Early mobilisation after right middle cerebral artery stroke with neglect and pushing behaviour
Mrs. L, a 67-year-old retired teacher, is 12 days after a right middle cerebral artery infarct. She has left hemiplegia, mild dysarthria, and left spatial neglect. She can sit unsupported for 30 seconds but needs supervision for transfers; she pushes strongly to the right when sitting and when assisted to stand. Passive left shoulder range is full, but she has 5/10 pain at the left shoulder and a one-finger subluxation; she avoids using the left arm. She is highly motivated to walk and asks daily when she can start. Her husband assists at home and is anxious about falls. The medical team has cleared her for mobilisation. Her medications include aspirin and atorvastatin; blood pressure is stable. She has no other major comorbidities.
1. Prioritise her physiotherapy goals for the next 2 weeks and justify your choices.
Read the worked answer
Priorities for the next 2 weeks are: safe sitting balance and transfers with carer education because falls risk and dependence are immediate; left upper-limb care and positioning to reduce shoulder pain and prevent learned non-use; and beginning task-specific sit-to-stand and stepping practice with midline cueing because she is motivated and medically stable. I would not prioritise walking distance over trunk control and transfer safety, although early mobilisation is appropriate. Using a goal-setting framework, short-term goals might be: sit unsupported for 2 minutes with visual cueing, stand with one-person assistance and a rollator, and complete a transfer with supervision. The neglect and pushing behaviour mean I would build in visual scanning and midline feedback rather than relying on verbal instruction alone. I would also involve her husband in a home programme and falls prevention.
2. How will you manage the left shoulder pain and subluxation during transfers and sitting?
Read the worked answer
Shoulder pain with subluxation after stroke is multifactorial: weakness, poor scapular control, traction, and handling. I would avoid pulling on the affected arm and support it during transfers with a hand under the proximal humerus or axilla, not by holding the hand. Position the arm on a table or lap with the shoulder supported when sitting. A sling may be used briefly for transfers or walking if pain is uncontrolled, but prolonged use can encourage learned non-use, so I would not use it as routine. I would check for signs of complex regional pain syndrome and discuss simple analgesia with the medical team. For subluxation, evidence does not support strapping or routine electrical stimulation as first-line; I would focus on scapular setting, supported reach, and education. Reassess pain and function at each session.
3. What is your plan for early gait training given the pushing behaviour and neglect, and what safety criteria will you use?
Read the worked answer
Gait training should be task-specific and started early, but with a graded plan. I would use a rollator or parallel bars, a gait belt, and one or two assistants initially. Because she pushes to the right, I would use visual midline cues, such as a mirror, tape on the floor, or a laser pointer, and encourage weight shift to the left with her attention drawn to the left side. I would avoid walking when she is fatigued or when neglect is marked, and I would practise sit-to-stand and stepping in short, frequent bouts. Safety criteria: able to sit unsupported for at least 30 seconds, no orthostatic drop, pain no more than 3/10, and two-person assistance for the first stands. I would record Functional Ambulation Category and trunk control, and stop if she becomes unsafe or unable to follow cues.