| 13.10.

21 - 22:44

5 Cerebrovascular Accident

24
General Information
Case no. 5.A Cerebrovascular Accident

/20
Authors Ethan Hood, PT, DPT, MBA, Board Certified Clinical Specialist in Geriatrics Physical
Therapy, Board Certified Clinical Specialist in Neurologic Physical Therapy
Jessica Schwartz, MSPAS, PA-C
Diagnosis Acute left middle cerebral artery (MCA), cerebrovascular accident (CVA)
Setting Emergency Department, with transfer to Neurology Ward

/09
Learner expectations ☑ Initial evaluation
□ Re-evaluation
□ Treatment session
Learner objectives 1. Recognize the symptoms of stroke and determine most likely location based on
presenting symptoms and physical exam.

14
2. Develop an appropriate rehabilitation plan of care, including the roles of the team
members involved.
3. Determine a safe and appropriate discharge plan for a patient who has been
diagnosed with a CVA, including any durable medical equipment that may eventually
be required.
4. Identify how to work collaboratively with other medical teams when caring for a

,
patient with a CVA (e.g., medicine, neurology, physical therapy, occupational therapy

ch
(OT), speech therapy (ST), case management, and nursing).

Medical
Te
Chief complaint “Right side weakness and unable to speak properly” for 2 hours
History of present illness The patient is a 67-year-old right-handed male who presented to the emergency
department due to severe right side weakness and speech deficits. He was last seen in his
normal state of health the night prior when going to bed. The symptoms started in the
morning around 06:00 when the patient woke up. The patient’s wife noted weakness on
iv

the patient’s right side, specifically that he was not using his right upper extremity. She
also noted that the patient’s right-side face looked “funny.” He was having difficulty with
his speech, which the wife described as “trouble finding words, can’t seem to get the
Un

words out.” The patient confirmed with shaking his head “no” that he cannot feel his
right arm. He denied headache or vision changes. The patient’s wife noted that although
he had walked this morning, he was still required some assistance. He is typically
independent with all mobility. His symptoms have been persistent without change since
he woke up 1 hour ago this morning. He has not had any fevers or chills, recent illness,
recent travel, or heart palpitations. He has never had symptoms like this in the past.
tin

Past medical history Hypertension, coronary artery disease, myocardial infarction with drug-eluding stent
placement 10 years ago, hypercholesterolemia, diabetes mellitus type 2, smoked for 25
years (1 pack/day)—quit 10 years ago, and obesity—body mass index = 30.1
Past surgical history Drug-eluding stent placed 10 years ago
r

Allergies No known drug allergies

Cu

Medications Lisinopril, Metoprolol tartrate, Aspirin, Atorvastatin, Metformin

Precautions/Orders Stroke team consult:
NPO until cleared by ST
Bedrest for 24 hours then activity as tolerated
Physical therapy and OT
:
er
Us

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Cerebrovascular Accident

24
Social history
Home setup ● Resides in a split-level house with his wife.
● Three steps are there to enter the home with a left railing.
● Eight steps to the second floor are with a right railing ascending.
● Bedroom and bathroom are on the second floor.

/20
● Woodworking shop and den are on the lower level, with eight steps and right rail to
descend.
Occupation ● Retired 2 years ago from teaching high school English for 35 years.
Prior level of function ● Independent with functional mobility, activities of daily living (ADLs), and instrumental
ADLs.

/09
● Walks 1 mile/day with his wife and dog
● (+) Drives
Recreational activities ● Fly fish and hunting (bow and arrow)
● Woodworking and makes his own furniture
● Visits two sons who live locally

14
Vital signs Hospital day 0: emergency department
Blood pressure (mmHg) 168/90
Heart rate (beats/minute) 88

,
Respiratory rate (breaths/
minute)
Pulse oximetry on room air
(SpO2)
Temperature (°F)
18

97%

96.9
ch
Te
Imaging/Diagnostic test Hospital day 0: emergency department
Electrocardiogram (ECG) 1. Atrial Fibrillation, no acute ST-T wave changes
Chest X-ray 1. No acute Cardiovascular and pulmonary pathology noted
iv

Computed tomography 1. No acute masses, hemorrhages, or infarcts noted

(CT)—head without contrast
Un

Magnetic resonance imaging 1. Acute infarction in the left frontal and parietal lobes in the MCA territory
(MRI)—brain (▶ Fig. 5.1)
Magnetic resonance angiog- 2. No hemorrhage or mass noted
raphy (MRA)—head and neck 3. Moderate occlusion noted at middle one-third of left M1 segment of the left MCA
with and without contrast with some collateral flow
Transthoracic two-dimen- 1. Left ventricle ejection fraction 65%
tin

sional echocardiography 2. No wall motion abnormalities

3. Left and right ventricles without any hypertrophy or increased wall thickness
4. Left and right atrial sizes normal, no dilation. No evidence of any valvular stenosis or
regurgitation
5. No evidence of clots or vegetation noted based on the limitations of transthoracic
r

approach
Cu

Medical management Hospital day 0: emergency department

Medications 1. Continue aspirin
2. Metformin
3. Hold lisinopril and metoprolol tartrate for first 2–3 days to allow permissive hypertension
:

Diet 1. Nothing by mouth (NPO) until seen by speech therapy

er

2. Diet safety to be determined with swallow evaluation

Vitals 1. Every 4 hours with neuro checks
2. Monitor telemetry for arrhythmias
Us

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| 13.10.21 - 22:44

Cerebrovascular Accident

24
/20
/09
, 14
ch
Te
Fig. 5.1 (a,b) Acute infarction in the left frontal and parietal lobes in the MCA territory. (Source: Arterial Ischemia.
In: Valdueza Barrios J, Schreiber S, Röhl J, et al, ed. Neurosonology and Neuroimaging of Stroke: A Comprehensive
Reference. 2nd ed. Thieme; 2017.)
iv

Hospital day 0:
Lab Reference range
emergency department
Un

Complete blood cell count White blood cells 5.0–10.0 × 109/L 7.6
Hemoglobin 14–17.4 g/dL 14.1
Hematocrit 42–52% 44
Platelets 140–400 k/μL 190
Basic metabolic profile Glucose 60–100 mg/dL 200
tin

Blood urea nitrogen (BUN) 6–25 mg/dL 21

Creatinine 0.7–1.3 mg/dL 1.07
Sodium 135–145 mEq/L 139
Potassium 3.5–5.0 mEq/L 4.0
r

Chloride 98–106 mEq/L 105

Cu

Bicarbonate 21–28 mEq/L 25

Calcium 8.6–10.3 mg/dL 8.8
Other Fingerstick glucose 60–100 mg/dL 210
International normalized
1.0 0.8–1.2
ratio (INR)
:

Troponin < 0.02 ng/mL < 0.02

er

Hemoglobin A1C 4.0–5.6% 8.5%

Cholesterol < 200 mg/dL 240
Low-density lipoprotein 65–180 mg/dL 170
Us

(Continued)

90

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| 13.10.21 - 22:44

Cerebrovascular Accident

24
(Continued)
Hospital day 0:
Lab Reference range
emergency department
High-density lipoprotein > 35 mg/dL 55

/20
Triglycerides < 150 mg/dL 105

Pause points
Based on the above information:

/09
● Is there any significance with the diagnostic tests and measures?
● Who are the members of the stroke team and what are their roles?
● Based on the above findings, describe what should be prioritized for the physical therapy examination.

Hospital Day 1: Physical Therapy Examination

14
Subjective
“I have difficulty finding the right word.”
“My right side is weak.”
Objective

,
Pre-treatment
Vital signs

Blood pressure (mmHg)

Heart rate (beats/min)
136/78
77
Supine
ch140/80
76
Sitting
142/84
84
Standing
Post-treatment

144/86
88
Te
Respiratory rate (breaths/min) 12 12 16 16
Pulse oximetry on room air
97% 96% 97% 96%
(SpO2)
Modified rate of perceived
1/10 2/10 3/10 4/10
exertion (RPE) scale (0–10)
iv

Pain 1/10 at right 1/10 at right

0/10 0/10
shoulder shoulder
General ● A 67-year-old male, well developed and well nourished
Un

● Supine in bed, awake, and in no acute distress

● Lines notable for peripheral intravenous line, urinary catheter, and telemetry
Cardiovascular and ● Auscultation: Clear lung sounds, irregularly irregular cardiac rhythm
pulmonary ● Pulses: 3 + bilateral dorsalis pedis and posterior tibialis
Gastrointestinal ● Slight abdominal distension, no tenderness to palpation
Genitourinary ● (+) urinary catheter
tin

Cognition ● Awake and alert

● Oriented once—able to state his name but not his birthdate, location, time, or situation
● Speech appears very slow and labored; has difficulty finding correct words to answer
questions
r

● Follows one-step commands 100% of the time

Cu

Musculoskeletal Range of motion ● Passive range of motion of right upper extremity (RUE) and
right lower extremity (RLE): within functional limit (WFL).
● Active range of motion of left upper extremity (LUE) and left
lower extremity (LLE): WFL.
Strength ● L shoulder flexion: 5/5
● R shoulder flexion: 1/5
:

● L elbow flexion: 5/5

er

● R elbow flexion: 1/5

(Continued)
Us

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| 13.10.21 - 22:44

Cerebrovascular Accident

24
(Continued)
Hospital Day 1: Physical Therapy Examination
● L wrist extension: 5/5
● R wrist extension: 0/5

/20
● L hip flexion: 5/5
● R hip flexion: 3 + /5
● L knee extension: 5/5
● R knee extension: 3 + /5
● L ankle dorsiflexion: 5/5
● R ankle dorsiflexion: 3 + /5

/09
Aerobic ● Not tested
Neurological Balance ● Static unsupported sitting: fair + , requires tactile cues for
midline posture.
● Static unsupported standing: poor + , requires minimal assist
with tactile cues for midline posture.

14
● Berg Balance Scale = 30/56
Coordination ● L cerebellar function intact with no dysdiadochokinesia
● LUE finger to nose intact. Unable to be performed on RUE
● Pronator drift unable to be performed due to weakness in RUE
● LLE heel to shin intact. RLE ataxic with heel to shin

,
Cranial nerves ● II–XII grossly intact except for noted right side facial droop,

Reflexes
●

●
ch sparing the forehead
Vision intact, fully tracking with eyes, with no visual field
deficits. Denies diplopia.
Brachioradialis: 1 + L, 2 + R
Biceps brachii: 1 + L, 2 + R
Te
●
● Triceps brachii: 1 + L, 2 + R
● Patellar: 1 + L, 2 + R
Sensation ● RUE: loss of sensation to crude touch and pinprick
● LUE, RLE, LLE: intact to crude touch and pinprick
Tone ● RUE flaccid, RLE hypotonic
iv

Functional status
Bed mobility ● Rolling to left: supervision with bedrails
Un

● Supine to sit: minimal assistance once with head of bed elevated ~30 degrees
Transfers ● Sit to/from stand: minimal assistance once with wide base quad cane
Ambulation ● Ambulated 15 feet with minimal assistance and wide base quad cane
● Gait deviations notable for right hemiparetic gait, lack of right arm swing and
movement requiring physical therapist to support, and poor right weight shift
requiring physical therapy verbal and tactile cues to facilitate.
tin

● Gait speed 0.20 m/second

● ▶ Fig. 5.2
Stairs ● N/A
Other ● Barthel Index: 30/100
r

● Functional independence measure: 51 total score (35 motor, 16 cognitive)

: Cu
er
Us

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| 13.10.21 - 22:44

Cerebrovascular Accident

24
/20
/09
, 14
ch
Te
Fig. 5.2 An example of a physical therapist guarding the patient during an ambulation trial.
iv

Assessment
☑ Physical therapist’s Assessment left blank for learner to develop.
Un

Goals
Patient’s “To walk normal again”
Short term 1.
Goals left blank for learner to develop.
2.
Long term 1.
tin

Goals left blank for learner to develop.

2.
r

Plan
☑ Physical therapist’s
Cu

Patient is to be seen twice a day for 4–5 days for therapeutic exercise, gait training,
transfer training, endurance training, neuromuscular reeducation, patient and family
education, positioning to minimize shoulder pathology and pain, and to facilitate
discharge to appropriate care level.

Bloom’s Taxonomy Level Case 5.A Questions

:

Create 1. Synthesizing the medical data and physical examination findings, develop an
er

appropriate physical therapy assessment of the patient.

2. Develop two short-term physical therapy goals, including an appropriate timeframe.
3. Develop two long-term physical therapy goals, including an appropriate timeframe.
Us

(Continued)

93

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| 13.10.21 - 22:44

Cerebrovascular Accident

24
(Continued)
Bloom’s Taxonomy Level Case 5.A Questions
Evaluate 4. Based on the patient’s presentation, what would be the best discharge environment?
Why?

/20
5. Based on this patient’s current presentation and history, what would be appropriate
physical therapy prognosis?
6. How should the physical therapist rate the patient’s right hemibody tone?
Analyze 7. What is the significance of the patient’s Berg Balance Scale?
8. In terms of function, what is the importance of the patient’s gait speed?
9. What outcome measures may assist with functional prognosis?

/09
10. What is the most likely etiology of this patient's infraction based on his clinical
presentation and workup thus far?
Apply 11. What cranial nerves are involved with eye function?
Understand 12. Why did medical management withhold blood pressure medications despite the
patient’s current readings? What is the rationale?

14
13. What would be the most therapeutic position for this patient while he is in bed? Why?
Remember 14. What is the typical presentation of an MCA infarction?
15. What are some differences in presentation between a right MCA and a left MCA infarct?
16. What affected area of the brain causes expressive aphasia?

,
Bloom’s Taxonomy Level Case 5.A Answers
Create ch
1. Patient presents with right hemibody weakness with reduced tone, impaired transfers,
gait, and high fall risk on standardized balance testing due to the effects of L MCA
distribution stroke impairing ADLs and function. Recommend skilled physical therapist
to address the following goals. Recommend assisting once with all mobility while in
Te
hospital. Anticipate patient being a good acute inpatient rehabilitation candidate.
2. Short-term goals:
● Patient will demonstrate sit to/from stand transfer with contact guard assistance

within 3 days to facilitate improved transfer ability.

● Patient will ambulate 30 feet on level surfaces with minimal assistance and wide

base quad cane, demonstrating step to pattern, within 3 days to improve gait and
iv

endurance.
3. Long-term goals:
● Patient will ambulate 50 feet on level surfaces with contact guard assistance with
Un

wide base quad cane within 7 days to facilitate improve function in home.
● Patient will ascend/descend three steps with minimal assistance and left handrail

when ascending within 7 days to facilitate getting into and out of his home.
Evaluate 4. Based on the patient’s age, prior level of function, past medical history, level of
cognition, current functional status, and tolerance to activity, a discharge location of
acute inpatient rehab would be most appropriate.
tin

5. Based on the patient’s presentation, past medical history, and prior level of function,
it is anticipated that the patient will be able to return to independence with
functional mobility and community ambulation. He may, however, need adaptive
equipment to assist with ADLs depending on his right upper extremity’s return.
r

6. The patient’s hemibody tone would be rated as follows: RUE, 0/4; RLE, 1/4.
Cu

Analyze 7. The Berg Balance Scale indicated that the patient is a high fall risk.
8. The patient’s current speed of 0.20 m/second is extremely slow and not conducive to
the patient being a safe community ambulatory at this time.
9. The outcome measures that may assist with functional prognosis are the Functional
Independence Measure and the Stroke Rehabilitation Assessment of Movement.
10. This patient most likely has a cardioembolic stroke due to atrial fibrillation. His
electrocardiogram suggests evidence of atrial fibrillation, and his cardiac exam
:

reveals an irregularly irregular rhythm. This is an example of a cerebrovascular

er

accident as the initial presentation of new onset atrial fibrillation.

Apply 11. Cranial nerves II, III, IV, VI, and VIII are involved with eye function.
Us

(Continued)

94

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| 13.10.21 - 22:44

Cerebrovascular Accident

24
(Continued)
Bloom’s Taxonomy Level Case 5.A Answers
Understand 12. Medical management withheld for antihypertensives to allow the patient to have
permissive hypertension in the first 24 hours after his acute ischemic stroke. This

/20
allows for adequate perfusion to areas of salvageable brain tissue (penumbra).
13. The most therapeutic position for this patient while he is in bed is right side lying.
This is to maintain glenohumeral joint integrity (▶ Fig. 5.3).
Remember 14. The typical presentation of an MCA infarction is upper extremity, followed by face
and lower extremity, respectively.
15. While the following is not inclusive, a right MCA would have findings on the left side

/09
of the body with behavioral changes of impulsivity and minimal insight into deficits.
An infarct of the left MCA would have deficits on the right side of the body, with
insight into their deficits and tendencies to be extremely cautious.
16. Broca area (located in the dominant frontal lobe) causes expressive aphasia.

, 14
ch
Te
iv
Un
r tin

Fig. 5.3 An example of how to position the patient to protect the glenohumeral joint when he is in bed.
Cu

Key points
1. MCA distribution stroke typically involves the upper extremity greater than the lower extremity. Based on the side of
lesion, very specific characteristics may arise.
:

2. Based on this patient’s presentation, he will need intensive acute inpatient rehabilitation, which is to include physical
er

therapy, OT, and ST, to maximize overall function and quality of life. Durable medical equipment needs will be
addressed in acute inpatient rehabilitation, as prescription will be dependent on the patient’s level of function at
discharge.
Us

(Continued)

95

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This document is intended for personal use only and may not be passed on to third parties in any form! Usage subject to terms and conditions of license.
| 13.10.21 - 22:44

Cerebrovascular Accident

24
(Continued)
Key points
3. To properly care for a patient who has had a stroke, a team approach is required. The team can include physiatry,
nursing, rehabilitation therapy, and case management, all of who will ensure the patient’s needs are met, education is

/20
holistic, and risk factors to reduce a second stroke are discussed. Key risk factors for stroke include hypertension,
hyperlipidemia, diabetes, obesity, and smoking history. These risk factors must be addressed by the medical team to
help prevent future ischemic events.

General Information

/09
Case no. 5.B
Authors Ethan Hood, PT, DPT, MBA, Board Certified Clinical Specialist in Geriatrics Physical
Therapy, Board Certified Clinical Specialist in Neurologic Physical Therapy
Jessica Schwartz, MSPAS, PA-C
Diagnosis Acute left middle cerebral artery (MCA), cerebrovascular accident (CVA)

14
Setting Acute inpatient rehabilitation
Learner expectations ☑ Initial evaluation
□ Re-evaluation
□ Treatment session
Learner objectives 1. Identify how to work collaboratively with other medical teams when caring for a

,
patient with a CVA (e.g., medicine, neurology, physical therapy, occupational therapy

ch
(OT), speech therapy, case management, and nursing).
2. Comprehend the integration of setting specific goals of care into a proper physical
therapy plan of care.
3. Integrate latest evidence-based treatment ideas into proper physical therapy
interventions.
Te
4. Appreciate how changes in medical status can influence patient function and physical
therapy care.

Medical
Chief complaint “Right side weakness and unable to speak properly”
iv

History of present illness The patient is a 67-year-old right-handed male admitted to the hospital 5 days ago due
to severe one-sided weakness and speech deficits. Imaging confirmed a left MCA infarct
Un

with resultant Broca aphasia. Electrocardiogram revealed new onset atrial fibrillation,
and this was confirmed on telemetry throughout the patient’s hospital stay. He was
started on apixaban 5mg PO twice daily to prevent further cardioembolic events. He was
also started on sitagliptin 100mg PO daily to help better control his blood glucose levels.
His atorvastatin was increased to 80mg PO nightly, given his elevated cholesterol levels
and diagnosis of CVA. Consultations in the hospital included speech language pathology,
which showed moderate expressive aphasia and dysphagia. A video fluoroscopic
tin

swallowing study was performed, and the patient was placed on a level 1 dysphagia
puree diet with nectar-thick liquids. He was progressed to a level 2 dysphagia
mechanically altered diet with nectar-thick liquids by speech therapy prior to hospital
discharge. Other consults include physical therapy and OT. The patient was able to
r

perform transfers and ambulation of 60 feet with minimal assistance and a wide base
quad cane. He was seen by physiatry with recommendations for acute inpatient
Cu

rehabilitation. The patient was admitted to acute inpatient rehabilitation last night.
Past medical history Hypertension, coronary artery disease, myocardial infarction with drug-eluding stent
placement 10 years ago, hypercholesterolemia, diabetes mellitus type 2, and obesity
Past surgical history Drug-eluding stent placed 10 years ago
Allergies No known drug allergies (NKDA)
:

Precautions/Orders Vitals every 8 hours

er

Activity as tolerated
Head of bed (HOB) elevated 30 degrees at all times
Dysphagia and thickened liquids diet
Assist with all out of bed (OOB) mobility
Us

96

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| 13.10.21 - 22:44

Cerebrovascular Accident

Social history

24
Home setup ● Resides in a split-level house with his wife.
● Three steps are there to enter the home with a left railing.
● Eight steps are there to the second floor with a right railing ascending.
● Bedroom and bathroom are on the second floor.

/20
● Woodworking shop and den are on the lower level, with eight steps and right rail
to descend.
Occupation ● Retired 2 years ago from teaching high school English for 35 years.
Prior level of function ● Independent with functional mobility, activities of daily living (ADLs), and
instrumental ADLs

/09
● Walks 1 mile/day with his wife and dog.
● (+) Drives
Recreational activities ● Fly fish and hunting (bow and arrow)
● Woodworking and makes his own furniture
● Visits two sons who live locally

14
Vital signs Day 1: acute inpatient rehabilitation
Blood pressure (mmHg) 152/88
Heart rate (beats/minute) 68

,
Respiratory rate (breaths/minute) 14
Pulse oximetry on room air (SpO2)
Temperature (°F)
99%
98.5 ch
Te
Imaging/Diagnostic test Day 1: acute inpatient rehabilitation
Patient Health Questionnaire 14/27 = moderate depression
(PHQ-9)

Medical management Day 1: acute inpatient rehabilitation

iv

Medications 1. Lisinopril, Metoprolol tartrate, Aspirin, Clopidogrel, Atorvastatin, Metformin, Sitagliptin

2. Lisinopril to be increased due to elevated blood pressures
Un

3. Start on citalopram for depression

Diet 1. Mechanical soft/nectar thickened liquids
Vitals 1. Every 8 hours with neuro checks

Day 1: acute inpatient

tin

Lab Reference range

rehabilitation
Complete blood cell count Hemoglobin 14–17.4 g/dL 13.4
Hematocrit 42–52% 41.5
r

White blood cell (WBC) 5.0–10.0 × 109/L 9.1

Cu

Platelets 140–400 k/μL 140

Basic metabolic profile Glucose 60–100 mg/dL 168
Blood urea nitrogen 7–20 mg/dL 20
Creatinine 0.4–1.10 mg/dL 0.98
Sodium 135–145 mEq/L 135
:

Potassium 3.5–5.0 mEq/L 3.6

er

Chloride 98–106 mEq/L 103

Bicarbonate 21–28 mEq/L 22
Calcium 8.6–10.3 mg/dL 8.4
Us

Other Fingerstick glucose 60–100 mg/dL 182

97

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| 13.10.21 - 22:44

Cerebrovascular Accident

Pause points

24
Based on the above information,
● Why were the patient’s medications changed/adjusted?
● How should the physical therapy examination be structured? What objective tests and measures seem most

appropriate?

/20
● Explain the role of physical therapy, OT, and ST in the rehabilitation of this patient. Explain what specific areas a

physical therapist may collaborate.

Day 1, Acute Inpatient Rehabilitation: Physical Therapy Examination

/09
Subjective
“I want to get back to a normal life.”
Objective
Pre-treatment Post-treatment
Vital signs

14
Supine Sitting Standing Sitting
Blood pressure (mmHg) 150/88 152/86 148/86 150/86
Heart rate (beats/min) 66 66 68 80
Respiratory rate (breaths/min) 13 14 14 18
Pulse oximetry on room air

,
98% 99% 99% 97%
(SpO2)
Modified rate of perceived
exertion (RPE) scale (0–10)
Pain
0/10

5/10 at right
shoulder
ch
1/10

5/10 at right
shoulder
5/10

6/10 at right
shoulder
6/10

7/10 at right
shoulder
Te
Cognition ● Awake and alert
● Oriented three time—able to tell his name, birthdate, location, and current date
● Speech appears very slow and labored; had difficulty finding words to answer
questions
● Follows one-step commands 100% of time
iv

Musculoskeletal Range of motion ● Left upper extremity (LUE), active range of motion (AROM):
within functional limit (WFL)
● Right upper extremity (RUE), passive range of motion (PROM):
Un

Shoulder flexion: 0–80 degrees

Shoulder abduction: 0–60 degrees
Shoulder external rotation: 0–45 degrees
Elbow extension: 0–45 degrees
Hand: able to extend digits with significant pain
*ROM appears to be limited due to increased tone and pain.*
● Left lower extremity (LLE), AROM: WFL
tin

● Right lower extremity (RLE), PROM: WFL

Strength ● L shoulder flexion: 5/5

● R shoulder flexion: 1/5
● L elbow flexion: 5/5
r

● R elbow flexion: 1/5

Cu

● L wrist extension: 5/5

● R wrist extension: 0/5
● L hip flexion: 5/5
● R hip flexion: 3 + /5
● L knee extension: 5/5
● R knee extension: 3 + /5
:

● L ankle dorsiflexion: 5/5

● R ankle dorsiflexion: 3 + /5
er

(Continued)
Us

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| 13.10.21 - 22:44

Cerebrovascular Accident

24
(Continued)
Day 1, Acute Inpatient Rehabilitation: Physical Therapy Examination
Unable to formally assess strength in RUE with Manual Muscle
Testing (MMT) due to increased spasticity. The above strength

/20
grades are based on functional movements.
Aerobic ● NuStep for 5 minutes, level 2
● RPE = 15/20. Heart rate: 84 beat/minute post
Neurological Balance ● Static unsupported sitting: fair + , requires tactile cues for
midline posture

/09
● Static unsupported standing: poor + , requires minimal assist
with tactile cues for midline posture
● (+) Romberg Test
● Berg Balance Scale = 36/56
Coordination ● Rapid alternating movements: LUE intact, unable to assess in
RUE

14
● Heel to shin—LLE intact, RLE ataxic
Cranial nerves ● II–XII grossly intact except for noted right-side facial droop,
sparing the forehead
● Vision intact, fully tracking with eyes, with no visual field deficits
● Denies diplopia

,
Reflexes ● Brachioradialis: 2 + L, 3 + R

Sensation
●
●
●

●
ch Biceps brachii: 2 + L, 3 + R
Triceps brachii: 2 + L, 3 + R
Patellar: 2 + L, 3 + R
RUE: loss of sensation to crude touch and pinprick
Te
● LUE, RLE, LLE: intact to crude touch and pinprick
Tone ● RUE: 2 + /4 spasticity on modified Ashworth Scale
● RUE: 2 finger sulcus sign on right shoulder
● RUE flexor synergy
● RLE: hypotonic
Other ● Stroke Rehabilitation Assessment of Movement (STREAM): 32/
iv

70 (6/20 upper extremity; 13/20 lower extremity; 13/30 basic

mobility)
● Functional Independence Measure: 77 total (52 motor, 25
Un

cognitive)
● ▶ Fig. 5.4
Functional status
Bed mobility ● Rolling to left: supervision with bed rails
● Supine to sit: contact guard assist once with HOB elevated ~ 30 degrees and use of
tin

bedrails
Transfers ● Sit to/from stand: minimal assistance once with wide base quad cane
Ambulation ● Ambulated 60 feet with minimal assistance and wide base quad cane
● Gait deviations notable for right hemiparetic gait with slight right knee hyperextension
r

(genu recurvatum) during midstance and RUE in flexor synergy

● Gait speed = 0.25 m/second
Cu

Stairs ● Ascend/descend four steps with moderate assistance and left railing ascending. Tactile and
verbal cues provided for midline posture
● Demonstrated step-to pattern
:
er
Us

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| 14.10.21 - 17:55

Cerebrovascular Accident

24
/20
/09
, 14
ch
Te
iv

Fig. 5.4 Functional Independence Measure. Copyright @1997 Uniform Data System for Medical Rehabilitation, a division
of UB Foundation Activities, Inc. Reprinted with permission.
Un

Assessment
☑ Physical therapist’s Assessment left blank for learner to develop.
Goals
Patient’s “To be able to walk and talk normal again”
tin

Short term 1.
Goals left blank for learner to develop.
2.
r

Long term 1.
Goals left blank for learner to develop.
Cu

2.

Plan
☑ Physical therapist’s Patient to be seen 1–2 hours/day for 5–6 day/week. Treatment to include bed mobility,
:

transfer training, gait training, stair training, therapeutic exercise, endurance activities,
er

neuromuscular reeducation, and patient and family education.

Us

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| 13.10.21 - 22:44

Cerebrovascular Accident

24
Bloom’s Taxonomy Level Case 5.B Questions
Create 1. Synthesizing the medical data and physical examination findings, develop an
appropriate physical therapy assessment of the patient.
2. Develop two short-term physical therapy goals, including an appropriate timeframe.
3. Develop two long-term physical therapy goals, including an appropriate timeframe.

/20
4. Create an appropriate intervention program for this patient in acute inpatient rehab,
including dosing.
Evaluate 5. What is the philosophical difference in blood pressure management in the acute
phase vs. subacute phase for a patient after stroke?
Analyze 6. Is there anything his physician could prescribe to reduce his spasticity?

/09
7. What is the significance of his PHQ-9 score?
8. Why are different functional measures (i.e. Fugl-Meyer, Functional Independence
Measure [FIM], and STREAM) performed?
9. Are there any relationships between the aforementioned functional measures?
10. Can these measures be prognostic? Please explain.

14
Apply 11. What are the main goals for this patient in the acute inpatient rehab setting?
12. What treatments can be performed to reduce his RUE spasticity?
Understand 13. Given the initial exam findings, are there any concerns for arm positioning or long-
term effects of his arm?
Remember 14. Why would the patient present with a flaccid RUE in the hospital and then a spastic

,
RUE in the acute inpatient rehab?

Bloom’s Taxonomy Level

Create
ch Case 5.B Answers
1. Patient presents with right hemibody weakness and abnormal tone, impaired
Te
transfers, balance, and gait due to the effects of left MCA infarct impairing ADLs and
function. Recommend skilled physical therapist to address goals below. Anticipate
successful discharge to home after meeting rehab goals.
2. Short-term goals:
● Patient will perform sit to/from stand transfers with supervision within 7 days to

facilitate return to independent function.

iv

● Patient will ambulate 100 feet with contact guard and wide base quad cane within

7 days to facilitate ability to ambulate around his home.

3. Long-term goals:
Un

● Patient will ambulate 300 feet with modified independence and wide base quad

cane to facilitate ability to ambulate around his community.

● Patient will ascend/descend eight steps with modified independence and one rail to

get to second floor of his home where his bedroom and bathroom are located.
4. An appropriate intervention program for this patient in acute inpatient rehab,
including dosing, is as follows:
tin

● Aerobic: 3–5 days per week; 40–70% VO2 reserve or heart rate reserve;

20–60 minutes (or 3–10-minute sessions)

● Strengthening: 2–3 days per week; 50–80% 1 repetition maximum (RM) (resistance

gradually increased over time as tolerated); 1–3 sets of 10–15 repetitions of 8–10
exercises involving the major muscle groups
r

● Balance: dynamic exercises focusing on improving weight shift and coordination of

Cu

right hemibody
Evaluate 5. In the acute phase of treatment for stroke, the goal is to allow permissive hypertension
and keep blood pressure less than 220/120 mmHg. After about 24 hours, permissive
hypertension is no longer necessary and goal blood pressure is less than 130/
80 mmHg.
Analyze 6. Baclofen can be prescribed by the physician to reduce the patient’s spasticity.
:

7. The patient’s PHQ-9 score suggests that the patient is suffering from depression,
er

which is very common after a stroke.

8. Each functional outcome measure looks at different aspects of performance and
function. The Fugl-Meyer is a stroke-specific outcome measure that looks at motor
function, balance, sensation, movement quality, synergies, and tone. The Functional
Us

(Continued)

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| 13.10.21 - 22:44

Cerebrovascular Accident

24
(Continued)
Bloom’s Taxonomy Level Case 5.B Answers
Independence Measure (FIM) is not stroke specific; however, it is used to measure the
level of a patient’s disability and indicates how much assistance is required for the

/20
patient to successfully complete activities. The FIM is popular with many insurance
companies to assess level of assistance needed. The Stroke Rehabilitation Assessment
of Movement (STREAM) is a stroke-specific outcome measure and designed for
physical therapists to assess motor function, as well as functional activities such as
transfers and gait.
9. There is a correlation between the Fugl-Meyer and FIM. A change on the upper or

/09
lower extremity, Fugl-Meyer correlates with change in FIM scores. The STREAM also
correlates with the Fugl-Meyer and FIM, in addition to numerous functional measures.
10. Initial scores on standardized measures can be basic prognostic indicators of
functional outcomes. The patient’s change in FIM from a total of 51 to 77 (26 points)
exceeds the MCID of 22 points for a patient who is status post stroke.

14
Apply 11. The main goal for this patient in the acute inpatient rehab setting is to become as
independent as possible with all functional mobility and ADLs to facilitate a safe
transition to home.
12. A treatment that can be performed to reduce the patient’s RUE spasticity is
positioning the patient on his right side with his right arm extended and shoulder at
90 degrees or positioning on left side with his right arm extended shoulder at 90

,
degrees, and arm resting on pillow so that his right shoulder is not in horizontal

Understand
ch
adduction. This positioning schedule should be in collaboration with nursing and
occupational therapy. Other treatments include PROM, moist heat, and potential
medications, although this would require a discussion with the physician.
13. Because the patient is experiencing pain and has capsular laxity (as demonstrated by
Te
the positive sulcus sign), there are concerns to maintain proper positioning of the
glenohumeral joint to prevent long-term negative effects. It is imperative that the
right upper extremity is supported at all times to minimize further capsular laxity and
assist in the reduction of pain.
Remember 14. Due to cerebral shock, his extremity was flaccid during the acute phase. During
recovery, increased spasticity will be realized.
iv
Un

Key points
1. Collaboration among all medical disciplines is imperative to properly care for patients after stroke.
2. The goal of inpatient rehab is to maximize functional independence to facilitate the patient returning home.
Afterward, he will receive additional rehabilitation services via home care and/or outpatient settings. The goals of
therapy should be designed to reflect the patient’s anticipated functional status and needs for returning home.
3. Evidence-based practice is imperative to facilitate maximum improvement with physical therapy.
tin

4. Medical management to control risk factors must continue throughout acute inpatient rehabilitation to prevent
secondary sequelae, including a second stroke. Patient and family education regarding upper extremity positioning
can assist in reducing pain and improving overall outcomes.
r
Cu

General Information
Case no. 5.C
Authors Ethan Hood, PT, DPT, MBA, Board Certified Clinical Specialist in Geriatrics Physical
Therapy, Board Certified Clinical Specialist in Neurologic Physical Therapy
Jessica Schwartz, MSPAS, PA-C
:

Diagnosis Acute left middle cerebral artery (MCA), cerebrovascular accident (CVA)
er

Setting Outpatient clinic

Learner expectations ☑ Initial evaluation
□ Re-evaluation
□ Treatment session
Us

(Continued)

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| 13.10.21 - 22:44

Cerebrovascular Accident

24
(Continued)
General Information
Learner objectives 1. Appreciate the need to monitor vitals and patient performance to identify additional
medical sequelae.

/20
2. Identify appropriate tests and measures that provide information regarding patient
function.
3. Design an appropriate plan of care and interventions based on the patient’s needs.

Follow-up visit with primary care provider

/09
Chief complaint “Pain, R shoulder”
History of present illness A 67-year-old right-handed male presents to his primary care provider’s office after a 5-
day hospitalization and 2-week acute inpatient rehab stay (total 21 days poststroke). He
presents with expressive aphasia but is able to make his needs known and answer
multistep questions if given time for processing. His wife admits that he does not enjoy

14
drinking thickened liquids and his oral intake is decreased. He still seems somewhat “sad”
per the wife, but there is some improvement in his mood and energy levels after starting
citalopram at rehab. He has also been continuing to complain of discomfort in his right
shoulder that has not improved with usage of baclofen. He describes the pain as sharp,
shooting pains that are worse with activity. He would like to discuss this further with
physical therapy before any medication adjustments.

,
Past medical history

Past surgical history

ch
Recent right MCA, recent new onset atrial fibrillation. CVA, hypertension, coronary artery
disease, myocardial infarction with drug-eluding stent placement 10 years ago,
hypercholesterolemia, diabetes mellitus type 2, obesity.
Drug-eluding stent placed 10 years ago
Te
Allergies No known drug allergies (NKDA)
Medications Lisinopril, Metoprolol tartrate, Aspirin, Apixaban, Atorvastatin, Metformin, Sitagliptin,
Baclofen, Citalopram

Social history
iv

Home setup ● Resides in a split-level house with his wife

● Three steps to enter the home with a left railing
Un

● Eight steps to the second floor with a right railing ascending

● Bedroom and bathroom are on the second floor
● Woodworking shop and den are on lower level, with eight steps and right rail to
descend
Occupation ● Retired 2 years ago from teaching high school English x 35 years
Prior level of function ● Independent with functional mobility, activities of daily living (ADLs), and instrumental
tin

ADLs
● Walks 1 mile/day with his wife and dog
● (+) Drives
Recreational activities ● Fly fish and hunting (bow and arrow)
r

● Woodworking and makes his own furniture

● Visits two sons who live locally
Cu

Medical examination by primary care provider

Vitals ● Blood pressure: 148/88 mmHg
● Heart rate: 72 beat/min
:

● Respiratory rate: 14 breath/min

er

● Pulse oximetry: 96% on room air

● Temperature: 97.2 °F
General ● 67-year-old male, well developed and well nourished
● Awake and in no acute distress
Us

(Continued)

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| 13.10.21 - 22:44

Cerebrovascular Accident

24
(Continued)
Medical examination by primary care provider
Head, ears, eyes, nose, and ● Head nontraumatic
throat (HEENT) ● Pupils equal, round, reactive to light, accommodation

/20
● Extra ocular movement intact
● No ptosis or lid lag
● Visual fields intact
● Mucus membranes appear dry
● Neck supple, trachea midline
● Thyroid not enlarged

/09
● No carotid bruits
Cardiovascular and ● Irregularly irregular rhythm, no murmurs/rubs/gallops
pulmonary ● Peripheral pulses 2 + with no lower extremity edema
● Lungs clear to auscultation bilaterally without wheezes/rhonchi/rales
● No accessory muscle use

14
Abdomen ● Protuberant abdomen
● Positive bowel sounds four times
● Nontender to palpation with no rigidity, rebound, or guarding
Musculoskeletal ● No noted deformities
● Active range of motion of right upper extremity limited secondary to weakness and
pain. All other active range of motion intact.

,
● Passive range of motion with significant resistance to movement in right upper

Neurological ●
●
●
ch
extremity. All other passive range of motion intact.
Alert and oriented × 34
Follows commands without difficulty
Expressive aphasia noted
Te
● Cranial nerves II–XII grossly intact except some mild right side facial droop, sparing the
forehead
● Spasticity in right upper extremity
● Left upper extremity (LUE) and left lower extremity (LLE): 5/5 strength. Left hemibody
weakness
Other tests PHQ 9 = 8 (mild depression)
iv

●
Un

Medical management
Medications ● Continue metoprolol tartrate, Aspirin, Apixaban, Atorvastatin, Metformin, Sitagliptin,
Baclofen, Citalopram 20 mg PO daily
● Increase Lisinopril
Diet Level 2 mechanical soft diet with nectar-thick liquids
tin

Vitals As needed with rehab

Lab work Order complete blood cell count (CBC) and basic metabolic panel (BMP)
Precautions/Orders ● Activity ad libitum
● Fall risk
r

● Outpatient physical therapy, occupational therapy (OT), speech-language

pathology—evaluate and treat
Cu

Pause points
Based on the above information,
● What may be the best objective tests to quantify function and fall risk?
:

● How should the physical therapist best structure the outpatient physical therapy examination?
er

● How should the physical therapist make the goals of therapy meaningful to the patient?
● What will be the role of family education in making sure teachings are also utilized at home and in the community?

How should the physical therapist structure patient and family education?
Us

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| 13.10.21 - 22:44

Cerebrovascular Accident

24
Physical Therapy Examination
Subjective
“I want to get stronger to walk my dogs.”
Objective

/20
Pre-treatment Post-treatment
Vital signs
Supine Sitting Standing Sitting
Blood pressure (mmHg) 140/90 138/88 110/60 130/80
Heart rate (beats/min) 72 70 100 84

/09
Respiratory rate (breaths/min) 12 12 18 14
Pulse oximetry on room air
99% 99% 95% 97%
(SpO2)
Modified rate of perceived
0/10 0/10 6/10 6/10
exertion (RPE) scale (0–10)

14
Pain 7/10 at right 7/10 at right 7/10 at right 6/10 at right
shoulder shoulder shoulder shoulder
Musculoskeletal Range of motion ● LUE, active range of motion (AROM): within functional limit
(WFL)
● Right upper extremity (RUE), passive range of motion (PROM):

,
WFL
● LLE, AROM: WFL

Strength
ch
●

●
●
Right lower extremity (RLE), AROM: within functional limits
(WFL)
L shoulder flexion: 5/5
R shoulder flexion: 2/5
Te
● L elbow flexion: 5/5
● R elbow flexion: 2/5
● L wrist extension: 5/5
● R wrist extension: 1/5
● L hip flexion: 5/5
● R hip flexion: 4–/5
iv

● L knee extension: 5/5

● R knee extension: 4–/5
● L ankle dorsiflexion: 5/5
Un

● R ankle dorsiflexion: 4–/5

Aerobic ● NuStep for 15 minutes, level 3. (RUE secured to handle, with it
increased to minimize R shoulder flexion)
● RPE =14/20. Post vitals: blood pressure: 132/80 mmHg, heart
rate: 86 beat/minute
Neurological Balance Static sitting unsupported: good
tin

●
● Dynamic standing: good
● (–) Romberg eyes closed
● Berg Balance Scale = 44/56
● Functional gait assessment = 6/30
r

Cognition ● Alert and oriented x 4

Cu

● Follows multistep commands 100%

● Limited conversation due to expressive aphasia
Coordination ● Finger to nose: LUE intact, unable to perform with RUE due to
spasticity and weakness
● Heel to shin: LLE intact, RLE ataxic
Cranial nerves ● II–XII grossly intact except for noted right side facial droop,
:

sparing the forehead

er

● Vision intact, fully tracking with eyes, with no visual field deficits

(Continued)
Us

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| 13.10.21 - 22:44

Cerebrovascular Accident

24
(Continued)
Physical Therapy Examination
Reflexes ● Brachioradialis: 2 + L, 3 + R
● Biceps brachii: 2 + L, 3 + R

/20
● Triceps brachii: 2 + L, 3 + R
● Patellar: 2 + L, 3 + R
● Achilles: 2 + L, 3 + R
Sensation ● RUE: loss of sensation to crude touch and pinprick
● LUE, RLE, LLE: intact to crude touch and pinprick

/09
Tone ● RUE increased tone, 2 + /4 MAS
● RUE flexor synergy and loss of fractionated movement
● RLE hypotonic, 1 + /4 MAS
Other ● STREAM: 44/70 (6/20 upper extremity, 18/20 lower extremity,
20/30 basic mobility)
● Five Times Sit-to-Stand (5xSTS) Test = 35 seconds

14
● Timed Up and Go (TUG) test = 40 seconds
● 6-Minute Walk Test—deferred due to symptoms of lighthead-
edness with prolonged standing
Functional status
Bed mobility ● Rolling to left: independent on mat table

,
● Supine to/from sit: independent on mat table
Transfers ●

ch
Sit to/from stand: modified independent with bilateral upper extremities (BUE)
support via armrests. Deficits notable for excessive weight shift to left with sit to stand
and touching right knee to chair. When asked to perform sit to stand without knee
touching chair, patient requires multiple attempts but able to perform with arm rests.
Te
He reports feeling “lightheaded” with standing
Ambulation ● Ambulates 100 feet with modified independence and wide base quad cane
● Gait deviations notable for right hemiparetic gait with right upper extremity in flexor
synergy, right hip circumduction in swing, right foot flat at initial contact, right knee
hyperextension (genu recurvatum) in midstance, and unequal stride length. Ambulation
trial stopped due to patient reporting of progressive worsening lightheaded sensation with
iv

gait
● Gait speed = 0.45 m/second
● ▶ Fig. 5.5
Un

Stairs ● Ascend/descend four steps with modified independence, using one rail and wide base
quad cane

Assessment
tin

☑ Physical therapist’s Assessment left blank for learner to develop

Goals
Patient’s “To be able to walk without a cane around town”
Short term 1.
r

Goals left blank for learner to develop.

Cu

2.
Long term 1.
Goals left blank for learner to develop.
2.
:
er
Us

106

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| 13.10.21 - 22:44

Cerebrovascular Accident

24
/20
/09
, 14
ch
Te
iv
Un

Fig. 5.5 An example of the patient's current gait posture and pattern.

Plan
☑ Physical therapist’s Plan left blank for learner to develop.
tin

Bloom’s Taxonomy Level Case 5.C Questions

Create 1. Synthesizing the medical data and physical examination findings, develop an
appropriate physical therapy assessment of the patient.
r

2. Develop two short-term physical therapy goals, including an appropriate timeframe

Cu

for home care.

3. Develop two long-term physical therapy goals, including an appropriate timeframe for
home care.
4. Create a physical therapy plan of care and specific treatment interventions, including
frequency, dosing, and rationale for each intervention.
Evaluate 5. Is there anything abnormal with the patient’s vitals and response to activity during the
:

examination? If so, explain.

er

6. If so, what should the physical therapist do?

7. The patient is now almost 30 days’ post stroke. Given the current status of their upper
extremity function, based on the research, what is the best prognosis for the return of
upper extremity function?
Us

(Continued)

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| 13.10.21 - 22:44

Cerebrovascular Accident

24
(Continued)
Bloom’s Taxonomy Level Case 5.C Questions
Analyze 8. What type of positioning/splinting recommendations should be given to the patient?
9. What norms on the various tests performed (5xSTS, TUG, functional gait assessment

/20
[FGA], Berg Balance Scale) would indicate the patient is at low fall risk?
10. In this outpatient setting, what will be the frequency of treatment and why?
Apply 11. What gait speed does the patient need to be able to ambulate to cross most streets?
12. Is it anticipated that this patient will continue to require an assistive device? If so,
based on the information, which one and why?

/09
Understand 13. What can be done for the patient’s arm pain? What may be the cause(s)?
14. Describe the concept of fractionated movement.
Remember 15. What criteria does the patient need to meet to be considered an unlimited
community walker?

14
Bloom’s Taxonomy Level Case 5.C Answers
Create 1. The patient presents status post left CVA with right hemiparesis. Physical therapy exam
notable for RUE increased spasticity with inability to fractionate movement, RLE weakness
resulting in gait deviations, impaired balance with high fall risk as noted across numerous
measures (FGA, Berg Balance Scale, TUG, 5xSTS), and reduced endurance due to effects

,
of stroke and prolonged hospitalization. All of the aforementioned impaired the patient’s

ch
return to independence with ADLs and function. Additionally, during the examination,
hypotension with positional changes was noted. The physician was notified, and patient is
pending follow-up with PCP—will await physician recommendations before initiating
formal exercise regimen. The patient was also complaining of significant shoulder pain.
Physical therapist will discuss findings with occupational therapist to optimize positioning
Te
to minimize shoulder discomfort. Skilled physical therapist is recommended to address
the aforementioned deficits. It is anticipated that the patient should be able to perform all
ADLs and ambulate without device.
2. Short-term goals:
● Patient will demonstrate independence with home exercise program to improve

bilateral lower extremity (BLE) muscle strength and endurance.

iv

● Patient will ambulate for 5 minutes, five times a day around home to improve

endurance.
● Patient will improve gait speed ≥ 0.60 m/second with least restrictive assistive device
Un

to improve safety with community ambulation.

3. Long-term goals:
● Patient will score > 51/56 Berg Balance Scale to reduce fall risk with ADLs and

functional mobility.
● Patient will ambulate > 600 meters with least restrictive assistive device to improve

safely navigate community distances.

tin

● Patient will improve gait speed > 0.8 m/second with least restrictive assistive device

to improve safety with community ambulation.

4. The recommended dosing according to the American Stroke Association are as
follows:
● Aerobic: 3–5 days per week; 40–70% VO2 reserve or heart rate reserve;
r

20–60 minutes (or 3–10-minute sessions).

Cu

● Strengthening: 2–3 days per week; 50–80% 1 repetition maximum (RM) (resistance

gradually increased over time as tolerated); 1–3 sets of 10–15 repetitions of 8–10
exercises involving the major muscle groups.
● Balance: dynamic exercises focusing on improving weight shift and coordination of

right hemibody.
Focus of the exercise prescription should assist patient to return to independence with all
:

aspects of function. Exercise construction should be centered around tasks that are
meaningful to the patient.
er

Evaluate 5. Patient demonstrated orthostatic hypotension. Lack of fluid intake increase in blood
pressure medications, and addition of antidepressant can cause hypotension.
6. If a patient demonstrates orthostatic hypotension, one or many of the following
Us

(Continued)

108

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| 13.10.21 - 22:44

Cerebrovascular Accident

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(Continued)
Bloom’s Taxonomy Level Case 5.C Answers
interventions can be implemented: counsel the patient on fluid intake, utilize
thrombo-embolus deterrant (TED) stockings, perform therapeutic exercise prior to

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positional changes, and perform positional changes gradually. Vitals should be
monitored throughout treatment. Lastly, the physical therapist should alert any other
discipline who may be treating the patient—such as OT and/or ST—of the findings, and
depending on the severity contact the physician’s office.
7. At 20–30 days after stroke, indicators of poor prognosis include:
● No/minimal grip strength → no/minimal hand function later

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● No/minimal shoulder flexion → no/minimal hand function later

Analyze 8. The patient should lie on his affected side with his right arm at 90 degrees shoulder
flexion and elbow extended. The use of a GivMohr Sling, as compared to a traditional
sling, would assist with shoulder positioning, reducing pain, and maintaining function
of the upper extremity.

14
9. The norms of the fall risk measures are as follows:
● 5xSTS = < 12 seconds
● TUG = community dwelling older adults < 13.5 seconds; older patients post

stroke < 14 seconds

● FGA = > 22/30 (older adults)
● Berg Balance Scale = > 45 (out of 56 points)

,
10. While recent evidence on neuro recovery suggests providing a high dosage of

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interventions to facilitate neuroplasticity, traditional OP/physical therapy frequency is
three times per week, primarily due to insurance coverage. The patient may benefit
from an extensive Home exercise program (HEP) and family education/training to
supplement his OP/physical therapy.
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Apply 11. City planners may use 1.2 m/second as the reference speed to be able to cross the
street. However, the speed required to cross at lights may be dependent on local
ordinance.
12. It is anticipated that the patient will require SPC use.
Understand 13. A discussion with the patient’s PCP regarding the patient’s RUE pain is warranted.
Potential conservative interventions that physical therapists can provide include
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positioning, splinting, patient and family education, modalities (including trans-

cutaneous electrical nerve stimulation [TENS]) as needed, and collaboration with our
OT colleagues. Pain may be caused by spasticity and/or subluxation of the
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glenohumeral joint. With that said, the PCP may choose medical management, which
could include gabapentin for pain and/or baclofen/Botox injections for spasticity.
14. Fractionated movement is the ability to finely control and coordinate movement
across a single joint.
Remember 15. To be an unlimited community ambulator, the patient must be able to independently
navigate all home and community activities, including crowds and uneven terrain, and
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demonstrate complete independence in shopping centers.

Key points
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1. Need to monitor vitals with patients after stroke—ischemic strokes are generally caused by cardiovascular pathology.
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Hypertension and hypercholesterolemia are risk factors for stroke. Medication management may be changing in the
outpatient setting and proper monitoring of vitals can assist the health care team with medication dosing. Atrial
fibrillation is also a risk factor for stroke, especially if a patient is not already taking an anticoagulant medication.
2. Gait speed is one of the best ways to determine overall functional capability. Gait speed is the “sixth vital sign.”
3. When designing physical therapy interventions (especially in the outpatient setting), use the patient’s hobbies and
interests to develop specific interventions. This will improve their interest in physical therapy and motivation, and
:

potentially lead to improved compliance.

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Skrzat et al., Clinical Case Studies Across the Medical Continuum for Physical Therapists, First Edition (ISBN 978-1-68420-187-7), © 2022. Thieme. All rights reserved.
This document is intended for personal use only and may not be passed on to third parties in any form! Usage subject to terms and conditions of license.
| 13.10.21 - 22:44

Cerebrovascular Accident

Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early
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Skrzat et al., Clinical Case Studies Across the Medical Continuum for Physical Therapists, First Edition (ISBN 978-1-68420-187-7), © 2022. Thieme. All rights reserved.
This document is intended for personal use only and may not be passed on to third parties in any form! Usage subject to terms and conditions of license.