Early mobilisation after stroke with atrial fibrillation
Fatima, a 67-year-old retired teacher, is day 4 after a left middle cerebral artery infarct. She has right hemiparesis, NIHSS 9, and trunk control of 2/5 in sitting; she can stand with two assistants for 10 seconds. Her medical history includes atrial fibrillation on warfarin (INR 2.8), hypertension, and a transient ischaemic attack 2 years ago. She is on continuous telemetry. Blood pressure is 150/85 mmHg, heart rate 92 beats/min and irregular, and she is afebrile. Her haemoglobin is 11.8 g/dL and platelets are 210 × 10^9/L. She has a peripheral intravenous line and a urinary catheter. She wants to walk to the toilet and is frustrated at being bed-bound. The nursing staff ask whether she can start mobilising today. She has no new focal deficits and no chest pain or breathlessness.
1. Evaluate her readiness for mobilisation today. List the safety criteria you would check before and during the session, and explain how the INR and irregular heart rate affect your decision.
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She is likely ready for assisted mobilisation, not independent walking. Day 4 after stroke, no new deficits, no chest pain or breathlessness, BP 150/85 (acceptable permissive hypertension), HR 92 irregular but likely her baseline AF, and therapeutic INR 2.8. I would check: neurological stability (new weakness, speech change, pupil), BP limits set by the team (usually withhold if systolic >200–220 or <100 with symptoms), HR and telemetry for new arrhythmia, SpO2, temperature, glucose, pain, and fatigue. INR 2.8 is within therapeutic range for AF and is not itself a contraindication, but it raises bleeding risk if she falls, so use a gait belt, two assistants, and a clear falls plan. Irregular HR is common in AF; I would not delay mobilisation solely for an irregular pulse if she is rate-controlled and asymptomatic, but I would review telemetry before and after. Escalate if new arrhythmia, chest pain, desaturation, or new neurological signs.
2. Choose two outcome measures-one for sitting balance and one for gait-that are feasible in this inpatient setting. Justify each choice and state how you would use the results.
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For sitting balance, the Trunk Impairment Scale (TIS) is feasible at the bedside, validated in stroke, and scores static sitting, dynamic sitting, and coordination (0–23). It is quick and can be repeated without walking. For gait, the Functional Ambulation Categories (FAC) is appropriate because she can stand with assistance but cannot yet walk independently; it records the level of human assistance needed (0–5). The FAC is simple, clinically meaningful, and guides safe mobilisation. I would record baseline scores, use them to set goals (e.g., TIS +2 points, FAC from 1 to 2), and repeat weekly. If she becomes able to walk, I would add the 10-metre walk test for speed.
3. Plan the first mobilisation session, including assistance level, duration, target intensity, and stopping rules.
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Session plan: check vitals and telemetry; ensure two assistants plus me; gait belt; sit on edge of bed. Start with trunk control in sitting (weight shifts, reaching) for 5 minutes. Then stand with two assistants for 30–60 seconds, three repetitions with seated rest. Target intensity: light, RPE 11–13, no breathlessness beyond mild. Use the toilet as a goal for later, not today; a bedside commode is a safer first step. Stop if: chest pain, SpO2 <90%, HR >130 or new irregularity, systolic BP >200 or symptomatic drop, dizziness, new weakness, or severe fatigue. Document baseline and response. Reassess tolerance next session and progress assistance level gradually.