Neurology · Year 3 · from Neurology
Case 1: Stroke Rehabilitation
Patient Demographics
- Age: 62 years old
- Sex: Male
- Occupation: High school history teacher (prior to stroke)
Acute Event
Mr. James Henderson presented 3 weeks ago with sudden onset right hemiparesis and aphasia. CT head showed left middle cerebral artery territory infarct. He received IV tPA within 3 hours with partial improvement. Hospital course was complicated by aspiration pneumonia.
Referral to Rehabilitation
Now medically stable, being evaluated for inpatient rehabilitation admission.
Current Neurological Status (Day 21 post-stroke)
Motor:
- Right upper extremity: 2/5 proximally, trace distally (no functional hand movement)
- Right lower extremity: 3/5 proximally, 2/5 distally
- Left side: 5/5 throughout
Sensory:
- Decreased light touch and proprioception on right
Language:
- Broca's aphasia (expressive > receptive)
- Comprehends simple commands
- Speech non-fluent, effortful, telegraphic ("want...water")
- Naming impaired
- Repetition impaired
Cognition:
- Attention adequate
- Memory grossly intact
- Neglect: None (right hemisphere spared)
Swallowing:
- Failed bedside swallow evaluation
- VFSS (video fluoroscopic swallow study): Aspiration with thin liquids, no aspiration with nectar-thick liquids
Functional Status:
- Transfers: Moderate assist (50% effort from helper)
- Ambulation: Unable (cannot bear weight on right leg)
- Self-care: Requires maximum assist for bathing, moderate assist for dressing, minimal assist for feeding (can use left hand)
- Communication: Significantly impaired
Clinical Image
Image: Illustration showing the interdisciplinary rehabilitation team including physiatrist, physical therapist, occupational therapist, speech-language pathologist, rehabilitation nurse, neuropsychologist, and social worker working together for comprehensive stroke rehabilitation.
Image Source: Wikimedia Commons Attribution: Medical education, Public Domain URL: https://commons.wikimedia.org/wiki/File:Rehabilitation_team.png
Rehabilitation Assessment
FIM Score (Functional Independence Measure):
| Domain | Admission Score | Max Score |
|---|---|---|
| Self-care (6 items) | 15 | 42 |
| Sphincter control (2 items) | 8 | 14 |
| Transfers (3 items) | 6 | 21 |
| Locomotion (2 items) | 2 | 14 |
| Communication (2 items) | 6 | 14 |
| Social cognition (3 items) | 12 | 21 |
| TOTAL | 49 | 126 |
(FIM scores: 1=total assist, 7=complete independence)
Eligibility for Inpatient Rehabilitation:
- Medically stable: YES
- Can tolerate 3 hours of therapy daily: YES (per therapy evaluation)
- Multiple therapy needs: YES (PT, OT, SLP)
- Potential for functional improvement: YES
- Insurance approval: YES
Decision: Admitted to inpatient rehabilitation facility
Rehabilitation Goals (Set with Patient and Family)
Short-term Goals (2 weeks):
- Transfers: Minimal assistance
- Ambulation: 50 feet with hemi-walker and minimal assist
- Right upper extremity: Improve proximal strength for positioning
- Swallowing: Advance to mechanical soft diet
- Communication: Use yes/no reliably, 2-3 word phrases for basic needs
Long-term Goals (6 weeks - discharge):
- Transfers: Supervision only
- Ambulation: Community ambulation with device
- Self-care: Modified independence with adaptive equipment
- Swallowing: Regular diet
- Communication: Functional communication for daily needs
Interdisciplinary Treatment Plan
Physical Therapy:
- Gait training with body weight support initially
- Progressive strengthening of right lower extremity
- Balance training
- Endurance training
- Brace fitting (ankle-foot orthosis) for foot drop
Occupational Therapy:
- Constraint-induced movement therapy (CIMT) - controversial with this severity but may try modified version
- Task-specific training for ADLs
- Adaptive equipment training (one-handed techniques, rocker knife, button hook)
- Right upper extremity positioning and range of motion
Speech-Language Pathology:
- Intensive aphasia therapy (goal: 3-4 hours/week)
- Melodic Intonation Therapy (for Broca's aphasia)
- Compensatory strategies (gesture, writing, AAC device)
- Swallowing therapy and diet advancement
Nursing:
- Skin integrity monitoring
- Bowel and bladder program
- Medication management
- Patient and family education
Neuropsychology:
- Cognitive assessment
- Mood assessment (screening for post-stroke depression)
- Coping strategies
- Family counseling
Social Work:
- Discharge planning
- Home assessment
- Community resources
- Family support
Spasticity Management
Assessment at Week 2:
- Right elbow flexors: Modified Ashworth Scale 2 (more marked increase in tone)
- Right wrist flexors: MAS 1+ (slight increase)
- Right ankle plantar flexors: MAS 2
Management:
- Stretching program (PT and OT)
- Positioning to prevent contracture
- Splinting: Resting hand splint at night, AFO for ambulation
- Pharmacology: Not initiated yet (spasticity helping with standing)
Note: Some spasticity can be functional (helps with transfers and standing). Treat only if interfering with function or causing pain.
Clinical Course
Week 2:
- Ambulating 50 feet with hemi-walker and contact guard
- Transfers with minimal assist
- Tolerating nectar-thick liquids, pureed solids
- Speaking 2-3 word phrases with effort
- PHQ-9: 12 (moderate depression symptoms)
Depression Management:
- Started sertraline 50 mg daily
- Counseling support
- Increased family involvement
Week 4 (Discharge):
| Measure | Admission | Discharge |
|---|---|---|
| FIM Total | 49 | 78 |
| Ambulation | 0 feet | 150 feet with quad cane, supervision |
| Transfers | Moderate assist | Supervision |
| Self-care | Max assist | Modified independent with equipment |
| Diet | NPO then thickened | Regular diet with precautions |
| Communication | 1-2 words | 4-5 word phrases |
Discharge Plan
Discharge Destination: Home with wife (who is trained caregiver)
Equipment:
- Hospital bed (rental)
- Quad cane
- Ankle-foot orthosis
- Tub bench and grab bars
- Adaptive equipment for dressing and eating
Outpatient Services:
- Physical therapy 2x/week
- Occupational therapy 2x/week
- Speech therapy 2x/week
- Neuropsychology follow-up
Medical Follow-up:
- Physiatrist in 4 weeks
- Neurologist in 6 weeks
- PCP in 2 weeks
Prognosis Discussion:
- Most motor recovery occurs in first 3 months
- Language recovery can continue for 12+ months
- Continued improvement expected with outpatient therapy
- May need to consider disability retirement from teaching
Teaching Points
- Neuroplasticity is activity-dependent - "use it or lose it"; high-intensity, task-specific practice drives recovery
- Inpatient rehab requires ability to tolerate 3 hours of therapy daily - determines appropriate level of care
- FIM (Functional Independence Measure) is the standard outcome measure in rehabilitation
- Interdisciplinary team is essential: physiatrist, PT, OT, SLP, nursing, neuropsychology, social work
- Post-stroke depression affects 30-50% - screen and treat; impairs rehabilitation participation
- Spasticity management - treat only if interfering with function; some spasticity is helpful
- Most stroke recovery occurs in first 3-6 months but continues beyond with ongoing therapy