Stroke Rehabilitation and Discharge Planning for a Patient Who Lives Alone Upstairs
Ms. L, 58, is 18 days after a left middle cerebral artery stroke. Right hemiparesis: shoulder flexion 2/5, elbow extension 2/5, hip flexion 3/5, ankle dorsiflexion 1/5 with two beats of clonus. Berg Balance Scale 34/56; Functional Ambulation Categories 3 (supervised ambulation). She demonstrates mild right hemi-inattention on cancellation testing and reports fatigue after about 10 minutes of activity. She needs verbal cueing to don her ankle-foot orthosis. Her home is a two-story house with six steps to enter and the only full bathroom upstairs; her husband works 12-hour shifts and is home mainly at night. MMSE 27/30. Today's BP 138/84, resting HR 78.
1. The team asks for your discharge recommendation. What do you recommend, and how do you justify it?
Read the worked answer
Recommendation: not home alone during the day without modification. Support a short-term stay at a skilled facility or a home discharge only with a structured plan that neutralizes the stairs, the upstairs bathroom, and the unsupervised hours.
Justification - match the data to the environment:
- Berg 34/56 and FAC 3: she walks only with supervision. Supervision is not available from 7 a.m. to 7 p.m., which is the majority of her waking day.
- Six steps to enter plus the only full bathroom upstairs: this is a daily, unavoidable requirement, not an occasional barrier. Without rails, trained stair technique, and standby assist, this is a fall waiting to happen.
- Hemi-inattention plus need for AFO cueing: both reduce safety awareness and carryover. A patient who forgets the orthosis when supervised will not don it reliably when alone.
- Fatigue at 10 minutes: limits how much she can self-manage in a day and raises fall risk later in the day.
Practical alternatives to present to the team: bedside commode and a main-floor sleeping setup, durable medical equipment (grab bars, rails, raised toilet seat), and home health or day rehabilitation if home is chosen. Frame this as a shared team and family decision with your assessment as the physical therapy input, and document what would need to change for home to be safe.
2. She has 14 days of therapy left. Which three interventions do you prioritize, and what do you deliberately deprioritize?
Read the worked answer
Prioritize function that her discharge environment demands:
- Gait and AFO training with fading cues. Practice donning the orthosis as a distinct, timed task so it becomes a habit rather than a therapist-dependent step. Progress supervision only as Berg items improve.
- Stair negotiation and bathroom/household mobility. Train on an actual six-step flight with a rail; train toilet transfers and a main-floor setup. This is where her discharge will succeed or fail.
- Hemi-inattention and safety awareness training woven into every task. Visual scanning, cueing to look right, and having her identify hazards herself rather than having you point them out.
Manage fatigue rather than ignoring it: short bouts with scheduled rest, work-rest intervals, and higher-demand tasks early in the session. Build endurance by density, not by session length.
Deliberately deprioritize: isolated high-repetition distal strengthening and body-weight-supported treadmill work. Ankle dorsiflexion at 1/5 with clonus will not resolve in two weeks, and treadmill training in a harness does not transfer to her six steps and upstairs bathroom. Spend the limited sessions on the tasks she must perform.
3. Her husband asks why she still needs the brace and wants to start practicing stairs without it so she "gets used to it." How do you respond?
Read the worked answer
Answer with the specific findings, not with policy.
Say, in plain terms: her ankle dorsiflexion is 1/5 with clonus, meaning she cannot actively pick up her toes. Without the orthosis, the foot drops and the toe catches on the step edge - the exact mechanism that causes falls on stairs. She also requires verbal cueing to put it on, which tells you the habit is not yet automatic.
Offer a compromise that keeps you in control of the risk:
- Continue the AFO for all stair and community-level practice.
- Trial short, supervised, level-surface walking without the orthosis while you measure foot clearance, toe drag, and knee hyperextension - data, not opinion, decides when the brace comes off.
- Set a concrete criterion with the family for revisiting: independent donning plus safe clearance on the trial.
Address the underlying concern: he is worried about dependence. Acknowledge that, and redirect it toward the AFO donning practice and the home setup plan, which are the things that will actually reduce his burden.