Early Mobilization After Left Middle Cerebral Artery Stroke
A 67-year-old man is on day 3 of admission after an acute left middle cerebral artery ischemic stroke. His NIHSS score is 12. He has a dense right hemiparesis with Medical Research Council grade 1/5 at the shoulder and 2/5 at the hip, a right facial droop, and left hemineglect. He can sit with the assistance of two people for 30 seconds but has poor trunk control and falls to the right. Blood pressure is 158/84 mmHg, heart rate 88/min, and SpO2 96% on room air. He is afebrile. He has dysphagia and a nasogastric tube in place. There is 1 cm of right shoulder subluxation. His wife is keen for him to start walking. The stroke team has requested physiotherapy.
1. Prioritize the patient's physiotherapy problems for the next 48 hours. Justify each priority and identify findings that would stop mobilization.
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Priorities
- Trunk control and safe sitting - needed for feeding, wheelchair tolerance, and reducing aspiration risk. Two-person assist for 30 s with rightward collapse is not yet safe for unsupervised sitting.
- Right shoulder protection - grade 1/5 deltoid with 1 cm subluxation means the arm must be supported; avoid pulling it during transfers.
- Left hemineglect - increases falls, wheelchair collisions, and injury risk; needs cueing and environmental anchoring.
- Prevention of deconditioning and DVT - early mobility within safe limits, ankle pumps, hydration review.
- Carer education - wife expects walking; explain that sitting balance and shoulder protection come first.
Stop mobilization if: systolic BP >180 mmHg or <100 mmHg with symptoms, HR <50 or >120/min, SpO2 <92%, fever, new arrhythmia, worsening neurological status, or increasing drowsiness. Also confirm the nasogastric tube is secure before upright sitting.
2. Describe a safe early mobilization session, including positioning, assistance, monitoring, and stopping rules.
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Session
- Check observations and neurological status before starting.
- Use a two-person assist. Sit him at the edge of the bed with feet flat, affected arm supported on a pillow, and the left side anchored with a visual cue.
- Begin with 5–10 min of supported sitting and trunk facilitation, progressing to 20 min only if he remains stable and oriented.
- Use verbal cueing to attend to the left and to keep the trunk upright. Do not use overhead pulleys or pull on the affected arm.
Monitor: BP, HR, SpO2, facial colour, dizziness, and new weakness before, during, and after. Stop if SpO2 falls below 92%, systolic BP changes by more than 20 mmHg with symptoms, HR exceeds 120/min, he becomes dizzy, or new neurological signs appear. Document the session and his response.
3. Explain how you would manage the right shoulder and the left hemineglect during functional training.
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Right shoulder: support the arm in a sling or on a table during sitting and transfers; avoid traction on the hemiplegic arm. Teach scapular setting and gentle pain-free range of motion within available movement. Educate staff and family not to lift the patient by the affected arm. Reassess subluxation and pain daily.
Left neglect: place objects and food on the left side, use verbal and visual scanning cues, and start tasks on the left. Anchor the left arm in view during sitting. Use mirror or video feedback only if it does not increase distress. In wheelchair mobility, cue him to check the left side before moving. Combine neglect training with functional tasks such as washing the left side of the face. Reassess safety each session.