Stroke Day 10: Sitting Balance, Neglect, and a Falls Risk
A 72-year-old man is on day 10 after a left middle cerebral artery infarct. He has right hemiparesis with shoulder and hip flexion grade 2/5, knee extension grade 1/5, and no active ankle dorsiflexion. He has dense right sensory loss and left-sided visual inattention on testing; he bumps his right arm on the bed rails and does not notice it. He can sit with the help of one person for 2 minutes but drifts to the right and needs continual repositioning. He has a history of two falls at home in the year before the stroke and takes antihypertensive medication. He is keen to walk and asks daily when he can start. The ward is short-staffed today and the nurse asks whether he can be left sitting in the chair for lunch.
1. Assess his falls risk and explain how the neglect, sensory loss, and strength findings interact to shape your recommendations about sitting in the chair.
Read the worked answer
Falls risk is high. Contributing factors: two falls in the prior year, right hemiparesis with insufficient hip and knee extension to bear weight or recover from a loss of balance, dense right sensory loss meaning he cannot feel where his limb is or when it contacts a surface, left visual inattention meaning he does not register people or objects on the right, and trunk control that is not yet independent (2 minutes with assistance and continual drift). Antihypertensive medication adds a risk of postural hypotension.
How the factors interact: the neglect and sensory loss mean he will not spontaneously correct the rightward drift, because he is not receiving or attending to the relevant information. The weakness means that if he does drift past his base of support, he cannot generate the hip and knee extension needed to recover. The result is a fall that occurs without warning and without an attempt to save himself.
Recommendation on the chair: he should not be left unsupervised in the chair for lunch today. If he is to sit out, it should be with a lap belt or tilt-in-space chair as locally approved, a nurse or therapist within sight and reach, and a position that supports the right side. The safest option given staffing is a shorter supervised sit with his trunk supported and the call bell on his left, with regular checks. Document the rationale and escalate the staffing concern through the appropriate channel rather than accepting an unsafe arrangement.
2. He wants to start walking tomorrow. Justify whether this is appropriate and outline the progression you would use.
Read the worked answer
Walking tomorrow is not appropriate on current findings. He cannot sit independently, has hip and knee extension strength insufficient to support body weight, and has neglect and sensory loss that would make a fall likely and hard to predict. Attempting walking now risks injury and may undermine his confidence.
Justification to give him: walking safely requires being able to sit steady, to take weight through the leg, and to notice where the leg is. We will build those first, and that will get him walking sooner and more safely than trying now.
Progression:
- Sitting balance: short, frequent, supervised practice with feedback and cueing to the right; use visual anchors and verbal cueing to encourage attention to the right side. Aim for independent sitting with a stable base before standing.
- Trunk control and weight shift: seated reaching activities toward the right with cueing, and bed mobility practice.
- Standing: standing frame or standing with a tilt table to load the affected leg safely; then standing with a high plinth and two-person assistance, monitoring for postural drop given his antihypertensive medication.
- Stepping: step transfers and stepping in parallel bars with assistance once he can take weight and has some hip and knee extension.
- Walking: only when he can stand with minimal assistance and demonstrates awareness of the right side; use appropriate aids and assistance, with a falls prevention plan.
Review daily, record progress, and set a shared goal date with him so he can see the pathway.