Day Three After Right MCA Infarct: Hypertension, Left Neglect and Mobilising With a Language Barrier
A 71-year-old right-handed woman is reviewed on day 3 after a right middle cerebral artery infarct on the stroke unit of a MOH hospital; she was outside the thrombolysis window. Left upper limb power is 1/5 and left lower limb 2/5. She has a left homonymous hemianopia and consistently neglects the left side of her face, plate and clothing. She sits with the assistance of two people, drifts leftwards and needs constant cueing. Blood pressure 172/96 mmHg on amlodipine, pulse 88 regular, SpO2 96% on room air, capillary glucose 11.2 mmol/L, NIHSS 16. She has a left peripheral cannula and an indwelling urinary catheter. Medications: aspirin, atorvastatin, metformin, enoxaparin 40 mg subcutaneously. She speaks Kuwaiti Arabic only and her daughter-in-law translates. The medical note reads 'mobilise as tolerated'.
1. Is it safe and appropriate to mobilise her today? Justify your decision and describe exactly what you would do in the first session.
Read the worked answer
Yes - but the decision is about dose and monitoring, not whether.
- Day 3 is outside the window in which harm has been demonstrated. The AVERT trial found that very early, higher-dose mobilisation started within 24 hours of stroke did not improve and probably worsened 3-month outcome; that is an argument against aggressive, frequent out-of-bed activity in the first day, not against mobilising a stable patient on day 3.
- Stability screen before starting: no deterioration in neurological status in the last 24 hours, no unstable cardiac rhythm, blood pressure below roughly 180/110 mmHg without symptoms, SpO2 acceptable, glucose 11.2 mmol/L acceptable unless she is drowsy.
- Dose: dangle at the bed edge with two assistants plus a hoist nearby, 5–10 minutes, observations before, during and after; two short sessions rather than one long one. Do not treat through a symptomatic rise in blood pressure, new headache, drowsiness or a systolic fall greater than 20 mmHg.
- Escalate rather than persist: if she cannot tolerate sitting because of symptomatic hypertension, document it and speak to the medical team. Uncontrolled blood pressure on day 3 is a medical problem, not a physiotherapy failure.
- Reasoning: the risks of immobility (DVT, atelectasis, deconditioning, pressure injury) are real on day 3, but the dose–response evidence means early activity must be short, graded and monitored.
2. How would you translate the finding of left neglect into your handling and cueing during sit-to-stand and early standing?
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Treat neglect as a performance problem embedded in every transfer, not as a separate cognitive session.
Mechanism: left neglect after a right MCA infarct reflects disrupted orienting of attention to contralesional space; her leftward drift in sitting is a postural expression of it, not non-compliance or poor balance alone.
- Engineer the environment: stand on her left, place the chair so she must turn left to see the target, put the call bell and water on the left, and anchor her left hand on the plinth before standing.
- Cue with space rather than words: a bright strip on the left of the bed, a target on the left wall, and short instructions ('look left, then stand'). Long verbal streams worsen performance in neglect.
- Limb activation: active left-hand reaching or holding a cone before and during sit-to-stand increases attention to that side.
- Scanning training: systematic left-to-right search for targets, then apply it to walker placement and doorway navigation.
- Keep two-person assistance until trunk control is consistent; she will not reliably judge the neglected side, so 'being careful' is not a strategy.
- Reassess functionally (dressing, wheelchair placement), not just with paper-and-pencil tests, and record what cueing actually worked.
3. Which outcome measures would you choose, and how would you handle consent and the language barrier with the daughter-in-law translating?
Read the worked answer
Measure trunk control and activity, not stroke severity.
- Trunk Impairment Scale: static and dynamic sitting balance plus coordination, with a low floor and good responsiveness in the first weeks - it targets exactly the problem you are treating.
- Postural Assessment Scale for Stroke: covers lying, sitting and standing, responsive early after stroke.
- Functional Ambulation Category once she stands; Rivermead Mobility Index for mobility milestones; Barthel Index for activity limitation.
- A simple cancellation or line-bisection test plus a functional observation to document neglect at baseline and discharge.
- Do not use NIHSS as a physiotherapy outcome; it measures stroke severity and will not reflect your intervention.
Language and consent: her daughter-in-law translating is common but not ideal - family members summarise, filter and may protect her from bad news, and consent obtained through a relative is weaker consent. Ask the ward for a formal Arabic interpreter for the consent conversation and for explaining the measures, confirm understanding with teach-back, and document who consented, in which language, and how understanding was checked. Use validated Arabic versions of measures where they exist; if only an English version is available, state the adaptation and interpret scores cautiously. Also confirm the daughter-in-law is willing to translate and is not being asked to make decisions on the patient's behalf.