# Clinical Cases: Neurorehabilitation

## 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
![Stroke Rehabilitation Team](case_01_image.jpg)

*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

1. **Neuroplasticity is activity-dependent** - "use it or lose it"; high-intensity, task-specific practice drives recovery

2. **Inpatient rehab requires ability to tolerate 3 hours of therapy daily** - determines appropriate level of care

3. **FIM (Functional Independence Measure)** is the standard outcome measure in rehabilitation

4. **Interdisciplinary team is essential:** physiatrist, PT, OT, SLP, nursing, neuropsychology, social work

5. **Post-stroke depression affects 30-50%** - screen and treat; impairs rehabilitation participation

6. **Spasticity management** - treat only if interfering with function; some spasticity is helpful

7. **Most stroke recovery occurs in first 3-6 months** but continues beyond with ongoing therapy

---

## Case 2: Spinal Cord Injury Rehabilitation

### Patient Demographics
- **Age:** 28 years old
- **Sex:** Male
- **Mechanism:** Diving accident into shallow water

### Acute Event
Mr. Michael Torres sustained a cervical spinal cord injury after diving into shallow water at a lake 4 weeks ago. CT and MRI showed C5-C6 fracture-dislocation with spinal cord injury. He underwent emergent decompression and stabilization surgery. He has been in the acute care hospital for 4 weeks and is now transferring to spinal cord injury rehabilitation.

### Current Neurological Status

**ASIA (American Spinal Injury Association) Examination:**

**Motor Level:**
| Muscle | Right | Left |
|--------|-------|------|
| C5 (Elbow flexors) | 5 | 5 |
| C6 (Wrist extensors) | 4 | 4 |
| C7 (Elbow extensors) | 0 | 0 |
| C8 (Finger flexors) | 0 | 0 |
| T1 (Finger abductors) | 0 | 0 |
| L2-S1 (Lower extremity) | 0 | 0 |

**Sensory Level:** C6 bilaterally (normal sensation through C6 dermatome)

**Sacral Sparing:** None (no sensation or voluntary anal contraction)

**ASIA Classification:**
- **Motor Level: C6**
- **Sensory Level: C6**
- **ASIA Impairment Scale: A (Complete)**

### Clinical Image
![Spinal Cord Injury Levels](case_02_image.jpg)

*Image: Diagram showing functional expectations at different spinal cord injury levels, from high cervical (ventilator-dependent) through thoracic (paraplegia with upper extremity function) to lumbar (ambulatory potential).*

**Image Source:** Wikimedia Commons
**Attribution:** Medical education, Public Domain
**URL:** https://commons.wikimedia.org/wiki/File:Spinal_cord_injury_levels.png

### Functional Expectations for C6 Complete SCI

| Function | Expected Outcome |
|----------|------------------|
| Breathing | Independent (no diaphragm involvement) |
| Transfers | Independent with sliding board |
| Bed mobility | Independent |
| Wheelchair | Independent manual wheelchair on flat surfaces |
| Driving | With hand controls |
| Self-care | Modified independent with equipment |
| Bowel/bladder | Requires assisted management |
| Ambulation | Not functional (wheelchair user) |

*C6 level preserves wrist extension (tenodesis grasp) which enables many functional tasks*

### Rehabilitation Goals

**Phase 1 (Weeks 1-4):**
- Medical stabilization
- Education about SCI
- Range of motion/prevent contractures
- Skin integrity program
- Bowel/bladder program initiation
- Psychological support

**Phase 2 (Weeks 5-8):**
- Strength training for preserved muscles
- Transfer training (bed, wheelchair, car)
- Wheelchair skills
- Self-care training with adaptive equipment
- Bowel/bladder program independence

**Phase 3 (Weeks 9-12):**
- Advanced wheelchair skills
- Community reintegration
- Driving evaluation
- Vocational planning
- Discharge planning

### Medical Complications Management

**1. Neurogenic Bladder:**
- Type: Upper motor neuron (reflex bladder)
- Management: Intermittent catheterization every 4-6 hours
- Training patient in self-catheterization with adaptive equipment
- Anticholinergic medication (oxybutynin) for detrusor overactivity

**2. Neurogenic Bowel:**
- Bowel program: Every other day
- Digital stimulation technique
- Stool softeners and high-fiber diet
- Timed bowel care after meals (gastrocolic reflex)

**3. Skin (Pressure Ulcer Prevention):**
- Pressure-relieving wheelchair cushion
- Weight shifts every 15-30 minutes
- Daily skin inspection (using mirror for areas patient cannot see)
- Specialized mattress

**4. Autonomic Dysreflexia (AD) Education:**
- **Critical teaching** - patient has T6-level injury (above T6 = AD risk)
- Triggers: Bladder distension (#1), bowel impaction, skin breakdown
- Symptoms: Headache, hypertension, flushing above injury, sweating above injury, bradycardia
- Management:
  1. Sit patient up
  2. Loosen restrictive clothing
  3. Check bladder (catheterize if distended)
  4. Check bowel (disimpact if needed - use lidocaine gel)
  5. If BP remains >150 systolic, give nifedipine
  6. If unresolved, emergency care

**5. DVT Prevention:**
- Low molecular weight heparin (enoxaparin) for 8-12 weeks
- Compression stockings
- Range of motion exercises

**6. Spasticity:**
- Expected to develop over weeks to months
- Currently minimal
- Will treat if interferes with function (baclofen, tizanidine, botulinum toxin, intrathecal baclofen pump)

### Psychological Support

**Adjustment to Disability:**
- Stages are not linear: shock → denial → grief → adaptation
- This patient currently in grief stage - expressing sadness, anger about lost function
- Support groups with peers (other SCI patients)
- Individual counseling
- Family counseling
- Antidepressant considered if depression criteria met

**Vocational Counseling:**
- Prior occupation: Construction worker
- Will not be able to return to this occupation
- Vocational rehabilitation referral
- Exploring options: Office work, education, entrepreneurship

### Discharge Planning (Week 10)

**FIM Scores:**
| Domain | Admission | Discharge |
|--------|-----------|-----------|
| Self-care | 12 | 32 |
| Sphincter | 4 | 10 |
| Transfers | 4 | 16 |
| Locomotion (wheelchair) | 2 | 12 |
| Communication | 14 | 14 |
| Social cognition | 18 | 20 |
| **TOTAL** | **54** | **104** |

**Achieved Goals:**
- Independent transfers with sliding board
- Independent wheelchair mobility on flat surfaces
- Modified independent self-catheterization
- Independent bowel program with setup
- Upper body dressing independent; lower body with minimal assist
- Demonstrates autonomic dysreflexia management plan

**Discharge Destination:** Home (modified apartment)

**Home Modifications:**
- Wheelchair ramp
- Roll-in shower with shower chair
- Grab bars
- Hospital bed with trapeze
- Widened doorways

**Equipment:**
- Ultra-light manual wheelchair
- Cushion for pressure relief
- Sliding board
- Reacher
- Catheterization supplies

**Follow-up:**
- Physiatrist every 3 months for first year
- Urology (annual renal ultrasound, urodynamics)
- Dermatology as needed for skin issues
- Lifetime surveillance for secondary complications

### Teaching Points

1. **ASIA classification is the standard for SCI:**
   - A = Complete (no motor/sensory below injury)
   - B = Sensory incomplete
   - C = Motor incomplete (most muscles <3)
   - D = Motor incomplete (most muscles ≥3)
   - E = Normal

2. **Functional level predicts independence:**
   - C6: Can be independent in wheelchair and most self-care
   - C7: Independent in most activities
   - T1+: Upper extremities normal

3. **Autonomic dysreflexia is a medical emergency** - occurs with injuries T6 and above; can cause stroke if untreated

4. **Neurogenic bladder/bowel require lifelong management** - prevent complications (UTI, renal damage, skin breakdown)

5. **Pressure ulcers are preventable** - weight shifts, proper cushion, skin inspection

6. **Psychological adjustment is essential** - support groups, counseling, vocational rehabilitation

---

## Case 3: Disorders of Consciousness

### Patient Demographics
- **Age:** 45 years old
- **Sex:** Female
- **Event:** Cardiac arrest 6 weeks ago

### Acute Event
Ms. Sarah Thompson suffered an out-of-hospital cardiac arrest 6 weeks ago secondary to ventricular fibrillation. CPR was initiated by bystanders after approximately 5 minutes of down time. ROSC (return of spontaneous circulation) was achieved after 18 minutes of resuscitation. She was treated with targeted temperature management (33°C for 24 hours) and remained comatose. She is now 6 weeks post-arrest, transferred to a specialized disorders of consciousness rehabilitation program for further assessment and treatment.

### Current Examination

**Level of Consciousness Assessment:**

**Arousal:**
- Eyes open spontaneously
- Sleep-wake cycles present

**Awareness:**
- Does not follow commands
- No visual tracking
- Does not reach for objects
- No emotional responses to family members
- Occasional non-purposeful movements

**Coma Recovery Scale - Revised (CRS-R):**

| Domain | Best Response | Score |
|--------|---------------|-------|
| Auditory | Startle | 1 |
| Visual | Startle | 1 |
| Motor | Non-purposeful withdrawal | 2 |
| Oromotor | None | 0 |
| Communication | None | 0 |
| Arousal | Eyes open without stimulation | 2 |
| **TOTAL** | | **6** |

*CRS-R score <8 with no purposeful responses = Vegetative State/Unresponsive Wakefulness Syndrome*

### Clinical Image
![Disorders of Consciousness Spectrum](case_03_image.jpg)

*Image: Diagram showing the spectrum of disorders of consciousness from coma (no wakefulness or awareness) through vegetative state (wakefulness without awareness) to minimally conscious state (inconsistent awareness) to emergence (functional communication or object use).*

**Image Source:** Wikimedia Commons
**Attribution:** Medical education, Public Domain
**URL:** https://commons.wikimedia.org/wiki/File:Disorders_of_consciousness.png

### Classification of Disorders of Consciousness

| State | Wakefulness | Awareness | Patient Status |
|-------|-------------|-----------|----------------|
| Coma | Absent | Absent | No |
| **Vegetative State (VS)** | **Present** | **Absent** | **CURRENT** |
| Minimally Conscious (MCS) | Present | Inconsistent | No |
| MCS+ | Present | Command-following | No |
| Emerged | Present | Consistent | No |

**Diagnosis: Vegetative State (Unresponsive Wakefulness Syndrome)** - 6 weeks post-anoxic injury

### Diagnostic Workup

**MRI Brain:**
- Diffuse cortical and subcortical injury
- Particularly involving watershed zones
- Bilateral hippocampal atrophy

**EEG:**
- Severe diffuse slowing
- No reactivity to stimulation
- No seizure activity

**Somatosensory Evoked Potentials (SSEP):**
- Bilateral N20 responses present (favorable prognostic sign)

**Family Meeting Discussion:**

"Mrs. Thompson's brain was deprived of oxygen during her cardiac arrest, which caused widespread damage. She is currently in what we call a vegetative state - she has sleep-wake cycles and her eyes are open, but she is not showing awareness of herself or her environment.

At 6 weeks, it is still early. We consider a vegetative state 'persistent' after 1 month and 'permanent' after 3-12 months depending on the cause (longer timeline for traumatic injury, shorter for anoxic). The fact that her SSEP responses are present is a somewhat favorable sign.

We recommend a trial of specialized rehabilitation to see if she shows any signs of emerging awareness. We will monitor her closely and reassess her regularly. We also need to discuss her prior wishes and what she would want for herself in this situation."

### Rehabilitation Approach

**Goals of Rehabilitation in Disorders of Consciousness:**
1. Optimize medical status
2. Provide sensory stimulation to promote recovery
3. Prevent complications (contractures, skin breakdown)
4. Serial assessment for signs of awareness
5. Support family coping and decision-making

**Sensory Stimulation Program:**
- Auditory: Familiar voices, music
- Visual: Faces, objects, light
- Tactile: Range of motion, textured objects
- Olfactory: Familiar scents (perfume, coffee)

**Medical Management:**
- Nutrition via PEG tube
- Bowel/bladder program
- DVT prophylaxis
- Contracture prevention (stretching, splinting)
- Spasticity management

**Serial Assessment:**
- CRS-R weekly
- Document any signs of purposeful behavior

### Clinical Course

**Week 8:**
- No change in examination
- Family visiting daily, participating in stimulation program

**Week 10:**
- Nursing notes: "Patient appeared to track husband across room"
- CRS-R: Visual pursuit confirmed! (Score now 8)
- **Diagnosis changed: Minimally Conscious State (MCS)**

**Week 12:**
- Following simple commands inconsistently (squeeze hand)
- Emotional response to daughter's visit
- CRS-R: 14

**Week 16:**
- Following commands reliably
- Localizing to noxious stimuli
- Beginning to vocalize
- **Diagnosis: Minimally Conscious State Plus (MCS+)**

### Family Meeting - Week 16

"Mrs. Thompson has shown significant improvement over the past 2 months. She has emerged from vegetative state and is now in what we call 'minimally conscious state plus' - she can follow commands and is showing signs of awareness, though still inconsistently.

This is meaningful progress and gives us reason for cautious optimism. However, I want to be honest that we still don't know how much further she will recover. Some patients with MCS continue to improve and regain functional communication; others remain at this level. We will continue rehabilitation and reassess."

### Outcome at 6 Months Post-Arrest

- Following commands reliably
- Speaking single words
- Recognizing family members
- Feeding with assistance
- Severe memory impairment
- Requires 24-hour supervision and moderate assist for all ADLs

**Discharge:** To long-term care facility specializing in brain injury, with family involvement and continued outpatient therapies

### Teaching Points

1. **Disorders of consciousness exist on a spectrum:**
   - Coma → Vegetative State → Minimally Conscious State → Emergence

2. **Vegetative state = wakefulness without awareness** (eyes open, sleep-wake cycles, but no purposeful behavior)

3. **Minimally conscious state shows inconsistent but reproducible signs of awareness** (visual tracking, command-following, emotional responses)

4. **CRS-R (Coma Recovery Scale-Revised) is the gold standard assessment tool** for serial monitoring

5. **Misdiagnosis of vegetative state is common (up to 40%)** - careful serial assessment is essential

6. **Prognostication is challenging:**
   - Anoxic injury: Generally poorer prognosis than traumatic
   - Time matters: Earlier emergence = better outcome
   - Negative SSEP: Very poor prognosis
   - Positive SSEP: Does not guarantee good outcome but is favorable

7. **Family support and honest communication are essential** - help families understand prognosis while maintaining appropriate hope

---

## Key Teaching Points Summary

### Stroke Rehabilitation
- Neuroplasticity is activity-dependent; high-intensity therapy drives recovery
- FIM measures functional independence (1-7 scale per item)
- Interdisciplinary team: physiatrist, PT, OT, SLP, nursing, neuropsychology, social work
- Post-stroke depression is common (30-50%) and impairs rehabilitation
- Most recovery in first 3-6 months but continues with therapy

### Spinal Cord Injury Rehabilitation
- ASIA classification (A-E) defines injury completeness
- Functional level (C6, T1, etc.) predicts independence potential
- Autonomic dysreflexia (T6 and above) is a medical emergency
- Neurogenic bladder/bowel require lifelong management
- Pressure ulcer prevention is critical

### Disorders of Consciousness
- Spectrum: Coma → Vegetative → Minimally Conscious → Emerged
- Vegetative state = wakefulness without awareness
- CRS-R is gold standard for serial assessment
- Misdiagnosis is common - careful repeated assessment needed
- Family support and honest prognostic communication are essential