer to the age as of the last Birthday.

Gender. It is the classification by which words are grouped as masculine,

feminine, or neuter. In this study gender is classified as to male or female.

Types of infarction. This terms refers to the specific areas that being damage

in the brain. In this study, it shows the particular damage in the brain of the

respondents and how thus Physical Therapy affects the recovery rate of the patient

with Cerebrovascular accident depending on the types of infarction.

Occupation. According to Webtsters Third new International Dictionary, it is

an activity in which one engages. This term refers to the patients work thus,

contributing factors to his condition.

Length of Time. It refers to particular time, either minimum or maximum. It

is used to determine how many hours are spent for Physical Therapy intended in the

therapy rendered to the respondents.

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Chapter II

REVIEW OF RELATED LITERATURE AND STUDIES

Introduction

This section consists of two (2) parts, the compilation of review of related

literature and the compilation of review of related studies. Theoretical framework

and Conceptual framework are also included in this chapter and the topics provided

are the following ; what Cerebrovascular Accident is, the incidence, types of

infarction, its causes, risk factors, signs and symptoms, pathophysiology and

Nursing Intervention. What physical therapy is, the effects, and benefits to patients

with Cerebrovascular Accident.

According to World Health Organizations International Classification of

Functioning, Disability, and Health organizes the effects of conditions such as stroke

into problems in the "body structure and function dimension" and in the "activity and

participation dimension." Body structure and function effects (known as

"impairments"), such as hemiplegia, spasticity, and aphasia, are the primary

neurological disorders that are caused by stroke. Activity limitations (also referred to

as "disabilities") are manifested by reduced ability to perform daily functions, such

as dressing, bathing, or walking. The magnitude of activity limitation is generally

related to but not completely dependent on the level of body impairment (ie, severity

of stroke). Other factors that influence level of activity limitation include intrinsic

motivation and mood, adaptability and coping skill, cognition and learning ability,

severity and type of preexisting and acquired medical comorbidity, medical stability,

physical endurance levels, effects of acute treatments, and the amount and type of

rehabilitation training. Therapeutic interventions to improve sensorimotor

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performance after stroke vary considerably. Although there is emerging evidence that

rehabilitation can be effective in improving both intrinsic motor control and

functional status, systematic trials comparing the relative effectiveness of various

motor control intervention types generally have been few in number and suboptimal

in design.

According to the book of Diseases; A Nursing process Approach To

Excellent Care cerebrovascular accident, also known as stroke or brain attack is a

sudden impairment of cerebral circulation in one or more blood vessels supplying

the brain and it interrupts or diminishes oxygen supply and commonly causes

serious damage or necrosis in brain tissues.

World Health Organization (WHO) also stated that Cerebrovascular Accident

is the number one cause of death globally, causing one third of all deaths. In 2005,

11.8 million people died of heart attacks and other heart diseases, and 5.7 million

died of stroke. Around 80% of these deaths were in low- and middle-income

countries. By 2015, an estimated 20 million people will die from CVD annually,

mainly from heart attacks and strokes. Socioeconomic costs of premature deaths and

disability, and escalating costs of medical care make it all the more urgent to take

measures to prevent and control this burgeoning epidemic in low- and middle-

income countries where health care resources are limited.

A stroke or "brain attack" occurs when brain cells die because of inadequate

blood flow. When blood flow is interrupted, brain cells are robbed of vital supplies

of oxygen and nutrients. About 80 percent of strokes are caused by the blockage of

an artery in the neck or brain; the remainders are caused by a burst blood vessel in

the brain that causes bleeding into or around the brain. Functions compromised

when a specific region of the brain is damaged by stroke can sometimes be taken
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over by other parts of the brain. This ability to adapt and change is known as

plasticity. If a stroke has occurred, treatment should begin as soon as the stroke is

diagnosed to ensure that no further damage to the brain occurs. Initially, the doctor

may administer oxygen and insert an intravenous drip to provide the affected person

with adequate nutrients and fluids (Wikipedia 2009).

Medicalnewstoday2009 reported that, a stroke is a condition where a blood

clot or ruptured artery or blood vessel interrupts blood flow to an area of the brain. A

lack of oxygen and glucose (sugar) flows to the brain leads to the death of brain cells

and brain damage, often resulting in impairment in speech, movement, and memory.

The two main types of stroke include ischemic stroke and hemorrhagic stroke.

Ischemic stroke accounts for about 75% of all strokes and occurs when a blood clot,

or thrombus, forms that blocks blood flow to part of the brain. If a blood clot forms

somewhere in the body and breaks off to become free-floating, it is called an

embolus. This wandering clot may be carried through the bloodstream to the brain

where it can cause ischemic stroke. A hemorrhagic stroke occurs when a blood

vessel on the brain's surface ruptures and fills the space between the brain and skull

with blood (subarachnoid hemorrhage) or when a defective artery in the brain bursts

and fills the surrounding tissue with blood (cerebral hemorrhage). Both result in a

lack of blood flow to the brain and a buildup of blood that puts too much pressure on

the brain. The outcome after a stroke depends on where the stroke occurs and how

much of the brain is affected. Smaller strokes may result in minor problems, such as

weakness in an arm or leg. Larger strokes may lead to paralysis or death. Many

stroke patients are left with weakness on one side of the body, difficulty speaking,

incontinence, and bladder problems.

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Dr. Harold Shryock, in 1998 mentioned that the demands of the brain for a

continuous supply of fresh blood are so great that one fifth of the blood pumped by

the heart is delivered to the brain. An interruption of the blood supply to any part of

the brain causes permanent damage to the cells within about five minutes. About 80

percent of the deaths from stroke occur in people sixty-five years old and above.

Four out of five persons survive their first attack of stroke, but these people are

usually handicapped to some degree, perhaps by paralysis of some muscles resulting

from brain damage.

Joyce M. Black and Esther Matassarin-Jacobs stated in 1997 that

Cerebrovascular Accident, commonly known as a stroke, is the term used to describe

neurologic changes brought on by an interruption in blood supply to the brain

(ischemia).The two of a major causes of ischemia are occlusion and hemorrhage.

The occlusion blood vessels can be brought about by either progressive thrombosis

or emboli. Approximately 75% of strokes are from brain infarctions, 15% are from

intracerebral or sabarchnoid hemorhages, and the remaining 10% are from the other

causes.

According to myDr, 2009, there are 2 main types of strokes: ischaemic

stroke and haemorrhagic stroke. Ischaemic stroke is the most common type of stroke

and is caused by a blockage of the blood vessels supplying the brain. This may be

due to hardening and narrowing of the arteries (atherosclerosis) or by a blood clot

blocking a blood vessel. One type of ischaemic stroke is a thrombotic stroke. This is

caused by a blood clot (thrombus) in one of the arteries of the head or neck, which

severely reduces the blood flow. The thrombus may be a result of a build-up of fatty

deposits (plaques) in the blood vessels. Another type of ischaemic stroke is an

embolic stroke (or cerebral embolism), caused when a blood clot that forms
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elsewhere in the body (for example, the chambers of the heart) travels through the

circulatory system to the brain. The travelling clot is called an embolus. The most

severe type of stroke is a haemorrhagic stroke. It occurs when a blood vessel in the

brain bursts, allowing blood to leak and cause damage to an area of the brain. There

are 2 types: subarachnoid haemorrhage, which occurs in the space around the brain;

and an intracerebral haemorrhage, the more common type, which involves bleeding

within the brain tissue itself.

Ischemic strokes are ultimately caused by a thrombus or embolus that blocks

blood flow to the brain. Blood clots (thrombus clots) usually occur in areas of the

arteries that have been damaged by atherosclerosis from a buildup of plaques.

Embolus type blood clots are often caused by atrial fibrillation - an irregular pattern

of heart beat that leads to blood clot formation and poor blood flow.

Hemorrhage strokes can be caused by uncontrolled high blood pressure, a head

injury, or aneurysms. High blood pressure is the most common cause of cerebral

hemorrhage, as it causes small arteries inside the brain to burst. This deprives brain

cells of blood and dangerously increases pressure on the brain. Aneurysms is an

abnormal blood-filled pouches that balloon out from weak spots in the wall of an

artery - are the most common cause of subarachnoid hemorrhage. If an aneurysm

ruptures, blood spills into the space between the surfaces of the brain and skull, and

blood vessels in the brain may spasm. Aneurysms are often caused or made worse

by high blood pressure (medicalnewstoday, 2009)

Anyone can suffer from stroke. Although many risk factors for stroke are out

of our control, several can be kept in line through proper nutrition and medical care.

Risk factors for stroke include the following: Over age 55, Male, African American,

Hispanic or Asian/Pacific Islander , A family history of stroke , High blood pressure,

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High cholesterol, Smoking cigarettes, Diabetes , Obesity and overweight,

Cardiovascular disease, A previous stroke or transient ischemic attack (TIA), High

levels of homocysteine (an amino acid in blood) , Birth control use or other hormone

therapy, Cocaine use, Heavy use of alcohol (medicalnewstoday,2008).

According to Department of Health, in 1997, Hypertension is persistent

elevation of atrial blood pressure. It is generally accepted that the patient is

hypertensive if the systolic blood pressure is persistently above 140 mmHg or the

above 90 mmHg. Hypertension is a very common chronic condition which affects a

significant proportion of adult population and which makes an important

contribution to human mortality. Hypertension may be classified into: primary or

essential hypertension and secondary hypertension. Primary hypertension is usually

unaccompanied by the other manifestation in the early stage and does not interfere

with daily activities. The condition is however progressive, unless properly treated

and can lead to complication and early death. The following factors, while not

directly causative, are believed to predispose to essential hypertension. Hereditary, if

both parents are hypertensive, the chances are great that the offspring will be

hypertensive. Age, the frequency of hypertension increases steadily with age. Sex,

hypertension is generally more frequent in females but the severe form, malignant

hypertension, is more common in males. Ischemic heart Disease is usually caused by

the occlusion of the coronary arteries by thrombus (clot) formation in areas of

narrowing and hardening (arteriosclerosis) in these arteries. The supply of oxygen in

the coronary arteries becomes inadequate to provide for the oxygen demands of the

heart when the arteries are obstructed or constricted. The lack of blood supply

causes necrosis or death of the affected tissues (myocardial infarction or heart

attack).
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Department of Health also stated that the occurrence of the disease increases

as one grows older and is higher among the males than females because the females

are afforded some protection by female hormone estrogens before menopause. There

are many factors which predispose a person to coronary atherosclerosis. Major

factors are the following; Hypertension, the incidence of coronary artery disease is

three times the normal in people with hypertension. Diabetes mellitus, the incidence

of Coronary artery disease is greater in the patients with diabetes mellitus and occurs

10-12 years earlier. This is probably related to the abnormal lipid metabolism

associated hypertension. Obesity and accelerated aging prevalent in patients with

diabetes mellitus. Serum lipid concentration, the incidence of Coronary artery

disease is directly correlated with increased lipid concentration. Individuals with

familial hypercholesterolemia are subject to premature Coronary artery disease in

the third decade of life. Elevated cholesterol levels are also correlated with an

increased incidence of Coronary artery disease. Cigarette smoking, the incidence of

heart attack or myocardial infarction is increased more than three times in cigarette

smokers. The increased incidence of infarction appears related to changes in

coagulation, myocardial irritability and possibly coronary artery spasm. Minor

factors are the following; Stress, is a complicated risk factor and is probably related

to lifestyle, including physical activity, dietary habits, smoking, etc. then to

Coronary artery disease. A strong family history is important, the incidence of

Coronary artery disease is more than double if two or more family members have a

history of Coronary artery disease. Hereditary partly determines cholesterol levels.

Obesity, obese patients have a markedly increased incidence of Coronary artery

disease. It is suggested that the increased workload demanded of the heart where

obesity may be a significant factor. Sex, the incidence of Coronary artery disease in
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the women before 60 years of ages is far less than in men of the same age. After

menopause, the incidence of Coronary artery disease in women increases yearly

until it equals that in men. This and other evidenced suggested that estrogens retard

the development of Coronary artery disease. Secondary hypertension is a reflection

of kidney or endocrine disease. It accounts for less than 10% of cases of

hypertension. Primary or essential hypertension result when more level of the blood

is elevated and that there is increased in resistance in the peripheral arteries. The

condition increases the load of the heart.

Initial symptoms occur suddenly. Generally, they include numbness,

paresthesias, weakness, or paralysis of the contralateral limbs and the face; aphasia;

confusion; visual disturbances in one or both eyes (eg, transient monocular

blindness); dizziness or loss of balance and coordination; and headache. Anterior

circulation stroke typically causes unilateral symptoms. Posterior circulation stroke

can cause unilateral or bilateral deficits and is more likely to affect consciousness,

especially when the basilar artery is involved. Other manifestations, rather than

neurologic deficits, often suggest the type of stroke. For example, sudden, severe

headache suggests subarachnoid hemorrhage. Impaired consciousness or coma,

often accompanied by headache, nausea, and vomiting, suggests increased

intracranial pressure, which can occur 48 to 72 h after large ischemic strokes and

earlier with many hemorrhagic strokes; fatal brain herniation may result. Stroke

complications can include sleep problems, confusion, depression, incontinence,

atelectasis, pneumonia, and swallowing dysfunction, which can lead to aspiration,

dehydration, or undernutrition. Immobility can lead to thromboembolic disease,

deconditioning, sarcopenia, UTIs, pressure ulcers, and contractures. Daily

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functioning (including the ability to walk, see, feel, remember, think, and speak)

may be decreased.

According to National Stroke Foundation, in 2010, Strokes have symptoms

which act as warning signs. Transient ischaemic attacks (TIAs) are an important

warning sign that a stroke may occur in the future. Symptoms can include a numb or

weak feeling in the face, arm or leg, trouble speaking or understanding, unexplained

dizziness, blurred or poor vision in one or both eyes, loss of balance or an

unexplained fall, difficulty swallowing, headache, confusion and unconsciousness.

Symptoms of a TIA are very similar to those of a stroke. They can include: A numb or weak

feeling in the face, arm or leg, Trouble speaking or understanding, Unexplained dizziness,

Blurred or poor vision in one or both eyes, Loss of balance or an unexplained fall ,Difficulty

swallowing ,Headache (usually severe or of abrupt onset) or unexplained change in the

pattern of headaches , Confusion ,Unconsciousness .The FAST test is an easy way to

recognize and remember the most common signs of stroke or a TIA.

In cases of ischaemic stroke, it is common to give aspirin to reduce the risk

of death or of a second stroke. If the cause of the stroke was a clot, it is possible that

the quick administration of certain clot-dissolving drugs, such as alteplase, may

prevent some symptoms such as paralysis. However, this is not a suitable treatment

for all strokes, and can increase the risk of haemorrhagic stroke, so there are strict

guidelines determining the circumstances in which it should be used. Once a stroke

has permanently damaged the brain, the damage can't be undone. However, many

symptoms can improve considerably in the days following a stroke, because the

areas of brain on the periphery of the stroke can recover. Also, your doctor will

suggest ways to prevent a future stroke, including modifying your lifestyle to

minimise your risks of stroke, and taking medications. Depending on the type and

cause of the stroke, anticoagulant drugs (blood thinners) may be prescribed to help
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prevent new blood clots from forming, in order to prevent a future stroke. Examples

include aspirin, aspirin plus dipyridamole (Asasantin), clopidogrel (e.g. Plavix) and

warfarin (Coumadin or Marevan). Where there is a blockage in a neck artery,

surgery may be performed to remove the build-up of plaque in order to prevent a

future stroke. This operation is called a carotid endarterectomy (myDr 2001).

Of all the Nursing theorists Martha Rogers theory is the theory of which I

admit I had a hard time grasping the true essence of what she wants to happened in

nursing. Rogers theory emerged from the knowledge bases of anthropology,

psychology, sociology, astronomy, religion, philosophy, history, biology, physics,

mathematics and literature to create a model of Unitary Human Beings and the

environment as energy fields integral to the life process. If I have to go on with the

theory of Martha Rogers probably I could say that man has something to do with

the environment and environment has something to do with man. Mans physical,

psychological, spiritual aspect changes as man goes into the type of environment he

is in.

Physical therapy is a health care specialty involved with evaluating,

diagnosing, and treating disorders of the musculoskeletal system. The ultimate goal

of physical therapy is to restore maximal functional independence to each individual

patient. To achieve this goal, physical modalities such as exercise, heat, cold,

electricity, and massage are utilized. Physical therapy is provided by physical

therapists, who are licensed health care professionals with a masters or doctorate

degree in physical therapy. Physical therapists evaluate, diagnose, and manage the

physical therapy treatment plan, customizing it to each individuals needs.it It is

ordered by a physician when it is felt that such a course of treatment would be

beneficial. It is offered to a wide variety of patients including newborn babies,

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children, adults, and geriatrics. Physical therapy is useful in treating many different

medical disorders. Sport and orthopedic injuries, neurological and muscular illness,

as well as cardiopulmonary diseases are only a few pathologic conditions which

physical therapy plays a treatment role in. Through patient and therapist interaction,

physical therapy can help restore movement and function helping patients return to

their prior level of independence (www.physicaltherapy.com).

Through Physical Therapy the patient recovering with Cerebrovascular

Accident will help them to continue regaining during therapy session in order to

remap muscle control in the brain and focuses patient to use limbs that have been

weakened or paralyzed by the stroke. Successful rehabilitation following a stroke

depends on many factors, including the extent of brain damage, attitude, the skill of

the rehabilitation team and the support of family and friends. As a result of advances

in treatment and rehabilitation, many people who have had a stroke are able to live

full lives. For some, recovery takes only a few weeks while for others it may take

months or even years. Strokes affect people in different ways depending on the type

of stroke and area of the brain affected. Often old skills have been lost, so new ones

will need to be learned. It is also important to maintain and improve physical

condition whenever possible. Rehabilitation should begin as soon after a stroke as

possible and may continue at home. Rehabilitation may consist of various types of

therapy including: physiotherapy to improve muscle control, co-ordination and

balance; speech therapy to retrain facial muscles and language, and help with

feeding and swallowing disorders; and occupational therapy to improve handeye

co-ordination and skills needed for daily living tasks, such as bathing and cooking.

Family is also important in the rehabilitation process. Family members will probably

be asked to help the person regain lost skills by encouraging them to use the affected
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arm or leg, helping them with their speech or teaching them how to do tasks which

may have been forgotten, such as combing their hair or using a cup, knife and fork

(www.mydr.com ).

According to Dr. Duncan, Physical Therapy is important because the home-

based intervention is more accessible, more feasible, and it was also associated with

fewer risks in our study. She explains, There has been an emerging use of

locomotor-style training in clinical practice, with some preliminary data in small

trials that suggests that this is an effective intervention. Using the repetition of

activities that are task-specific, this approach is based on principles of neural

plasticity, biomechanics and motor learning. It also promotes active subject

participation and environmental modification (Richards and Malouin 1997).

Cerebrovascular Accident are the third most common cause of death in

United States, preceded only by heart disease and cancer. Approximately 3 million

Americans are living with varying degrees of disability from stroke. Along with the

high mortality rate, strokes produce significant morbidity in people who survive

them. In the large Framingham Study, a 20 year follow-up of strokes survivors in the

45- to 74- year age group found the 31% needed assistant with self-care, 20%

required assistance with ambulation, 71% has some impairment in vocational ability

upto 7 years following the strokes, and 16% were institutionalized. Fortunately, the

incidence of stroke has been declining since the mid-1960s, partly as a result of

control of atherosclerosis through the improved control of hypertension, increased

diet consciousness, and a reduction in smoking in some segment of the population.

In the 1996, a national campaign was begun to increased public awareness of stroke.

According to the National Stroke Association; 10% of stroke survivors recover

almost completely, 25% recover with minor impairments, 40% experience moderate
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to severe impairments that require special care, 10% require care in a nursing home

or other long-term facility, 15% die shortly after the stroke, and 14% (approximate)

of stroke survivors experience a second stroke in the first year following a stroke.

The successful rehabilitation depends on the amount of damage to the brain, skill on

the part of the rehabilitation team, cooperation of family and friends. Caring

family/friends can be one of the most important factors in rehabilitation and the

timing of rehabilitation - the earlier it begins the more likely survivors are to regain

lost abilities and skills.

A study found that women are more likely to experience non-traditional

stroke symptoms. A stroke is a medical emergency, and anyone suspected of having

a stroke should be taken to a hospital immediately so that tests can be run and the

correct treatment can be provided as quickly as possible. Physicians have several

tools available to screen for stroke risk and diagnose an active stroke. These include:

Physical assessment - blood pressure tests and blood tests to see cholesterol levels,

blood sugar levels, and amino acid levels, Ultrasound - a wand waved over the

carotid arteries in the neck can provide a picture that indicates any narrowing or

clotting, Arteriography - a catheter is inserted into the arteries to inject a dye that can

be picked up by X-rays, Computerized tomography (CT) scan - a scanning device

that creates a 3-D image that can show aneurysms, bleeding, or abnormal vessels

within the brain, Magnetic resonance imaging (MRI) - a magnetic field generates a

3-D view of the brain to see tissue damaged by stroke, CT and MRI with

angiography - scans that are aided by a dye that is injected into the blood vessels in

order to provide clearer and more detailed images, Echocardiography - an ultrasound

that makes images of the heart to check for embolus. One way to prevent a stroke is

to notice a transient ischemic attack (TIA) - or mini stroke - that provides symptoms
 20

similar to stroke. Knowing the symptoms of stroke can lead to earlier treatment and

better recovery. Much of stroke prevention is based on living a healthy lifestyle. This

includes: Knowing and controlling blood pressure, Finding out if you have atrial

fibrillation, Not smoking, Lowering cholesterol, sodium, and fat intake, Following a

healthy diet, Drinking alcohol only in moderation, Treating diabetes properl,

Exercising regularly. Moderate aerobic fitness can reduce stroke risk, Managing

stress, Not using drugs, A study found that drinking three cups of tea per day

reduces the risk of stroke, Taking preventive medications such as anti-platelet and

anticoagulant drugs to prevent blood clots, Cholesterol lowering drugs can prevent

stroke recurrence (medicalnewstoday 2009).

According to proquest Journal, in 2006, In a randomized, controlled trial that

involved 42 hemiparetic stroke survivors, vigorous aerobic exercise training 3 times

per week for 10 weeks evoked significant improvements in peak oxygen

consumption and workload, submaximal exercise blood pressure response, exercise

time, and sensorimotor function; moreover, the latter was significantly related to

improvement in aerobic capacity. The findings demonstrated that stroke patients can

increase their cardiovascular fitness by a magnitude that is similar to that of healthy

older adults who engage in endurance training programs. The effect of a 6-month

home exercise training program was investigated in a prospective, randomized,

controlled clinical trial that involved 88 men with Coronary artery disease and

disability, two thirds of whom were stroke survivors .The subjects demonstrated

significant increases in peak left ventricular ejection fraction and high-density

lipoprotein cholesterol and decreases in resting heart rate and total serum cholesterol

with exercise training.

 21

A recent study evaluated the relative cardiovascular stress of physical therapy

and occupational therapy sessions in 20 patients undergoing a stroke rehabilitation

program. The time per session in which the achieved heart rate was within the

prescribed target heart rate zone was found to be extremely low, which suggests that

these sessions elicited inadequate cardiovascular stress to induce a training effect.

Both of these last 2 studies found that activities that evoked the greatest heart rate

increases were performed in the upright position and involved transitional

movements. Approximately one third to one half of the treatment time was

apportioned to standing activities. Some researchers have raised concerns that

occupational therapy sessions for post stroke patients may involve periods of intense

isometric work that induce excessive cardiovascular demands. In contrast, others

have suggested that workloads for stroke patients who participated in physical

therapy were appropriate, evoking relatively low levels of cardiovascular stress.

Moreover, it has been theorized that the predominantly static nature of most stroke

rehabilitation programs might contribute to the low physical endurance of post

stroke patients. Extrapolation of what is known about the training effect of regular

exercise by able-bodied individuals suggests that certain levels of exercise that are

achieved during many stroke rehabilitation programs may improve aerobic fitness

and thereby help reduce the risk for recurrent stroke and cardiovascular events.

Accordingly, professionals who design and conduct stroke rehabilitation programs

should consider allocating more time to aerobic exercise training to optimize patient

outcomes.

Extensive studies have shown that physical therapy is beneficial to stroke

patients and highly successful at allowing them to achieve some level of functional

independence. According to the American Heart Association, less than 14 percent of

 22

rehabilitated stroke victims return to their pre-incident level of function, while it is

estimated that nearly 50 percent need additional assistance, despite medically

successful physical therapy sessions. Currently, physical therapy has gravitated to

more leisurely-based activities to increase a patient's enjoyment, thus giving them

more incentive to complete their therapy sessions.

Theoretical Framework

The theory that was utilized for this study was Martha Rogers Theory of

Unitary Human Beings . The theory was develop in 1970 and comprised the four

major assumptions of person, health, environment, and nursing and involves a Four

major concepts of Energy field, Universe of open system, Pattern, and Pan

dimensionality.

According to Martha Rogers Human beings are dynamics energy fields

integral with environmental fields. Both human and environmental fields are

identified by patterns and characterized by a universe of open system. She also

consistently updated the conceptual models through revision of the homeodynamic

principles. Such changes correspondents with scientific and technological advances.

additional clarification of Unitary Human Beings as separate and different from the

term holistic stressed the Unique contribution of nursing to healthcare.

She also described the four major assumption includes; HUMAN as an

irreducible, indivisible, pandimensional energy field identified by pattern and

manifesting characteristics that are specific to the whole and cannot be predicted

from the parts. HEALTH is participation in the life process by choosing and

executing behaviors that lead to the optimum fulfillment of a persons potential and

that "health is a rhythmic patterning of energy that is mutually enhancing and

 23

expresses full life potential". Rogers defined the environment as being in constant

interaction with the person, or human field pattern manifestation. Furthermore, it has

been defined very simply as everything that is not of the human field pattern

manifestation,. It has been defined as: an irreducible, pandimensional energy field

identified by pattern and manifesting characteristics different from those of the parts.

Each environment field is specific to its given human field. Both change

continuously and creatively." NURSING as a science, designates the term nursing as

a noun and signifies that nursing is an organized body of abstract knowledge.

Traditionally, the term has been used as a verb. Nursing, the science-noun, indicates

that there is a body of knowledge specific to nursing. So nursing as a science is

using the word as a noun, but Rogers also stated that she believed that nursing is an

art, and in that case the word should be used as a verb. This has been consistently

reiterated throughout the history of the Science of Unitary Human Beings. "Nursing

seeks to promote symphonic interaction between the environment and man, to

strengthen the coherence and integrity of the human beings, and to direct and

redirect patterns of interaction between man and his environment for the realization

of maximum health potential". The goal of nursing according to Rogers Science of

Unitary Human Beings is to promote human-environment field patterning and the

nursing process.

On her four major concepts, she described the following; Energy field as

constitute the fundamental unit of both the living and the non living. Field is a

unifying concept and energy signifies the dynamics nature of the field. Energy fields

are infinite and pandimentional. Two fields are identified as Human field and

Environmental field. The universe of open system holds that energy field are

infinite, open, and integral with one another. The human and the environmental field
 24

are in the continuous process and are open system. Pattern identifies energy fields. It

is the distinguishing characteristic of an energy field and is perceived as a single

wave. The nature of the pattern changes continuously, innovatetively, and these

changes give identity to the energy field. Each human field pattern is unique and is

integral with the environmental field. And lastly, Pandimentionality, defined by

Rogers as nonlinear domain without spatial or temporal attributes. The term

pandimentional provides for an infinite domain without limit. It best expresses the

idea of a unitary whole.

Using Rogers framework, the researchers explored the Phenomenon of the

hope for fast recovering of patient with Cerebrovascular Accident especially who

undergo Physical Therapy.

According to Rogers Theory energy field is the fundamental unit of both

the living and nonliving, this energy field "provide a way to perceive people and

environment as irreducible wholes" and the energy fields continuously varies in

intensity, density, and extent . The human field and the environmental field are

constantly exchanging their energy There are no boundaries or barrier that inhibit

energy flow between fields, she called it Openness. Pattern is defined as the

distinguishing characteristic of an energy field perceived as a single waves . It is also

an abstraction and it gives identity to the field. and lastly Rogers defined Pan

dimensionality as a non linear domain without spatial or temporal attributes. And the

parameters that human use in language to describe events are arbitrary.

 25

Energy Field Pattern

Person
Health
Environment
Nursing

Openness Pandimentional

Figure 1: Schematic Diagram of the Theoretical Framework

This paradigm shows the four Metaparadigm in nursing which includes

Person, Health, Environment and Nursing and it is interconnected to the four major

Assumptions in the Martha Rogers Theory which includes the Energy Field,

Openness, Pattern and Pandimentional. Here there are elements that are

interconnected at this man and his environment. As a system of life and energy

sources, individuals are able to draw energy from the environment and information

and use of energy and information to the environment. Because of this exchange of

individuals are open systems that underlie and limit the main assumptions Martha E

Roger. In relation to the physical therapy, as a human being the energy of individual

deals with the wholeness of self that even though the capability of patient will not be

regained completely but by the aid of physical therapy the patients feel a self

importance and having a since of independence rather than they may feel that they

are burden to their family member.

 26

Conceptual Framework

In this study, it determine the variables including the independent variable

which is Effectiveness of Physical Therapy, the dependent variable is patients

recovering with Cerebrovasular Accident, and the moderator variables are Age,

Gender, Occupation, Types of Infarction, Length of Time.

Physical Therapy Recovering with

Cerebrovascular accident

Age
Gender
Occupation
Types of Infarction
Length of Time

Figure 2: Schematic Diagram of the Conceptual Framework

This paradigm shows that through rendering Physical Therapy is directly

related to the effectiveness of patients recovery rate with Cerebrovascular Accident.

There are also some contributing factors that hinder the effectiveness of Physical

Therapy which includes the Age, Gender, Occupation, Types of Infarction, Length of

Time. It present the relationship of the variable used in this study, whether correlated

or have a direct or indirect relationship in every variables.

 27

Chapter III

METHODOLOGY

This chapter present the research methodology used in the study. It includes

the research design, locale, respondent of the study, sampling technique, instrument

to be used, data gathering procedure and statistical treatment of the data.

Research Design

This made use of descriptive correlational research method. Descriptive

research design, describe the nature of the phenomenon under investigation after a

survey of current trends. It is concerned with existing condition, its meaning and

significance and then making adequate and accurate interpretations of these data

with or without the aid of statistics (Calderon: 1993). Under the types of descriptive

research is the correlational studies which examine the extent of relationship

between variables by determining how changes in one variable relate to changes into

another variable.

The researchers used the descriptive method since this study aims to

determine the effectiveness of physical therapy in patients diagnosed with

cerebrovascular accident.

Research Locale

The locale of the study is located within the Tacurong City. It is a 4th class

city found in central Mindanao, Region XII, a part of Sultan Kudarat province. It is a

dynamic, unique and progressive city.

 28

The researchers choose this area because the researchers recently residing at

Tacurong City, it is more accessible and for the practical reason. Also for the benefit

of the residence in the chosen area for the essential information that the researchers

can in part about the effectiveness of physical therapy in patients diagnose with

cerebrovascular accident.

Respondents of the study

The respondent of this study are three (3) patients diagnosed with

cerebrovascular accident, the underlying cause is hypertension and diabetes mellitus

and undergoing physical therapy in a certain area of Tacurong City.

The researchers interested to find out the effectiveness of physical therapy in

patients recovering with cerebrovascular accident. Age, gender, types of infarction,

occupation, length of time of rendering physical therapy are the factors to consider

in the selection and identification of the subjects.

Sampling Technique

In choosing the respondent the researchers used the purposive sampling

method. Purposive sampling also called judgement sampling is a sampling which the

subject are handpicked to be in the sampling frame based on certain qualities for

purposive of the study. It is commonly used in qualitative study.

Instrumentation and Data Gathering Procedure

The data gathering instrument that the researcher used is the questionnaire, it

contains questions that helped the researcher complete all the data needed. The
 29

researchers formulated questionnaire which can answer the problem of the study. It

includes the personal profile of the respondent and other data pertaining to the

factors that affect the effectiveness of physical therapy in patients with

Cerebrovascular Accident. The questionnaire is to be answered and accomplished by

the respondents according to its experiences and recent condition. The questionnaire

is s form of checklist, a scaling will be used in answering the questions after

gathering the answer, the data gathered will be graphed and tabulated. On the other

hand, secondary source of data will be coming from the journals, published books,

and article from the internet.

Prior to conducting the research, the researchers will provide an

authorization letter approved and signed by the adviser and the dean of college of

Nursing and submitted to Municipal health office to allow the researchers to conduct

the data gathering in the designated area. The questionnaire will be given to the

respondents and after gathering the data will be processed.

Statistical Treatment

The data will be collected, tallied and statistically treated by the researcher

based on the answers of the respondents in the questionnaire. To facilitate the

statistical processing and analysis of the data, the following tools will be used:

1. Each answer sheet is scored based on the answer key. One point is given

for each answer that shows an effectiveness of Physical Therapy in

patients recovering with Cerebrovascular Accident.

2. The scores will be interpreted using the following scale:

 30

0-5 full assistance

6-11 moderate assistance

12-17 minimal assistance

18-23 without assistance

 31

EFFECTIVENESS OF PHYSICAL THERAPY IN PATIENTS RECOVERING

WITH CEREBROVASCULAR ACCIDENT: A CASE STUDY

Presented to the Faculty of the

College of Nursing
Tacurong City

In Partial Fulfillment of the Requirements

For Nursing Research I

By:
Quezalyn Eloso
Truman Esmail Jr.
Farisha Kadalum

March 2011
 32

TABLE OF CONTENTS

Page

number

TITLE PAGE i

Chapter I

INTRODUCTION 1

Background of the Study 1

Statement of the Problem 2

Hypothesis of the Study 3

Scope and Delimitations of the Study 3

Significance of the Study 4

Definition of Terms 5

Chapter II

REVIEW OF RELATED LITERATURE AND STUDIES 7

Theoretical Framework 22

Conceptual Framework 26

Chapter III

METHODOLOGY 27

Research Design 27

Locale 27

Respondent of the study 28

Sampling Technique 28

Instrumentation and Data Gathering Procedure 28

 33

Statistical Treatment 29

SURVEY QUESTIONNAIRE

Name (Optional): _____

Age: _____

Gender: Male

Female

Occupation: _____

Length of time of Therapy: _____

General Instruction:

Read the following question carefully and please put a check mark ( / ) on

the box which you think appropriate answer for the question. These questions serve

as an evaluation on to the capacity of every respondent. Please do not leave items

unanswered.

Categories:

Full assistance refers to full support given by caregivers (fully dependent).

Moderate assistance refers to patient able to do activities with the used of

walking devices and by the supervision of the caregivers.

Minimal assistance refers to patient able to do activities with the used of

walking devices.

Without Assistance refers to without support by the caregivers (fully

independent).

Questions Full Moderate Minimal Without

Assistance Assistance Assistance Assistance
 34

A. General mobility

1. I am able to roll in bed

and transfer from supine
lying.
2. I am able to sit on
edge of bed.
3. I am able to hold
sitting and standing.
4. I am able to reach in
all directions and to the
floor while in sitting and in
standing.
5. I am able to transfer
from bed to chair and back.
B. Limbs motor function
1. I am able to perform
voluntary activities with
the affected upper limb
such as:
a. sitting with arms
supported on a table,
b. reaching forward,
c. weight bearing on
the affected hand,
d. bring a glass to my
mouth,
e. pick and release
object on a table,
2. I am able to perform
voluntary activities with
the affected lower limb
such as:
a. using a bed or table
for support in standing,
b. step up and down
forward on
a stool,
c. step up and down
sideways on a stool.
C. Activity of Daily Living
1. I am able to extend
and flex my four
extremities.
2. I am able to move out
of my bed.
3. I am able to take a
bath.
 35

4. I am able to comb my
hair.

5. I am able to dress up.

6. I am able to eat
without difficulty of
swallowing.
7. I am eat with the use
of spoon and fork.
8. I am able to
pronounce the words
clearly.
9. I am able to sweep the
floor.
10. I am able to write.

Assessment Tool
 36

This tool will represent as a guide of the researchers in assessing and

evaluating the ability of the respondents to perform their activities of daily living.

This assessment will be conducted three times, once in a week for determining the

progress of the patients condition through the help of physical therapy.

Patient and care givers education assessment

___A. Care giver will be able to participate to the overall physical therapy
management.
___B. Patient will be able to demonstrate an active learner attitude.
___C. Care giver and patient will be able to participate actively to the prevention of
muscle shortening and shoulder complications.
___D. Patient is able to prevent loss of muscle and soft tissue
Length.
___E. Patient is able to prevent shoulder complications.

General mobility assessment

___A. Patient is able to do effective bridging in bed.
___B. Patient is able to roll in bed and transfer from supine lying to sit on edge of
bed.
___C. Patient is able to hold sitting and standing.
___D. Patient is able to reach in all directions and to the floor while in sitting and in
standing.
___E. Patient is able to transfer from bed to chair and back.
___F. Patient is able to walk with or without assistive device and/or outside help
Limbs motor function assessment.

A. Patient is able to perform voluntary activities with the affected upper limb
such as:
___1a. In sitting with arms supported on a table.
___2a. Reaching forward.
___3a. Weight bearing on the affected hand.
___4a. Bring a glass to his mouth.
___5a. Pick and release object on a table, etc

B. Patient is able to perform voluntary activities with the affected lower limb
such as:
___1b. Using a bed or table for support in standing.
___2b. Step up and down forward on a stool.
___3b. Step up and down sideways on a stool.

THERAPEUTIC ACTIVITIES
___A. Supported sitting in bed with arms placed on a table or pillow
Patient is asked to reach and use his sound upper limb in activities according
to his interest.
___B. Assisted sitting on edge of bed, with arms supported on table and feet on floor
or stool.
 37

Asked patient to do any activity with sound upper and lower limbs.
(Remember that while he perform tasks with his sound side, he also apply
body weight on the affected side. Thus, stimulates activity in the affected
side.)
___C. Patient sits in the edge of bed.
By reaching and weight bearing activities with the affected side.
___D. Rolling in bed side to side.
The patient is asked to bring his head and affected shoulder towards the
opposite side while pushing himself with the affected foot.
___E. Patient is able to transfer from supine lying to sitting on the edge of bed.
From a supported 80 to 90 degrees sitting position in bed and patient asked
to come and sit on his sound side edge of bed.
Bring the head of the bed down so that patient is trained to achieve lie to sit
independently.
 38

Bibliography

(http://stroke.ahajournals.org/cgi/content/full/34/4/1056; Stroke.

2003;34:1056 2003 American Heart Association, Inc.)

(myDr, 2001. Adapted from original material sourced from MediMedia New

Zealand. Copyright: myDr, UBM Medica Australia, 2000-2011. All rights

reserved. Last Reviewed: 27 April 2009)

( Doctor Physical TherapyEarn your Doctorate in Physical Therapy at Seton

Hall Universitywww.SHU.edu/dpt-program).

http://www.pta-kw.com/uploads/PT%20PROTOCOL%20_part2-Adult
%20hemiplegia.pdf

http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/stroke_signs_and_sy
mptoms?open