Physical Therapy Management Across the Continuum of Care for a 59-year-old Female

Status Post an Acute Thrombotic Stroke

Author: Chase J. Cochran

Research Advisor: Linda Hall, PT, MS, DPT

Doctoral Program in Physical Therapy

Central Michigan University
Mount Pleasant, Michigan

Date: December 18, 2020

Submitted to the Faculty of the

Doctoral Program in Physical Therapy at

Central Michigan University

In partial fulfillment of the requirements of the

Doctorate of Physical Therapy

Accepted by the Faculty Research Advisors(s)

Linda Hall, PT, MS, DPT

Date of Approval:
 ABSTRACT

Background and Purpose

A cerebrovascular accident (CVA), is a medical condition, also known as a

stroke, that is caused by an ischemic or hemorrhagic event affecting the arteries of the brain,

which lead to them becoming occluded or bursting. 1 Common impairments associated with a

CVA are hemiparesis, aphasia, vision difficulty, gait impairments, and sensation deficits. Some

risk factors are age, gender, race, are hypertension, diabetes, heart disease, smoking, and a

history of a previous stroke.2 Given there are many impairments, a common intervention is

implementation of physical therapy for an individual following a stroke.18 The purpose of this

case report was to describe the physical therapy management and application of interventions for

gait, balance, and strength training in a 59-year-old woman following an acute-ischemic

thrombotic CVA throughout her entire continuum of care in the hospital setting.

Case Description

A 59-year-old right-handed female was transferred from an outside the hospital (OSH)

location following her complaints and results of imaging leading to her diagnosis. She presented

to the Intensive Care Unit (ICU) at the hospital. Upon arrival her chief complaints were aphasia,

slurred speech, weakness in the RUE, and numbness in the RUE. She was diagnosed with an

acute ischemic thrombotic CVA involving the left MCA territory.

Upon examination, the patient weakness in her RUE, and numbness in her right forearm

down into her right hand, no pain anywhere, and was having difficulty finding words. Prior to

admission, she was independent (IND) for all mobility. She scored a Modified Rankin Scale

(MRS) of 4 and a National Institutes of Health Stroke Scale (NIHSS) of a 4. A 5 time sit to stand

test was performed without use of the two-wheeled-walker 2WW, where she obtained a time of
29.5s. A 2-minute walk (2MW) test was administered once it was safe and appropriate for the

patient. The patient obtained a total distance of 445.5 ft. She required minimal physical

assistance to contact guard assistance (CGA) during her initial examination. Interventions

utilized during the patient’s admission during her inpatient rehabilitation (IPR) stay were focused

on increasing strength in her bilateral lower extremities (BLE)/RUE, balance, endurance, gait,

and for safe transfers, and were progressed appropriately.

Outcomes

After 10 days, 3 in the ICU, 2 on the neurorehabilitation floor, and 5 on IPR, the patient

achieved all goals that were set. She was independent for all mobility and transfers. She saw

improvements in her MRS, from a 4 to a 2, initial evaluation to discharge, and for the NIHSS

from a 4 to 1, initial evaluation to discharge. She had a decrease in her 5 time sit to stand test

from 29.5s to 15.2s. She also walked a further distance during the 2MW without use of an

assistive device (AD) to a total distance of 504.4 ft, improving from an initial distance 445.5 ft.

Discussion

This case report showed that physical therapy intervention may contribute to significant

improvements in functional mobility, strength, overall independence and balance tasks in a

patient following an ischemic thrombotic stroke. Areas that led to these positive outcomes were

patient motivation, prior level of function (PLOF), multiple health disciplines working with the

patient and decreased intensity of impairments upon admission. Limitations of this study were

the inability to directly correlate the outcomes with physical therapy solely, due to the patient

seeing multiple health disciplines, and the fact that the case report only looked at one individual.

Future research should look at a combined case report with physical therapy, occupational

therapy, and speech therapy to provide the most accurate improvements in functional recovery.
Background and Purpose

A cerebrovascular accident (CVA), is a medical condition, also known as a stroke, that

affects around 795,000 people a year.1 It is the third leading cause of death, and the leading cause

of long-term disability in the United States.1 It can have devastating effects on an individual’s

motor and cognitive function. A stroke may be caused by an ischemic or hemorrhagic event

affecting the arteries of the brain, which lead to arteries becoming occluded or bursting.2

Once considered to be a diagnosis primarily affecting men, the incidence and prevalence

of strokes occurring in women have been increasing. 60,000 more women have stroke as

compared to men in the US each year.3 Although there are more men than women in the US

globally, more women die following a stroke as compared to men.4, 5 Incidence rates are higher in

those 75 or greater as compared to the ages 45-74, but they are still far too common.6 The

incidence of suffering a stroke doubles after every decade when someone reaches the age of 55.2

The prevalence is more common in African Americans compared to Caucasians, as well as a

mortality ratio at 3.7 to 1 for men and 3.5 to 1 for women when compared African Americans

and Caucasians.7

Strokes are the most preventable diagnosis out of all neurological diagnosis.8 Risk factors

can be divided into both modifiable and nonmodifiable for a stroke. Some nonmodifiable risk

factors are age, gender, and race.2 This means that they can be prevented through daily habits or

through medication. The most common medical conditions, that are modifiable risk factors,

involved with an increased risk of suffering a stroke are hypertension, diabetes, heart disease,

smoking, and a history of a previous stroke.1, 8 Cessation of these negative habits or introduction

of new habits such as healthy daily nutrition or introduction of an exercise or medication regime

can reduce the risk for a stroke.9, 8Smoking, one of the greatest risk factors for a stroke to occur,

1
is also one of the easiest to prevent, and can have great influence on the prevention of a stroke.8

Cessation of smoking for 2-4 years can reduce the risk of a stroke and cessation of smoking for 5

or more years returns the risk level for a stroke in an individual to those of non-smokers.9

As listed earlier, there are different types of strokes depending on the events that cause

them. An ischemic stroke is the most common and is caused by a blood clot in the arteries that

supply blood to the brain. An ischemic stroke can be diagnosed as either thrombotic, embolic, or

hypoperfusion. 2 A thrombotic stroke occurs when the clot forms in an artery in the brain and

occludes blood from flowing through that artery to the brain.2,10 An embolic stroke occurs when

the clot forms somewhere else in the vascular system and travels to the arteries of the brain to

cause a stroke.2, 10 A hypoperfusion stroke occurs when there is low systemic perfusion pressure

in the cardiovascular system. This is often associated with a myocardial infarction (MI) or an

abnormal arrythmia in the heart which caused a global systemic hypotension decreasing the

amount of blood that flows to the brain. 2

The second most common type of stroke is a hemorrhagic stroke. This occurs when a

blood vessel bursts, otherwise known as an aneurysm, and blood begins to leak into the brain. As

with ischemic strokes, there are different types of hemorrhagic strokes. An intracerebral

hemorrhage occurs when an aneurysm occurs within the parenchyma of the brain. 2 When a

stroke occurs within the meningeal layers and the brain itself, it is classified as a subarachnoid

hemorrhage. 2

In hemorrhagic strokes, an increase in blood pressure leads to rupturing of small arteries

causing severe bleeding to occur. Chronic hypertension causes weakening of artery walls leading

to necrosis of the vessel walls which lead to aneurysms.2, 10 Once an aneurysm occurs, this

2
reduces the blood flow to its directed tissue, due to the blood leaking out of the blood vessel. The

extent of damage varies based on the amount of blood, speed, and the location of the bleed. 2

The pathogenesis behind the different types of strokes cause an overall reduction in blood

flow, no matter the type of stroke. Reduction of blood flow causes the main area of cell death,

where function is lost and cannot be gained back, called an infarct. 2 The surrounding area in the

brain, where there is a possibility of return to prior function, is called the penumbra. 2 Free

radicals, cytokines, and chemokines are released by endothelial cells and glial cells causing an

inflammatory process to occur in the penumbra which leads to the damage of the brain.2, 10

In ischemic strokes, the development of a thrombus or embolus occur commonly at

bifurcations in the vascular system.10 This is often associated with pathologies such as

atherosclerotic vascular disease where there is a formation of plaque in the walls of an artery

which cause stenosis of larger blood vessels, leading to formation of a blood clot.10 The larger

arteries that are commonly occluded are the middle cerebral artery (MCA), vertebral arteries, and

the internal carotids. 2 After a larger artery or a cerebral artery is occluded the distal arteries that

receive the blood and provide the oxygen to the brain become affected. Neuronal function

becomes impaired when the cerebral blood flow is less than 20mL/100mg of blood flow per

minute, and neuronal death occurs at less than 10mL/100mg of blood flow per minute. 2

Different impairments occur from a stroke depending on the location of the stroke. Each

area of the brain receives oxygen from a specific artery. This means that for an ischemic stroke,

depending on the artery that is affected, there will be definitive impairments because different

areas of the brain will be specifically affected. Hemorrhagic strokes occur in larger areas where

an artery bursts, so the residual impairments are somewhat irregular rather than following a

specific pattern. The middle cerebral artery (MCA) is the most commonly affect artery involved

3
in an ischemic stroke. 2 If the entire MCA is occluded, then the clinical findings are hemiplegia,

the loss of motor function, and hemianesthesia, sensation loss, on the contralateral side of the

body as compared to where the stroke occurred. 11, 12 Global aphasia, or the inability to

comprehend or produce fluent speech can occur if the stroke is on the dominant hemisphere in

the brain. 2 Aphasia, difficulty understanding or expressing speech, can be split up into two

different presentations. Wernicke’s aphasia is the loss or difficulty of the ability to grasp the

meaning of spoken words. This is also commonly referred to as receptive aphasia. 2 Broca’s

aphasia, also known as expressive aphasia, is defined as the partial loss to produce spoken

language, where comprehension remains intact. 2

If both segments of the anterior cerebral artery (ACA) are completely occluded

contralateral hemiparesis and loss of sensation occur in the lower extremities (LE) more than in

the upper extremities (UE).11, 12 Abulia, or a delay in both verbal and motor response can also

occur.2, 12 Due to the MCA and the ACA receiving blood flow from internal carotid arteries, if

there was an occlusion in the integral carotid arteries, the impairments would be the same as if

the MCA or the ACA were occluded.11, 12

If the posterior cerebral artery is occluded, the thalamus, temporal lobe, occipital lobe,

cerebral peduncles and the midbrain would all be affected.11, 12 This would lead to impairments

such as abnormal sensation, vision deficits, memory deficits, temperature impairments,

proprioception deficits, and pain as well as hemiplegia and coordination deficits such as ataxia

can occur. 2, 12

If the vertebral and posterior cerebellar arteries are completely occluded then deficits in

the brainstem, medulla, and cerebellum can occur.11 This means impairments such as vertigo,

4
nausea, dysphagia, or the difficulty to swallow, eye drooping, ataxia, hemiparesis, and sensation

deficits can occur.2, 12

If the basilar artery is completely occluded then bilateral symptoms occur with deficits in

brainstem functioning.11 If the superior cerebellar artery is occluded then there can be ipsilateral

cerebellar ataxia, nausea, dysarthria or slurring of speech, and loss of sensation. 2, 12 Finally, if the

anterior inferior cerebellar artery is occluded then impairments such as ipsilateral deafness, facial

weakness, vertigo nausea, ataxia, and nystagmus can occur.11, 12

Symptoms of a stroke have to be present for greater than 24 hours for the event to be

defined as a stroke. If they haven’t progressed past 24 hours, the event is listed as a transient

ischemic attack (TIA) and is a prominent warning sign of a future stroke. 2

After experiencing symptoms of a stroke as listed above, someone may, and should, seek

professional consultation. Neuroimaging has become a very standard procedure not only to

diagnose someone with a stroke, but also to see where the stroke occurred and how much

damage the stroke caused. Computed tomography (CT) scans can rule out other pathologies as

well as provide the extend and location of the stroke.13 Following an ischemic stroke, there are

areas of decrease density that can be seen, and it becomes difficulty to differentiate between

white and grey matter.14 This is how ischemic strokes are viewed via a CT scan. Hemorrhagic

evidence also can be seen on CT scans.13 This can be monitored over time to see how

intervention is progressing in correlation to the abnormal changes that are seen in the CT scan.

After the CT scan, magnetic resonance imaging (MRI) can be used within the 2 to 6-hour

range after symptom onset.15 An MRI can also differentiate between an ischemic and

hemorrhagic stroke.16 An MRI can provide minute differences between changes that occur after a

stroke which a CT scan cannot provide.16 Diffusion-weighted MRI (DWI) can measure the speed

5
at which water molecules self-diffuse, therefore it can detect where the brain damage has

occurred minutes before stroke onset.16 This is also utilized to see the progression of the stroke

following treatment and intervention.16

Lastly, positron emission tomographic (PET) imaging is another imaging procedure that

can analyze a stroke.15 A PET scan can assess the progression of stroke severity by detecting

subatomic particles in the brain.16 All three imaging procedures are often utilized to provide a

clear picture of the stroke.16 There are other neuro imaging procedures that can be applied to

assess the severity of a stroke, but CT scans, MRIs, and PET scans are the most widely used.

Following experiencing symptoms and diagnosing a stroke, management and treatment

occurs. Tissue plasminogen activator (tPA) is a gold standard treatment immediately following

the diagnosis of an ischemic stroke.17 It works by converting plasminogen to plasmin, which is an

enzyme that breaks down clots in the blood.17 Breaking down the blood clot will help normalize

blood flow back to the brain in the arteries where the stroke occurred. This must be administered

within 3 hours of treatment to produce the best overall outcomes.17 Following tPA, and once

medically stabled enough for exercise, therapy is ordered. Therapy is ordered from a multitude of

interdisciplinary rehabilitation teams from physical therapy, occupational therapy, and speech

therapy to name a few. These disciplines are viewed as the mainstay of acute care that is

provided to the patient initially after a stroke occurs.18 Occupational therapy focuses on UE

function while speech therapy focuses on speech itself.18 Physical therapy primarily focuses on

restoring or maintaining strength, balance, and endurance which correlate to activities of daily

living (ADLs).18 Although each discipline focus on different aspects of care for a patient, each

work together as an interdisciplinary team along with the other health care professionals to

provide care for the patient.

6
 According to the American Physical Therapy Association (APTA), Physical therapists

maintain, restore, and work to improve movement, and overall health which lead to someone

increasing their overall function and quality of life. This is done by providing effective

evidenced based interventions that re catered to each individual. This occurs through the

prescription of a progressive exercise program that is not only limited to improve strength and

range of motion (ROM), but also improve balance, coordination, endurance, and cognitive

impairments.19 Each program is individualized for each patient that is aimed at achieving the

patient’s fitness and functional goals.

Physical therapy has been shown in numerous studies to improve functional deficits in

patients following a stroke.18, 20, 21, 22, 23 As discussed earlier, depending on the location of the

stroke the impairments may differ. Physical therapists will perform an evaluation of the patient,

utilizing evidence-based measures to correctly grade the given impairments, and then

interventions are applied progressively to help return the patient back to their prior functional

level. UE function is more challenging to return back to normal function as compared to LE.22, 24

Although UE function can be severely impacted in patients following a stroke.24 LE function can

be affected as well.22 This is seen often in terms of muscular strength, balance, and coordination

as it relates to impairments in gait. Temporal and spatial coordination between the head, trunk,

and pelvis along with strength impairments lead to impaired control during different phases of

gait.25 Impaired gait including decreased stability and dynamic balance during gait can lead to an

increase risk of falls, especially when not utilizing assistance. It’s also known that restoration of

basic gait pattern has been associated with a lower fall risk.26

Even though many impairments are present following a stroke, there are multiple

different interventions that can be applied to help regain function. Overground training, including

7
obstacle courses and different multi-plane stepping has been shown to increase walking speed

and walking distance in individuals following a stroke.21 Overground training interventions can

be anywhere from very simple linear stepping with assistance to complex obstacle courses that

forces the individual to challenge both unilateral and bilateral balance, muscular endurance, and

reactive stepping. 3 months post CVA, 11.6% of patients achieved complete functional recovery

of their affected UE, while 38% had some dexterity function in their affected hand.22 In addition,

13% of patients following a CVA, the affected UE was entirely non-functional.24 This relates to

having increased difficulty performing activities of daily living (ADLs) such as cooking,

cleaning, and bathing/grooming due to the increased need to use both UE to complete tasks.

Strength training and task-oriented progressive resistance training has been shown to increase

grip strength, UE function, and LE muscle strength in individuals following a stroke as well.23, 27

The purpose of this case report was to describe the physical therapy management and

application of physical therapy interventions in a 59-year-old female status post-acute ischemic

thrombotic CVA throughout her entire continuum of care.

Prior to preparing this report, consent was obtained from the patient to proceed. All

information contained in this case report meets the Health Insurance Portability Accountability

ACT (HIPPA) requirements of the clinical agency for disclosure of protected health information.

This case report was completed under the direction of the Department of Physical Therapy and

with the oversight of the College of Graduate Studies at Central Michigan University.

Case Description

The patient is 59-year-old right-handed female with chief complaints of experiencing

slurred speech and right upper extremity (RUE) weakness while at work. The patient was

admitted outside hospital (OSH) prior to being transferred to a hospital location in the intensive

8
care unit (ICU). The patient was transferred following her complaints and results of imaging

leading to her diagnosis. Upon arrival her chief complaints were aphasia, slurred speech,

weakness in the RUE, and numbness in the RUE. The original admission location could not best

treat the patient for her given diagnosis, therefore she as transferred to a hospital that was suited

to treat her appropriately.

Patient History and Systems Review

The patient initially presented to an OSH where she had multiple images taken. Of

relevance was a CT scan that indicated that she had a possible carotid artery dissection. The

patient was then sent to a hospital due to her possible diagnosis to be treated with a higher level

of care that the OSH location could not provide. She was admitted into the ICU at the hospital.

Upon further evaluation, a CT scan of the head indicated that she suffered an ischemic penumbra

in her left MCA and there was a possibility of an ischemic penumbra in her left cerebellar

hemisphere. She was diagnosed with an acute ischemic thrombotic CVA involving the left MCA

territory. Following this medical dx, the patient was treated with tPA and Physical Therapy was

ordered the next day. See the timeline, Figure 1, for further clarification on the patient’s course

throughout the hospital.

Per chart review, chief complaints from the patient were RUE weakness, aphasia, slurred

speech, and RUE numbness. She was diagnosed with Broca’s Aphasia by the medical doctors.

Pertinent medical history that would affect physical therapy outcomes was obtained via

subjective interviewing. Although experiencing Broca’s aphasia, she was capable of giving such

information. It was obtained that she had a history of smoking, (around 1 pack a day for the past

20-30 years) she fractured her right radius around 20 years ago, she is not very physically active,

and did not have a history of a former CVA. The patient had no other comorbidities that would

9
predispose her to a CVA. Her list of medications she took throughout her continuum of care are

listed in Table 3. She was not on any of the listed medications prior to her stay in the hospital.

Clinical Impression #1

Following the chart review, there was nothing about any LE deficits, balance deficits,

and prior level of function (PLOF). Given that she had an ischemic CVA of her MCA the known

deficits associated with a stroke in this location means her chief complaints of RUE weakness

and numbness correlate with the usual presentation of contralateral weakness of the UE. Clinical

findings when the entire MCA is occluded are hemiplegia, the loss of motor function, and

hemianesthesia, sensation loss, on the contralateral side of the body with the UE more affected

than the LE.2, 12 Broca’s aphasia also can occur if the entire MCA is occluded.2, 12

Physical Therapy seems appropriate for the patient given her complaints of RUE

weakness and numbness, as well as to perform an in-depth screen of her LE. Gross MMT and

AROM of her BUE and BLE will be assessed. Functional mobility with be assessed beginning

with bed mobility and progressing to functional transfers and ambulation as appropriate. The

patient will be graded on stroke severity utilizing the Modified Rankin Scale (MRS) and the

National Institutes of Health Stroke Scale (NIHSS). Once able to safely, a 5 time sit to stand test

and 2-minute walk (2MW) test will be administered to track progress with both functional

movement patterns of sitting and standing as well as ambulation speed and distance.

Examination

The patient was admitted into the ICU on the first day. Initial Physical Therapy

examination of the patient occurred on the second day in the ICU. This began with obtaining

subjective information including her PLOF and home setup. Prior to her admission the patient

was independent for all bed mobility, transfers, and ambulation with no assistive device (AD).

10
She lived in a mobile home with her significant other. There were 4 steps to enter with bilateral

hand railings. She worked full time on a factory line.

Prior to examination, discussion with the registered nurse (RN) indicated the patient was

stable for examination and reported improvement since admission. Confirmation with the RN

allowed physical therapy to gain an understanding if the patient was medically stable enough to

be appropriate for physical therapy. Vitals were noted prior to examination and during the

examination and were all within normal limits (WNL).28 The only precaution listed was that she

was a fall risk. She was attached to multiple ICU lines monitoring her blood pressure (BP), heart

rate (HR), respiratory rate (RR) and her heart was also being monitoring via a heart monitor.

Upon arrival the patient was supine in bed. The patient reported no pain, only being tired at the

moment. She also reported weakness in her RUE, and numbness in her right forearm down into

her right hand.

Communication. Due to Broca’s Aphasia, when asked complex questions the patient was having

difficulty finding words. She would consistently almost complete a sentence, only missing the

last word. She didn’t fumble her words but would rather stop attempting to talk until a word was

cued and she would agree that this was the word she was looking for. There were no major issues

during conversations with the patient.

UE & LE ROM. The patient’s UE and LE active range of motion (AROM) were taken in the

supine position.29 ROM measurements have been shown to have good interrater reliability

(r=0.98, ICC: 0.99) and have a good content validity (r=0.97, ICC: 0.99) 30, 31 ROM

measurements have also been AROM was grossly screened without utilization of a goniometer.

AROM was screen in a non-standardized position but utilized the widely standardized norms to

grade.29 Within functional limits (WFL) is defined as the patient being able to achieve AROM

11
that would allow them to complete their activities of daily living (ADLs) independently.29 The

patient’s AROM was WFL for shoulder abduction and flexion on her LUE. She was also WFL

for elbow flexion and extension as well as finger flexion and extension in her BUE. She had

deficits in her AROM of RUE shoulder flexion which was around 110 degrees and shoulder

abduction which was also around 110 degrees. She had no deficits in her BLE which were both

WFL symmetrically. Her ROM measurements indicated that she only had movement deficits in

her R UE.

UE & LE Manual Muscle Testing (MMT). The patient’s UE and LE MMT were also taken in the

supine position.29 MMT has been shown to be both valid and reliable in previous research, with

good interrater reliability (k=0.62-0.67 for different muscle groups).32 MMT has been shown to

have strong content validity in previous research as well.33 MMT was also screened in a non-

standardized position but utilizing the widely known MMT scale ranging from 0-5.29 The

relevant grades for the patient are as listed: 3+/5: Full AROM against gravity; minimum

resistance. 4/5: Full AROM against gravity, moderate resistance. 5/5: Full AROM against

gravity; maximum resistance.29 She achieved 3+/5 in RUE shoulder flexion, shoulder abduction,

elbow flexion, elbow extension, finger flexion, and finger extension. She achieved a 4/5 in LUE

shoulder flexion and shoulder abduction, as well as a 5/5 in LUE elbow flexion, elbow extension,

finger flexion, and finger extension. She achieved 4/5 in BLE hip flexion via straight leg raise

(SLR), knee extension, ankle plantar flexion. She achieved a 5/5 in BLE ankle dorsiflexion.

During the UE MMT assessment the patient exhibited possible flexor synergistic muscle

actions as she went into forearm pronation and adduction upon shoulder flexion and elbow

flexion eccentric resistance. She was unable to write her name due to the grip strength deficit as

12
she is right-handed during her evaluation. Her MMT measurements indicated that she only had

strength limitations in her RUE.

Sensation. The patient also demonstrated a glove presentation sensation deficit to light touch in

the RUE, from the hands and fingers to 3 inches distal to the right wrist. This was present on

both the palmar and dorsal aspect. Sensation testing did not follow a specific protocol. Light

touch was assessed by having the patient close their eyes and different areas of the BUE were

lightly touching with the therapist’s fingers. The patient was then asked if it felt the same or

different on both sides, to assess where the sensation deficit was accurately.

Functional Mobility. The patient was then assessed for functional movement patterns. Bed

mobility with rolling to her left, and supine to sit was a stand-by assist (SBA) for safety. SBA

means that she required no physical assist but was in close guarding for safety. The patient

required minimum physical assistance while holding onto a gait belt around her waist, for a sit to

stand to a two wheeled walker (2WW). Minimum physical assistance means that she was able to

provide greater than 75% of effort as perceived by the therapist. She required verbal cueing for

hand placement to push from the bed instead of the 2WW into standing. She required minimum

physical assistance to sit down and minimum physical assistance for trunk descent from sitting to

supine in bed.

Pre-Gait & Gait. In standing, the patient tolerated static stance with the 2WW with contact guard

assist (CGA). CGA means that she required no physical assistance to perform the task but was

CGA for safety. The patient was then instructed to take positional lateral steps to the head of the

bed (HOB). and was able to take 2 steps both to her right and to her left with the 2WW utilizing

CGA.

13
Outcome Measures. While standing, a 5 time sit to stand test was performed without use of the

2WW. The patient was unable to safely complete a sit to stand without use of pushing from her

UE on the bed, so this was allowed. This was done receiving minimum physical assistance. The

5 times sit to stand has excellent test-retest reliability (ICC=0.994).34 and excellent criterion

validity with correlation between the muscle strength of affected and unaffected muscles in

patients following a stroke (r= -0.753-0.830).35 She obtained a time of 29.5s, where a mean value

of healthy individuals around the age of 60 was 11.4s.36 Her time can be interpreted that she is at

a high fall risk and has decreased functional muscle strength in her BLE.36

She was given a Modified Rankin Scale (MRS) score that was utilized to describe the

severity of the patient’s stroke. The MRS has been shown to have excellent test-retest reliability

(k=0.81-0.95) and a good predictor of disability following a stroke in the MCA based on the

overall score. 37, 38 She was given a grade of 4: indicating that she had moderately severe

disability: unable to walk without assistance and unable to attend to own bodily needs without

assistance. This was due to her inability to ambulate safely without use of the 2WW.

The NIHSS was used to also address the severity of her stroke. This test assesses the

severity of common impairments seen in a patient post stroke and gives them a grade. The grades

are added up to give a final score. This has been shown have excellent interrater reliability

(ICC=0.95).39 The NIHSS also is a great predictor of outcomes at 90 days post stroke as well as

having adequate correlation with hospital charges (r=0.276) and discharge destination

(r=0.320).39, 40 Her impairments included: 1 point for each category: UE drift, LE drift, mild-to-

moderate sensory loss, & mild-to-moderate aphasia. These impairments added to a total score of

4 for the NIHSS, indicating that the patient has a strong probability of a good recovery. 40

Reference to AROM, MMT, and outcome measures can also be viewed in Tables 1, 2 and 4.

14
Clinical Impression #2

The patient presents with moderate impairments in terms of the findings present upon

evaluation. She was high functioning in terms of required assistance levels and independence

with mobility. She has few impairments in her lower extremities other than possible endurance

deficits due to bedrest and overall prior fitness level. Most of her impairments were in her RUE

with functional tasks such as gripping and overall strength, which was her dominant UE, so this

was leading to a lot of decrease in functional UE tasks. There was a lot of frustration with

attempts to grip objects unsuccessfully, therefore the patient required a lot of education on

progression of grip strength and fine motor function, and the research on regaining full UE

function based off of her CLOF. She was very understanding, showing expressions of gratitude

following this education.

Based off of the findings, it can be interpreted based off of research that she will regain a

lot independence. This is based off the fact that non-ambulatory patients that regain sitting

balance and some sort of voluntary movement of the hip, knee, and/or ankle within the first 72

hours following a stroke, have a 98% chance that they will regain independent gait within 6

months.41 The fact that she had full finger extension by the 2nd day meant that she had a very

good chance to obtain full upper limb function within 6 months.42

Her acute care goals where written out after the examination. Patient to be independent of

all bed mobility by 4 days. Pt to be modified independent with all transfers while utilizing a

2WW by 4 days. Pt to be modified independent for gait with 2WW for at least 100 ft by 4 days.

Pt to be able to complete home exercise program (HEP) modified independent with assistance

from hospital staff by 4 days.

15
 The goals were designed to be reasonable, functional, and achievable within the next few

days. They all had the common goal of increasing the patient’s independence and return to her

PLOF. Once these goals were achieved and she was medically cleared by the other health

practices, she then would be discharged to the neurorehabilitation floor and monitored there. As

the patient progresses within the acute care stay, she will have her goals modified.

The proposed plan of care (POC) included physical therapy, occupational therapy, and

speech therapy to improve LE strength and endurance, ambulation ability, dynamic balance, and

transfer ability. The interventions that would be applied were to assist the patient to progress to

independence without use of an AD.

Intervention

The interventions section will proceed through this timeline the patient went through

during her stay in the hospital while addressing the different type of interventions that were

completed. The interventions will be broken up into therapeutic exercise, therapeutic activity,

neuromuscular activity, and gait for each given floor the patient was on. The patient was on the

ICU floor for a total of 3 days. Following the day stay in the ICU, she was transferred to the

neurorehabilitation floor for two days total. Following the patients stay on the neurorehabilitation

floor, she was transferred to IPR for 5 days. See Figure 1 for a visual representation of the

patient’s timeline in the hospital.

ICU Interventions. The patient was on the ICU floor for a total of 3 days. The evaluation

occurred on the second day, and no interventions were applied on the day of the evaluation. This

was only due to decreased time available following the evaluation. On day three the patient was

seen for her first treatment, and for one more treatment on day four. In the ICU, the patient

completed interventions while being monitored by multiple ICU lines. This limited the amount

16
of distance that could be ambulated and the range of exercises that could be done. The therapy

sessions were short, consisting of exercise interventions provided for 20-30 minutes. Prior to

each session her vitals were assessed and were deemed to be WNL.28

Therapeutic exercise in the ICU consisted of with multiplane stepping, anterior, lateral

posterior, and lateral, forming a square, with no AD. 3 steps were taken to in each direction with

CGA for safety provided by the therapist. This was performed to increase balance and muscular

endurance as over ground training has been shown to lead to positive functional outcomes in

patients following a stroke.21 Therapeutic exercise was then progressed to 2 sets of 5 each leg

alternating mini lunges, posteriorly, anteriorly, and laterally. This was done with CGA for safety

provided by the therapist. The goals of this exercise were to increase strength in her hip

extensors, knee flexors/extensors, ankle plantar/dorsiflexors to lead to an increase in gait

mechanics. Increasing strength in the muscles listed have been proven to improve gait mechanics

and speed on a level surface in patients following a stroke.20

Therapeutic activity on the ICU floor consisted of bed mobility and functional transfers.

The patient performed bed mobility prior to both sessions, due to her beginning each session in

supine in bed. This consisted of rolling in both directions and then progressing to sit up on the

edge of the bed (EOB). Rolling to the right was done once and the patient could do so IND

without any cues. Rolling to the left was performed 3x each treatment session due to the patient

requiring minimum physical assistance for reaching with her RUE across her midline to the bed

railing. Facilitation was provided for guidance of the movement on the patients RUE. Rolling to

the left was done with more repetitions to increase ease of movement and increase RUE strength

and AROM while performing this motion. Increased repetition of tasks has been shown to higher

levels of cortical reorganization in patients following a stroke which will lead to increase ease of

17
movement with more practice of the movement specifically.43 After rolling the patient practiced

transferring from supine to sitting. She was able to do so CGA for safety. This was only done to

progress sitting EOB or standing activities as she could do this movement each session with ease.

After bed mobility, the patient’s therapeutic activity progressed to functional transfers.

Sit to stands for progression to begin pre-gait activities and ambulation were performed on the

first treatment session to a 2WW with minimum physical assistance. She required verbal cues for

pushing off the bed rather than grabbing onto the walker. This was done to once again to increase

strength in her hip extensors, knee flexors/extensors, ankle plantar/dorsiflexors to lead to an

increase in gait mechanics as increasing strength in these muscles have been shown to improve

gait mechanics and speed on a level surface in patients following a stroke.20

Following therapeutic activity, the patient was progressed to performing neuromuscular

re-education. This consisted of static standing BUE reaching across her chest to a pressure relief

boot that was outside of the patient’s midline and performing a squeeze with her hand with no

AD. This was done 5 times on each side for 2 sets while standing shoulder width apart and then

for another set of standing statically in tandem stance with her right foot in front of her left. The

therapist stood on the patient’s right side minimum physical assistance was provided to facilitate

the RUE reaching. This exercise was done to increase static standing balance, incorporating a

functional reaching pattern, and increase grip strength by squeezing the foam pressure relief boot

at the end of each repetition. Increased repetitions were done of this movement to once again

promote neuroplastic changes in the brain, but this was done in a UE reaching pattern as this has

been shown to improve strength and ADL completion in patients following a stroke.43, 44 After

performing neuromuscular re-education in a static standing position, the patient was progressed

to performing multiplane 3-way lunging, anteriorly, posteriorly, and laterally. This was done for

18
2 sets of 5 each direction while holding onto the 2WW and receiving CGA for safety from the

therapist. The goal of this exercise was to not only to increase strength in the hip extensors, knee

flexors/extensors, ankle plantar/dorsiflexors to improve gait mechanics, but also to improve

balance with deceleration of an eccentric dynamic motion as increasing strength in these muscles

has been shown to increase dynamic balance in patients follow a stroke.20, 45

The patient then progressed to gait activities. This consisted of ambulating 75ft with

multiple turns with a 2WW and CGA in the first day of treatment. She had a slow but steady gait

pattern with both a symmetrical step length and width. She exhibited decreased handling ability

of the 2WW due to decreased RUE grip strength. She had two instances where her RUE came

off the walker and she had to readjust. This decreased RUE grip strength lead to her ambulating

to the left slightly because she could not control the 2WW. This was deemed safe though and no

further physical assistance was necessary. Following this, the patient experienced labored

breathing and had a heart rate (HR) of 92 beats per minute (bpm), and an oxygen saturation

percentage of 94% (SpO2). These were both WNL following low level aerobic exercise.28 The

second day the patient ambulated 100ft with multiple turns with a 2WW and SBA. She had two

instances where her RUE came off the walker and she had to readjust and grip ahold of the

walker. This was still deemed safe and she required to increase of physical assistance. Her HR

increased up to 90 bpm and she had no labored breathing. Ambulation was completed with goals

to increase gait speed, gait distance, and cardiovascular endurance. Early ambulation and over

ground training in patients following a stroke has been shown to increase gait speed, gait

distance and gait mechanics.21, 46 Following the three therapy sessions but two treatments

provided, the patient was transferred to the neurorehabilitation floor.

19
Neurorehabilitation Floor Interventions. Following the day stay in the ICU there she was

transferred to the neurorehabilitation floor for two days total. Interventions were applied in the

ICU prior to transferring to the neurorehabilitation floor, so the patient was only seen for one

visit total on the neurorehabilitation floor. She had no lines attached at this point so nothing

limited exercise via wiring or required specific monitoring during treatment. She had a re-

evaluation occur during treatment and her goal of ambulation was the only goal readjusted to be

modified independent for gait with 2WW for at least 150 ft by 2 days.

Therapeutic exercise began with sit to stands without use of an AD. CGA was provided

by the therapist for safety. The patient performed 2 sets of 10 using her BUE to push off from the

bed. This was done to increase strength in her hip extensors and knee extensors which will

correlate to better outcomes associated with gait. Increasing strength in these muscles has shown

to increase overall gait distance and mechanics.20, 47 Following sit to stands the patient performed

mini lunges as she did in the ICU. These were progressed to 3 sets of 5 each leg alternating mini

lunges, posteriorly, anteriorly, and laterally. This was done with CGA for safety provided by the

therapist. This also had the goal in mind to increase strength in the hip extensors, knee flexors

and extensors to increase gait distance and mechanics.20, 47

Therapeutic activity was incorporated during the session beginning with bed mobility.

The patient once again performed rolling to left with more repetitions to increase ease of

movement and increase RUE strength and AROM while performing this motion.43 Throughout

the therapy session the patient requested to use the bathroom, therefore this was an opportunity

to obtain a toilet transfer measurement as she was working on this with Occupational Therapy.

The patient was able to perform a toilet transfer with SBA for safety only, with use of bilateral

handrails around the toilet. This was the only therapeutic activity performed during the session.

20
 No neuromuscular re-education was provided during this treatment, but patient

progressed in her gait training. She was able to be progressed in her ambulation distance with

and without an AD without experiencing any cardiovascular endurance deficits. She ambulated

125ft with use of a 2WW while the therapist provided CGA for safety. She ambulated utilizing

the same steady and symmetrical gait pattern and had increased control of the 2WW due to

increased RUE grip strength. She had no instances of loss of the 2WW causing her to drift to the

left. The patient also ambulated around the room with no AD. She required CGA once again and

presented with a slower and mildly unsteady gait due to her decrease dynamic balance control

but visual improvements were noted from the previous attempt without an AD. Ambulation was

once again provided as a treatment due to gait training in patients following a stroke increase gait

speed, gait distance and gait mechanics.21, 46 Following the completion of this treatment, the

patient was later transferred to the IPR floor.

IPR Interventions. Following the patients stay on the neurorehabilitation floor, she was

transferred to IPR. She was on IPR for a total of five days receiving Physical Therapy,

Occupational Therapy, and Speech Therapy. The treatments ranged from 30 to 60 minutes. All

interventions were controlled by the same physical therapist with the exception of two days, due

to the patient receiving treatment over the weekend where she worked with different physical

therapists. In total, the patient received two days of treatment from the same physical therapist

that will be documented below. The first day she had no Physical Therapy treatment provided,

but rather had a revaluation to readjust her goals. Pt to be IND of all bed mobility by 7 days. Pt

to be IND with all transfers no AD by 7 days. Pt to be IND for gait with no AD for at least 250 ft

by 7 days. Pt to be able to complete 1 6” curb step IND no AD by 7 days. Pt to be able to pick up

object off floor IND no AD by 7 days. Pt to be able to walk across 10 ft. unstable surface IND no

21
AD by 7 days. Pt to be able to complete flight of stairs one sided hand railing IND by 7 days. Pt

to be able to complete HEP IND by 7 days. The patient completed all these activities with SBA

for safety from the physical therapist.

A 2MW test was introduced on the first day on IPR. The 2MW test was introduced to

receive an objective measure of ambulation distance in a given time frame to track progress

during the patients IPR stay. This was not administered earlier due to safety issues with the

patient’s endurance and dynamic balance during gait. The 2MW test has excellent test-retest

reliability (ICC=0.95) and excellent concurrent validity when compared to other outcome

measures such as the Berg Balance Scale (r=0.88).48 The patient achieved 445.5 ft with

supervision assistance without use of an AD.

Therapeutic exercise was progressed sit to stands in the therapy gym without use of an

AD. This was done receiving SBA for safety from the therapist. The patient performed 3 sets of

10 using her BUE to push off of the mat table to stand. This was done on both days of physical

therapy treatment provided on IPR. Sit to stands were done to increase strength in her hip

extensors and knee extensors which has been shown to increase overall gait distance and

mechanics.20, 47 Following sit to stands the patient also completed step ups in the parallel bars

with BUE support to a 6” step with SBA. She was able to perform 1x5 leading with each leg for

one set, then requested to reduce the repetitions down to 1x4 on each leg for the second set

secondary to fatigue. Step ups were performed to increase strength in the patient’s hip extensors,

knee extensors, and ankle dorsiflexors and plantar flexors which has been shown to increase

strength in these muscles.49 Resistance training in patients following a stroke, as well as over

ground training, has been shown to have positive outcomes in terms of increased gait speed and

overall gait mehcanics.21, 47Lateral stepping up and over a 4” roam roller inside the parallel bars

22
with BUE support was also performed. This was done as well for 2 sets of 5 each leg. The

patient received SBA for this exercise as well. This was done as well to improve strength in the

patient’s hip flexors and ankle plantar flexors.49 Over ground training as well as increasing

strength in these muscles has been associated with an increase in functional performance and gait

mechanics in patients post stroke.21, 47

Therapeutic activity was the main focus during the patients stay in IPR. By this time, she

was able to perform all bed mobility and functional transfers safe and independently. Therefore,

the patient’s therapeutic activity was progressed to incorporate functional movements while

using obstacle courses in the therapy gym. This was done on both days during the patients two

IPR treatments and consisted of a 40-foot-long obstacle course. The patient performed it twice

on both days, receiving SB for safety and verbal cueing for sequencing of events occurring

during the obstacle course. The obstacle course began with lateral stepping in a 25ft floor ladder

with one foot in each square. The patient would face one direction to lead with one foot the first

obstacle course repetition and then rotate to face the other direction to lead with the other foot

the following repetition. Following the ladder, the patient performed stepping over a 4” foam

roller and a 6” foam roller, leading with her right foot on all repetitions. Then finally, the patient

finished the obstacle course by walking tandem along a 10ft airex pad in the parallel bars with

BUE support. This was the only time where CGA was provided due to the increase risk of falling

with this activity. The patient then rested for two minutes and performed the course once again.

The goals of the obstacle course were to increase strength and endurance in the patients BLE

during functional movements, as well as to improve gait speed and distance. Overground training

such as walking in different directions, walking backwards, and laterally, as well as over

obstacles has been shown to improve walking speed and walking distance.21

23
 Therapeutic activity then progressed to a work specific task. Due to the patient working

on a factory line, a work simulated task was incorporated. The patient was standing facing

anterior to a table that was waist height. She reached with both hands to her left and grabbed a

10# weight and moved it to the right. The therapist then replaced the weight with another weight

along with a 10 second rest between grabbing each weight to simulate how the line works in the

factory. This was done for 3 sets of 10 receiving supervision level assistance from the therapist.

Task-oriented resistance strength training has been shown to increase muscular strength and

functional performance in individuals with stroke.23 Increasing repetitions has been shown to

induce further neuroplastic changes in the brain following a stroke, making the movement

easier.43

No specific nuero re-education was provided once again on the IPR floor due to time

constraints. Gait training was continuously progressed daily. The patient ambulated to the gym

from her room and from the gym to her room as well as going on a long bout of ambulation prior

to each treatment. At this time, she was no using an AD any more for ambulation. The very first

bout of ambulation she received CGA initially but then was progressed to SBA in the middle of

the distance ambulated due to visual increase in dynamic balance. She ambulated different

distances in each bout to different locations throughout her treatments. This was done either

intentionally to go for a long walk or to get to a specific destination to perform therapy. On the

first day she performed 445.5ft around IPR floor for the 2MW test, 25ft to stairwell, 50ft too

therapy gym 125ft around IPR floor back to room. She ambulated with a slow and mildly

unsteady gait pattern with symmetrical step length and width. On the second day she performed a

long bout of 400ft around the IPR floor to the gym and 125ft from the therapy gym back to her

room. It was visibly clear that she had an increase in gait speed, which was still deemed slow,

24
and a steadier gait pattern. On the last day she was progressed to modified independent

assistance level due to her continued increase in dynamic balance and reduced need for

assistance. She performed a total distance of 504.4ft around the IPR floor, 25ft to the gym, and

125ft back to her room. She still had a slow gait speed, and, on this day, she was very steady

during her gait. Repetitive gait training has been proven in multiple studies to be effective in

short term and long-term lower extremity function and performance.50

Outcome

AROM, MMT, sensation, and outcome measures were all reassessed on the final day

after intervention was provided prior to discharge from IPR. Functional mobility and gait were

both reassessed throughout the patients stay on IPR, rather than formally on the discharge date.

This information can all be found in Tables 1, 2, and 4.

UE and LE ROM

The patient’s AROM improved from having deficits in her RUE for shoulder flexion and

abduction. She was only able to achieve 110 degrees of AROM into right shoulder flexion and

abduction at initial evaluation. She improved to WFL for both motions at discharge. She was

able to maintain WFL for elbow flexion, elbow extension, finger flexion, and finger extension at

discharge as she was graded for WFL at initial evaluation. The patient was also able to maintain

WFL for shoulder flexion, shoulder abduction, elbow flexion, elbow extension, finger flexion,

and finger extension in her LUE at discharge as she was graded at WFL at initial evaluation. This

can be found in Tables 1 and 2.

UE and LE MMT

Her strength was grossly a 3+/5 upon evaluation in her RUE for shoulder flexion,

shoulder abduction, elbow flexion, elbow extension, finger extension and finger flexion. At

25
discharge the patient improved to 5/5 for all RUE MMT assessments with the exception of 4/5

for her RUE finger flexion strength. She was able to maintain all strength in her LUE receiving a

5/5 grossly at initial evaluation and at discharge. For her LE, at initial evaluation, the patient was

a 4/5 in her BLE for resisted hip flexion, knee extension, and plantar flexion. She improved these

to 5/5, along with maintaining a 5/5 grade for her bilateral dorsiflexors. This can be found in

Tables 1 and 2.

Sensation

The patient also demonstrated a glove presentation sensation deficit to light touch in the

RUE, from the hands and fingers to 3 inches distal to the right wrist. This was present on both

the palmar and dorsal aspect at initial evaluation. She did not see improvements in her sensation

impairments, that were present upon evaluation, at discharge.

Functional Mobility

Bed mobility with rolling to her left, and supine to sit was SBA for safety at initial

evaluation. The patient was minimum physical assistance for a sit to stand to a two wheeled

walker 2WW initial evaluation. She required minimum physical assistance to sit down and

minimum physical assistance for trunk descent from sitting to supine in bed initial evaluation. At

discharge she was graded as IND for all bed mobility and functional transfers.

Pre-Gait & Gait

At initial evaluation the patient was only able to take positional steps towards the HOB

with a 2WW and receiving CGA. At discharge she was able to walk the 502.4ft during the 2MW

without a 2WW and doing so modified independent. She was unable to perform stairs or a curb

step until her IPR evaluation. During her IPR evaluation she was able to perform 2 steps with a

right handrail for support and a 6” curb step with no UE support as well as walk across a 10ft

26
foam surface, all with SBA. At discharge she was able to perform a flight of stairs IND with a

right sided handrail and was IND for the curb step and 10ft foam mat ambulation. This can be

seen in Table 4.

Outcome Measures

The MRS and NIHSS were utilized to measure stroke severity. These were both assessed

daily. She began at achieving a score of a 4 on the MRS. Moderate severe disability; unable to

walk without assistance and unable to attend to own bodily needs without assistance. She

progressed to achieving the score of a 1 on the MRS: No significant disability, despite

symptoms; able to perform all usual duties and activities. She also saw drastic improvement in

her NIHSS score, beginning at a 4 due to her UE and LE drift, Broca’s aphasia, and sensation

loss. Although this still listed her in the mild stroke category, she improved to being a 1 with

only having aphasic symptoms.39 Complete results for these outcome measures can be found in

Table 4.

The 5 times sit to stand measured the ability for the patient to perform a functional

transfer safely with proper balance as quickly as she could. During her initial evaluation she

required UE support during push off to lift up her trunk and it took her 29.5s to complete. During

her discharge from IPR 9 days later she could perform the test with her arms across her chest in

15.2s. the 5 times sit to stand has a minimal detectable change of 4.2 seconds.34 This means that

the progression seen by the patient is a true value when using the 5 times sit to stand.

The 2MW test was used to assess the patient’s ability to walk further distances in a set

time frame. Her 2MW progressed from 445.5ft to 504.4ft. the 2MW has a minimal detectable

change of 40 ft (90% confidence).48 This means that her change can be attributed to be a true

27
value when utilizing the 2MW. Complete results for these outcome measures can be found in

Table 4.

The patient adhered to all interventions applied and to her HEP outside of her therapy

sessions, by asking if she adhered to it during the beginning of each session. Based off of her

progress it can be assumed that she was truthful, but she was not monitored 24/7 to ensure full

HEP completion. She participated in all Physical Therapy sessions with no adverse events during

them.

Discussion

The purpose of this case report was to describe the physical therapy management and

application of physical therapy interventions in a 59-year-old female status post-acute ischemic

thrombotic CVA throughout her entire continuum of care. This case report achieved its intended

purpose by showing how proper intervention planning and progression can improve an

individual’s overall strength and independence.

The patient demonstrated the clinical findings typically present in a patient status post-

acute ischemic thrombotic CVA. Physical therapy has been seen to be beneficial in treatment of

patient’s post stroke. 18, 20, 21, 22, 23 The interventions utilized were all evidence based, seen to be

beneficial in addressing impairments that are often seen in patient’s status post stroke. The

interventions included LE strengthening, UE strengthening, gait training, dynamic balance

training, circuit training, task specific training, and over-ground training. For clinical practice,

through proper goal setting and application of interventions, along with application of other

interventions and techniques from other health disciplines, allowed the patient to see positive

outcomes as well as be discharged safely home.

28
 The overall limitations of this case report were that it only looked at one individual who

suffered an acute CVA and the inability to directly correlate the outcomes with physical therapy

solely, due to the patient seeing multiple health disciplines. Alternative explanations to the

patient seeing an increase in overall physical function very quickly. Factors that could have

influenced the patient’s ability to obtain positive outcomes so quickly are the fact that the patient

demonstrated increased motivation. She had an independent PLOF, and she was not at a decrease

level of function upon admission as evident by her outcome measure scores for stroke severity.

The patient also had multiple health disciplines working with her, which could have led to her

seeing an increase in overall function very quickly. The patient could have been held back from

experiencing greater positive outcomes from her prior physical activity level, history of smoking,

history of poor nutrition, and Broca’s aphasia.

Future research should look at combined case reports with physical therapy, occupational

therapy, and speech therapy to provide the most accurate improvements in functional recovery.

Proper physical therapy intervention application and management throughout a continuum of

care can be effective to return close to PLOF when done so correctly in patients status post-acute

ischemic thrombotic CVA. This means utilizing progressive overload principles such as increase

repetitions, sets, time, decreased rest periods, and increase in exercise difficulty can help lead to

increase in strength, balance, and overall function.

29
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 Table 1.
AROM at Initial and Final

RUE LUE RLE LLE RUE LUE RLE LLE

Initial Initial Initial Initial Final Final Final Final

AROM AROM AROM AROM AROM AROM AROM AROM

Shoulder 110 deg WFL WFL WFL

flexion
Shoulder 110 deg WFL WFL WFL

abduction
Elbow WFL WFL WFL WFL

flexion
Elbow WFL WFL WFL WFL

extension
Finger WFL WFL WFL WFL

Extension
Finger WFL WFL WFL WFL

flexion
Hip flexion WFL WFL WFL WFL

Knee WFL WFL WFL WFL

extension
Plantar WFL WFL WFL WFL

flexion
Dorsi WFL WFL WFL WFL

flexion
Within functional limits (WFL): patient able to achieve AROM/MMT that would allow them to
complete their activities of daily living (ADLs) independently.2
 Table 2.
MMT at Initial and Final

RUE LUE RLE RUE RUE LUE RLE RUE

Initial Initial Initial Initial Final Final Final Final

MMT MMT MMT MMT MMT MMT MMT MMT

Shoulder 3+/5 4/5 5/5 4/5
flexion
Shoulder 3+/5 4/5 5/5 4/5

abduction
Elbow 3+/5 5/5 5/5 5/5

flexion
Elbow 3+/5 5/5 5/5 5/5

extension
Finger 3+/5 5/5 5/5 5/5

Extension
Finger 3+/5 5/5 4/5 5/5

flexion
Hip flexion 4/5 4/5 4/5 4/5

Knee 4/5 4/5 5/5 5/5

extension
Plantar 4/5 4/5 5/5 5/5

flexion
Dorsi 5/5 5/5 5/5 5/5

flexion
Degrees (deg); Manual Muscle Test (MMT) Scoring: 3+/5: Full AROM against gravity;
minimum resistance. 4/5: Full Active Range of Motion (AROM) against gravity, moderate
resistance. 5/5: Full AROM against gravity; maximum resistance. Within functional limits
(WFL): patient able to achieve AROM/MMT that would allow them to complete their activities
of daily living (ADLs) independently.29
Table 3.
Medication Initiated During Hospital Admission

Medication Dosage
aspirin tablet 81mg
atorvastatin tablet 8 mg
enoxaparin injection 40mg
midodrine tablet 10mg
nicotine patch 7mg/24hr
ticagrelor tablet 90mg
polyethylene glycol packet 17g
phenylephrine 20mg
NaCL 1.9% IV dosage not listed
Table 4.
Outcome Measures Initial to Discharge

Day Following MRS NIHSS 5 Times Sit to 2MW

Admission Stand
1
2 4 4 29.5s (UE
support for lift)
(minimum
physical
assistance)
3 4 4
4 3 4
5 3 4
6 3 2 26.2s (UE 445.5 ft
support for lift) (supervision
Contact guard assistance)
assist (CGA)
7 2 2
8 2 2
9 2 2
10 1 2 15.2s (arms 504.4 ft
across chest) (modified
modified independent)
independent
(modified
independent)
Scoring: Modified Rankin Scale (MRS): 4: Moderate severe disability; unable to walk without
assistance and unable to attend to own bodily needs without assistance, 3: Moderate disability;
requires some help, but able to walk without assistance, 2: Slight disability; unable to perform all
previous activities but able to look after own affairs without assistance, 1: No significant
disability, despite symptoms; able to perform all usual duties and activities.37
National Institutes of Health Stroke Scale (NIHSS): 1 point for each: Motor arm: drift, Motor
leg: drift, mild to moderate sensory loss, mild to moderate aphasia; 2 (mild stroke): 1 point for
each: mild to moderate sensory loss, mild to moderate aphasia.39

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 & 8 Day 9 Day 10

Admitted Phyiscal Therapy Physical Physical Therapy tx in Physical Therapy tx PT IPR evaluation IPR weekend Physical Pt d/c from IPR
from OSH Inital Evaluation in Therapy tx ICU, pt transferred to on uncontrolled PT Therapy Physical
into ICU ICU in ICU neurorehabiliation floor neurorehabilitaito from other physical IPR tx Therapy tx
after n floor, pt therapists provided prior
transferred to IPR to d/c
after

Figure 1. Timeline of Patient’s Course in Hospital

Intensive Care Unit (ICU), treatment (tx), patient (pt), Inpatient Rehabilitation (IPR), discharged
(d/c)