Adult Hemiplegia - Mr ACA

General Info:

 * 68 year old male
 * Left Anterior Cerebral Artery (ACA) infarct
 * Previously active with no limitations

PT assessment 2 weeks post stroke:
Sensation: Muscle tone (Modified ashworth) PROM MMT Chedoke Stages of Recovery Mobility  Balance  Ambulation 
 * Cognitive status - 30/30 MMSE (though family noticed he doesnt initiate conversation as much)
 * Speech - mild difficulties when fatigued
 * Light touch - 50% correct responses R U/E & L/E
 * Proprioception - 50% correct for R U/E & L/E
 * R U/E - normal
 * R L/E - 2/3 across the board
 * R hip E -             5 degrees
 * R ankle DF -     -10 degrees
 * R hip AB -          10 degrees
 * R knee F -          90 degrees
 * R U/E - 2 across the board
 * R L/E - hip E, hip AB, knee E = 3             hip F, hip AD, knee F, ankle AROM = 2
 * Arm & hand = 3
 * Leg & foot = 3
 * Bed mobility - Independent
 * Transfers - Supervised squat pivot to the left, min assist to the right
 * Sitting Static - Can independently sit for 10 minutes at edge of bed
 * Sitting Dynamic - Decreased equilibrium reactions (Synergy patterns activate in all directions) & unable to produce protective reactions (would fall over if not stopped)
 * Standing Static - Can stand 2 minutes with supervision
 * Standing Dynamic - Displays 10% of excursion of trunk and extremity movements in any direction, then loses balance
 * Min-mod assist x1 for 10m in treatment session (only walks in treatment) with cane in left hand
 * Circumduction w hip hike in in R swing phase
 * Decrease DF in R initial and midswing
 * Decreased knee F in R initial and midswing

Treatment program
He has good cognitive status, suggesting he has good capacity to follow directions and motor learning, though he is 68 years old, so learning may take a bit longer 

1. Improve static & dynamic sitting balance/ endurance - break synergy patterns during equilibrium reactions  2. Improve strength/coordination of R U/E 3. Improve standing balance/ edurance  
 * Might have perception issue (reason for no protective reactions) - teach compensatory approach?
 * Axial compression to increase proprioceptive input
 * Early in rehab phase (2 weeks) would benefit a lot from challenging practice of right arm
 * CIMT might be worthy at this phase
 * Use problem solving techniques that involve concepts of motor learning/ plasticity
 * challenge him to reach/ grasp/ manipulate objects (screw driver --> fork --> toothbrush --> haircomb --> scissors)
 * benefit more from random practice (part practice)
 * Resistance training - repetitive and challenging to point of fatigue (or until he shows signs of abnormal synergies)
 * Improve R ankle DF range (-10, so he cannot stand in neutral position)
 * Increase load through legs

4. Improve gait mechanics (future goal) 
 * Strengthen impaired knee F and ankle DF & hip F - increase to a MMT score of 3, then work on dorsiflexion and knee flexion during initial/ midswing phases + hip flexion
 * 4 point - work on knee flexion + hip flexion
 * Stand swing phase - practice swinging with right leg (resisting R: hip F, knee F, ankle DF)