Stroke Rehabilitation: Sitting Balance and Shoulder Pain at Week Three
A 67-year-old man is 18 days after a left middle cerebral artery infarct. He has right hemiparesis, Medical Research Council grade 2/5 in the right hip extensors and 1/5 in the right wrist extensors, dense right sensory loss, and mild neglect on the right. He cannot sit unsupported for more than 5 seconds and needs two assistants to transfer. He has right shoulder pain rated 6/10 on movement, with no subluxation on inspection. He is motivated but fatigued after 15 minutes of therapy. His goal is to walk to the mosque, which is 400 metres away, and he lives with his wife who cannot lift him.
1. What are the priorities for the next two weeks, and how would you justify them against his walking goal?
Read the worked answer
His goal is walking, but the rate-limiting impairments are trunk control, transfer independence, and shoulder pain, not leg strength alone. Without sitting balance he cannot safely use a wheelchair or begin standing, and his wife cannot manage two-person transfers at home. Priorities: (1) trunk control in sitting with a graded task (unsupported sitting with reaching, weight shifting, and visual search tasks to address neglect), (2) transfer training toward one-person assistance using a slide board or standing-pivot as hip extension improves, (3) shoulder management.
I would explain the link explicitly: sitting balance and transfers are prerequisites for standing and gait, so this is not a detour from his goal. Therapy should be in short, frequent blocks (for example 15 minutes with rest) because of fatigue, spread across the day. I would set a measurable two-week target, such as 60 seconds of unsupported sitting and one-person supervised transfer, and review it. I would also involve his wife early in transfer training so discharge is realistic.
2. How would you manage the painful right shoulder, and what would you avoid?
Read the worked answer
The pain is likely hemiplegic shoulder pain from poor scapular control, traction, and handling. I would check for subluxation with the arm unsupported, assess passive range painlessly, and look for signs of impingement or capsular restriction.
Management: support the arm in a lap tray or pillow in sitting and a sling for standing and transfers; educate all staff and family to never pull the arm; position the hemiplegic arm forward on a pillow when supine; teach the wife to support the arm during dressing. Use gentle pain-free passive and active-assisted range into flexion and external rotation, scapular setting, and postural alignment. Consider referral for botulinum toxin if there is focal spasticity limiting range, and discuss analgesia with the medical team. Avoid overhead pulleys, aggressive stretching into pain, and unsupervised sling use that encourages a flexed posture. Reassess pain scores and sleep, since night pain is a common marker of poor positioning.