1

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

8
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 middleincome 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

9
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

11
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,

17
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

18
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 homebased 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

19
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

Chapter I
INTRODUCTION

Background of the Study

Statement of the Problem

Hypothesis of the Study

Scope and Delimitations of the Study

Significance of the Study

Definition of Terms

Chapter II
REVIEW OF RELATED LITERATURE AND STUDIES

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