Subacute Management Following a Basal Ganglia Hemorrhage Using PNF and Lower

Extremity Strengthening in Combination with Best Physical Therapy Practices

Author: Jocelyn Braun

Research Advisor: Karen E.H. Grossnickle, PT, DHSc

Doctoral Program in Physical Therapy

Central Michigan University
Mount Pleasant, Michigan

April 21, 2020

Submitted to the Faculty of the

Doctoral Program in Physical Therapy at

Central Michigan University

In partial fulfillment of the requirements of the

Doctorate of Physical Therapy

Abstract

Background and Purpose

Stroke is the 5th leading cause of death in the United States, with 795,000 people each year

having a stroke. The subacute physical therapy episode of care for a patient who had a basal

ganglia stroke is discussed, with this treatment including proprioceptive neuromuscular (PNF)

and lower extremity exercises as well as other best physical therapy practices.

Case Description

A 45-year old male was referred to a subacute nursing facility (SNF) for therapy services,

including physical therapy (PT) due to impairments following a basal ganglia stroke. The patient

was limited in his ability to complete transfers and bed mobility independently, as well as being

able to ambulate without assistance. In addition, the patient showed deficits in lower extremity

strength, particularly the right lower extremity, as this was his paretic side. Interventions for this

patient included functional mobility and gait training best practices as well as PNF and lower

extremity strengthening exercises to help improve his mobility and decrease his need for

assistance for these tasks.

Outcomes

The patient showed improved scores of his Postural Assessment Scale for Stroke and the

Function in Sitting Test outcome measures following treatment. The patient had limited change

in his need for assistance for sit to and from stand and supine to and from sit but showed

improved quality in these transfers. The patient was able to progress his transfer from the

wheelchair to and from his bed as well as becoming more independent in ambulation. The patient
showed improved gait quality and speed as well as the ability to take steps with his right lower

extremity.

Discussion

Current literature does not offer the best treatment options for a patient following a basal ganglia

stroke in the subacute stage. While there are guidelines provided about the best practices, in

regard to gait training and mobility, there is not clear evidence as to how PNF and lower

extremity strengthening exercises may benefit patients following a stroke when combined with

these practices. From the outcomes of this case report, it can be suggested that PNF and lower

extremity strengthening exercises can be beneficial to patients following a stroke in the subacute

stage of treatment.
Background and Purpose
Someone will have a stroke every 40 seconds in the United States, totaling 795,000

people per year. Stroke is the fifth leading cause of death in the country.1 There are two main

types of stroke: ischemic and hemorrhagic. An ischemic stroke is when there is blockage in the

blood vessels of the brain from blood clots or particles that build up and cut off the blood

supply.1 A hemorrhagic stroke is when there is a buildup of blood that damages brain tissue due

to a bursting of a blood vessel in the brain.1 There are two types of hemorrhagic stroke:

intracerebral and subarachnoid. An intracerebral hemorrhage is more common and occurs when

there is blood surrounding tissue due to an artery in the brain bursting.1 A subarachnoid

hemorrhage is when there is a bleed in the brain that occurs between the brain and the tissue that

covers the brain.1 Common causes of hemorrhagic stroke are high blood pressure and aneurysms,

bulges in arteries that can burst when they are stretched.1

One of the areas of the brain that a hemorrhagic stroke may affect is the basal ganglia.

Located deep in the brain is a group of neurons called the basal ganglia that are responsible for

perception, judgement, and movement. Because of the basal ganglia’s role in movement, after a

stroke movement disorders are more likely to occur when the basal ganglia are affected

compared to when other brain structures are damaged.2 There is a three times greater risk for

developing movement disorders when the basal ganglia are involved compared to if the stroke

occurs on the outer surface of the brain.2 The movement disorders that result from damage to the

basal ganglia are usually unilateral and will occur on the contralateral side of the lesion. Some of

the movement disorders that may occur following basal ganglia stroke include chorea, limb

shaking, tremor, dysarthria, Parkinsonism, dystonia, stereotypic, and asterixis.2 Other

1
impairments that can arise following a stroke include sensation loss, cognitive, perceptual, and

language deficits, and motor deficits.3

To help address the impairments following a stroke, patients are usually referred to a

rehabilitation center following their stay in the acute care hospital. Two of the common

rehabilitation settings for patients with a stroke are inpatient rehabilitation facilities (IRFs) or

skilled or subacute nursing facilities (SNFs).4 In an IRF, the patient must receive 3 hours of

therapy a day between speech language pathology (SLP), occupational therapy (OT), and

physical therapy (PT) at least 5 days per week according to Medicare guidelines.5 Patients who

are discharged to IRFs are usually those who are expected to make significant improvements in

their abilities within a reasonable length of time and are expected to return to a community

setting.4 Patients that are discharged to SNFs will usually receive about 1 hour of therapy on

most days of the week from disciplines, such as OT, PT, and SLT that find that the patient would

benefit from their services under the Medicare skilled nursing benefit.4 Those who are

discharged to a SNF may be expected to not return to a community setting or whom providers

may feel that they may only partially recover from their stroke.4

The IRF and SNF rehabilitation sites both include a rehabilitation team that will provide

care to the patient following the stroke. This team usually consists of members from OT, SLT,

PT, neurology, and nursing professions. These members of the team are usually under the

supervision and lead by a physiatrist or neurologist.4 A part of this rehabilitation team that helps

to improve upon the functional deficits is a physical therapist. Physical therapists help to

improve upon motor control, in activities such as walking and other functional mobility.3

Following a stroke, physical therapy accounts for about 70% of the time that a patient will spend

doing therapeutic activities.6 The role of a physical therapist is to determine what motor function

2
impairments exist following the stroke and then design a treatment plan with different

interventions to address these impairments. Some of these interventions may include: improving

strength of voluntary motion, teaching methods to perform functional tasks such as walking,

transfers, and activities of daily living, patient and family education, and administering adaptive

equipment such as a walker or an ankle-foot orthotic (AFO).6

One of the main impairments that exists following a stroke, is reduced functional

mobility, with tasks including stair climbing, walking, transferring between surfaces, using a

wheelchair, or standing up and sitting down, all being potentially impaired. Common physical

therapy practices and guidelines from the American Stroke Association suggest that parameters

for mobility training include functional task practice, activity specific exercises, exercise that is

continuously more difficult and challenging, practice that has sufficient frequency, intensity, and

duration.4,7 It has been found that with no intervention or with no interventions involving walking

compared to interventions that involved treadmill training without body weight support there was

improved walking distance and speed following the interventions.8,9 In a study completed by

DePaul and associates,10 they compared bodyweight supported treadmill training with motor

learning over ground walking training. Those in the treadmill training group walked with a

normal gait pattern at high intensities. The motor learning group completed different activities

during their training including long walks, curbs, stairs, short walks, transitions which was sitting

to standing then walking, obstacle avoidance, and changes in direction. Both groups were treated

over 5 weeks with 15 total sessions during this time.10 The outcomes of this study identified no

significant difference between the two groups in their walking ability outcomes in walking

speed, the 6-Minute Walk Test, or the Functional Balance Test.10 There is also further evidence

to support that traditional gait training methods are equally effective in improving transfer and

3
walking ability when compared to body weight supported treadmill training from Hoyer and

associates.11

As mentioned, decreased trunk control, gait abnormalities, and deficits in balance can

occur following a stroke. Proprioceptive neuromuscular facilitation (PNF) can help to improve

control the pelvis which is important for gait mechanics, ability to maintain balance, and trunk

control.3 PNF is a technique used to facilitate motor performance that involves resistance to

movement in diagonal or spiral directions. Using this technique it is believed that there is a

greater neuromuscular response of proprioceptors that helps to facilitate muscle activation.3 In a

study completed by Ribeiro and associates,3 the authors found that a training program consisting

of PNF exercises for patients with chronic strokes was beneficial in improving functionality. The

exercise protocol in this study consisted of gait and mobility related exercises in combination

with PNF methods for 4 weeks with patients receiving treatment 3 days per week for 30 minutes

each time. Some of these exercises consisted of weight shifting anteriorly, posteriorly, and

laterally; dissociation of the waist in sidelying, sitting to rising, and gait with a focus on manual

contacts, stretching, and resistance while performing these exercises.3 After treatment was

completed, it was found that patients saw improvements in their abilities to complete transfers,

walk, bathe, dress themselves, and complete stairs. There were also improvements in upper and

lower limb function.3 Another study compared PNF with traditional physical therapy methods

such as stretching, side-lifting of the pelvis, bridging, and active and passive movements of the

hip.12 The PNF group received 3 PNF techniques: slow reversal, agonistic reversal, and rhythmic

initiation with pelvic anterior elevation and posterior depression.12 The results showed that those

in the PNF group had improved gait parameters and functional mobility. The authors found PNF

to be a good technique to add to a physical therapy program following a stroke.12 Using PNF to

4
improve mobility has been shown to have positive effects. It can be a critical component of a

rehabilitation program following stroke.3,12

Another method of training, that has been shown to be influential following a stroke, is

lower extremity strengthening exercises. According to guidelines for adult stroke rehabilitation

and recovery,4 there is strong evidence to support that lower extremity strengthening exercises in

patients who have had a stroke more than 6 months ago, improved gait speed, functional

outcomes, strength, and quality of life.13 Akbari and Karimi14 found evidence to support reduced

lower extremity spasticity and improved lower extremity strength for patients post stroke 6

months. In this study, both the exercise and control group received treatment 3 times per week

for 4 weeks for 3 hours at a time. The intervention groups received treatment from the balance,

strengthening, and functional protocol while the control group received treatment from the

balance and functional protocols.14 For the balance component, exercises consisted of standing

and sitting balance exercises, gait exercises, and aerobic fitness exercises. The functional

component exercises consisted of movements such as squatting, bridging, toe and heel walking,

alternating flexion and extension exercises for the lower extremities, and hiking and drooping

exercises. The strengthening component of the program focused on strengthening muscles used

in the gait cycle in the frontal and sagittal plane using the patient’s one-repetition maximum to

determine the intensity of the exercises.14 Authors found that, in the paretic lower extremity, all

muscle groups tested showed improved strength in the intervention group while in the control

group there was not improved strength in the hip or knee extensor muscles.14 The authors found

decreased tone in the quadriceps for the intervention group, but not in the control group; both

groups did see a decrease in tone in the gastrocnemius.14 Scianni and fellow researchers,15

hypothesized that lower extremity strengthening exercises would be beneficial for patients who

5
have had a stroke, greater than 6 months from the time the study was completed, in improving

their quality of life. Evidence then supports strengthening exercises to improve activity and

strength following a stroke; however, there is not a great deal of evidence to support what

intensity or frequency of exercise is best. The Scianni et al study design15 combined walking

exercises with strengthening exercises that consisted of squatting, stepping onto a block, standing

on one leg, stepping forwards and backwards, and stepping sideways. Participants exercised 3

times per week for 10 weeks. The experimental group was compared to the control group that

only received walking training. From this study, there is evidence to support that lower extremity

strengthening is beneficial following a stroke.15

To the author’s knowledge there is not currently any evidence that offers a specific

treatment plan for a patient that is in the subacute time frame following a basal ganglia stroke.

Much of the current literature supports the use of PNF exercises or lower extremity strengthening

exercises to improve mobility and quality of life 6 months after stroke, which is considered to

then be in the chronic stage.4,14,15 There is evidence to support the best gait training practices to

help improve walking and the ability to transfer immediately following stroke.7,8,9 These methods

consist of traditional gait training as well as gait training that includes functional task practice,

activity specific exercises, and there needs to be sufficient frequency, intensity, and duration.4,7

While there are current best practices to support some aspects of rehabilitation following a

stroke, there are other supplemental exercises, such as PNF and strengthening exercises, that may

be beneficial in improving outcomes for patients following a stroke.

The purpose of this case report is to identify the effects of lower extremity strengthening

exercises and pelvic PNF patterns when combined with best practices for gait training for a

patient who sustained basal ganglia hemorrhages with resultant impaired functional mobility.

6
The purpose was to determine if the patient would see improvements in the ability to walk and

transfer independently.

Prior to preparing this report, assent was obtained from the patient and consent was

obtained from the patient’s mother. All information contained in this case report meets the

Health Insurance Portability Accountability Act (HIPAA) requirements of the clinical agency for

disclosure of protected health information.  This case report was completed under the direction

of the Department of Physical Therapy and with the oversight of the College of Graduate Studies

at Central Michigan University.

Case Description
Patient History & Systems Review

The patient was a 45-year-old male who was referred to a SNF for physical therapy 9

days after sustaining a left basal ganglia hemorrhage. At the time of the initial encounter at the

acute care hospital, he presented with expressive aphasia and significant oropharyngeal

dysphagia. Prior to this event, the patient was living independently on his own and worked full

time as a radio disc jockey. He was independent with ambulation in the community as well as

driving and did not seem to be limited in any functional matter. Due to the patient’s impairments

in expressive and receptive language, more details about his past lifestyle and impairments were

not able to be obtained from the patient. The patient’s past medical history was significant for

hypertension, obesity, and mixed dyslipidemia. Medications that the patient had been currently

prescribed were enoxaparin sodium, lisinopril, magnesium hydroxide, and thiamine.

During his time in the acute care hospital, the patient spent time in the intensive care unit

(ICU). Also, during this time, the patient was treated by the physical therapy team there. Full

7
details of their evaluation and treatments are not known, but the team chose to discharge the

patient to a SNF. At the SNF, the patient was initially examined by another therapist, 9 days after

the basal ganglia hemorrhage occurred, and on the patient’s 1st day at the SNF. Please refer to

Figure 1 for a timeline of the patient’s course of treatment of therapy. Please refer to Table 1 for

results at the time of the initial examination, reexamination, and the end of treatment. This case

report will cover the time from the reexamination to the end of treatment with this patient by the

current author. Prior to the reexamination, the patient had received treatment from a different

physical therapist at the SNF. At the initial examination, the patient needed maximum assistance

of two people for all functional mobility and was unable to attempt ambulation. The patient

participated in therapy at the SNF, which occurred from the 1st day at the SNF to the 39th day at

the SNF. This physical therapy consisted of activities to improve the patient’s independence for

bed mobility and transfers including sit to and from supine and sit to and from standing. Physical

therapy treatment also consisted of PNF for the lower extremities and ambulating in the parallel

bars for short distances with assistance for trunk control as well as facilitation of the right lower

extremity to initiate swing phase. The patient was able to ambulate distances of about 8 feet, the

distance of the parallel bars, while using left upper extremity support from either the parallel bars

or on the therapist. The patient used a Rifton TRAM (TRAM, Community Products, LLC,

Rifton, NY) for gait training activities, but the use of this device was discontinued due to the

patient being uncomfortable in the machine with the sling that was used and not feeling safe

while using the machine. Several attempts of using the TRAM had been trialed, but did not work

sufficiently with this patient, and he refused further training in the device. About 2 weeks after

the initial examination, the Function in Sitting Test (FIST)16 was completed with the patient and

he scored 29 of 56 possible points. Two weeks after this date, the FIST16 and the PASS17 were

8
reassessed again and the patient scored 22 of 36 points on the PASS and 37/56 points on the

FIST. This case report starts at the time of the re-examination, which was 40 days after the start

of the patient’s care at the SNF. Please refer to Figure 1 for a timeline of the treatment that the

patient received.

Clinical Impression #1

The patient was chosen to be discharged to a SNF from the acute care hospital due to the

patient’s cognitive impairments as well as his decreased functional abilities at this time. The

patient would not have been able to tolerate at least 3 hours of therapy, which is one of the

admission requirements to be discharged to an IRF. Another reason why the patient was

discharged to a SNF was because it was not known whether he would be able to discharge to a

community setting following rehabilitation, which is a common requirement when discharging to

an IRF. Based on the patient’s abilities, both cognitively and physically, it seems that the SNF

was the right recommendation for this patient.

When looking at the functional level of the patient when he had started at the SNF

compared to where he was at the reexamination, the patient had made many functional

improvement towards becoming independent, but there were still areas in which he could

improve upon as well as other areas in which he could start working on, such as gait, to gain

even more independence. The patient could progress towards being independent for transfers and

progress towards being able to ambulate with an appropriate assistive device of least restriction.

The FIST16 and the PASS17 will be reassessed, to determine if there have been

improvements in the patient’s functional mobility and transfers. The patient’s need for assistance

with transfers and gait will also be reassessed along with his gait, strength, and cognition. These

9
assessments will also be completed at the time treatment is complete to further examine if there

have been improvements from the time of reassessment.

This patient makes a good candidate for a case report because he has shown great

improvement with physical therapy in a short amount of time, but he still has functional deficits

that he can improve upon. The patient shows potential in his ability to further progress towards

the goals that have been set for him as well as going beyond these goals to become more

independent for ambulation and transfers. Research has shown that PNF and lower extremity

strengthening is beneficial in improving functional mobility for patients that have had a stroke.

This patient is appropriate for this type of treatment in addition to other types of typical physical

therapy treatment to see if it can make an impact in the progress the patient can make in his

independence for functional mobility.

Reexamination

Functional Mobility. At the time of the reexamination, the patient presented to the therapy gym

in his wheelchair. To assess the amount of assistance the patient needed with each task, the

Functional Independence Measure (FIM)18 definitions of levels of assistance were used. Please

refer to Table 1 for definitions for each level of assistance. The FIM has been shown to have

adequate to excellent content validity and excellent intrarater reliability for those who have had a

stroke.19,20 The patient was able to transfer with a slideboard to and from his wheelchair with

minimum assistance18 when transferring to his left side, which was the non-paretic side. Also,

with minimum assistance,18 he was able to complete sit to stand transfers, with him relying

heavily on his left extremity for support to pull himself into standing. Once standing, he

continued to rely heavily on his left upper extremity for support to help himself remain upright,

and minimum assistance18 for steadying the patient once standing. He was able to complete

10
lateral weight shifting in standing with left upper extremity support on the parallel bars and

minimum support for steadying assist to maintain himself in an upright position while

performing weight shifting. When performing weight shifting, the patient needed additional

physical assistance of another therapist at his right knee, to keep it from buckling as he put

weight on his right leg and verbal cuing to shift towards his right side, as the patient was

apprehensive at times about shifting weight towards this side.

Ambulation. At the time of reexamination, the patient ambulated 8 feet in the parallel bars, which

was the entire length of the parallel bars. The patient used his left upper extremity on the parallel

bars for support and had minimum assistance18 on one person to help control his trunk during

ambulation. Moderate to maximum assistance18 of another person was needed to help the patient

take a step with his right lower extremity. This person had their hands on the anterior side of the

patient’s lower leg at his ankle and at the posterior side of the patient’s leg, proximal to his knee

joint. The patient needed verbal cuing for initiating gait as well as for sequencing steps during

ambulation. After ambulation, the patient had increased fatigued, and further ambulation was not

able to be done for more trials or for longer distances. During ambulation, another person was

used for a wheelchair follow-up in case the patient was to lose balance or wanted a place to sit.

FIST. At the time of reexamination, the FIST16 was completed with the patient. The FIST

contains 14 items that test sitting balance of the patient. The patient is scored on a scale from 0-4

with each value representing a varying amount of independence, with 4 being independent and 0

being dependent.16 At the time of reexamination, he scored 45 of 56 points. Please refer to Table

1 for a progression of the scores of the FIST throughout treatment. For the FIST, a higher score

is desired, and it indicates that the patient is independent in static and dynamic sitting balance

tasks. The FIST has been shown to have excellent intrarater and interrater reliability (r=.99)

11
when used with patients that have had a stroke.21 It has also been found to have excellent test-

retest reliability (r=.97) for those who have had a stroke.21

PASS. The PASS17 is another functional assessment that was used to assess this patient’s balance

in three different positions: lying, sitting, and standing. This test has a 4-point scale ranging from

0-3 with each value representing a different amount of independence: a 0 indicates dependence,

while a 3 indicates independence in completing the task.17 At the time of reexamination, he

scored 23 of 36. Please refer to Table 1 for a progression of the scores of the PASS throughout

treatment. For the PASS, a higher score is desired, and it indicates that the patient has higher

independence for sitting balance in different positions and the ability to change positions. The

PASS has been shown to have excellent interrater reliability (r=.98) for the total score of the test

for those who are in the acute or subacute stage of sustaining a stroke.17 There has also been

found to be excellent test-retest reliability for the PASS (r=.97).22

Strength. Right lower extremity strength was assessed with the patient lying in his bed with the

head of the bed elevated to about 30°. Strength was assessed using manual muscle testing

(MMT) techniques.23 Lying down with the head of the bed elevated is not the standard testing

position as described by Reese.23 For patients that have been in the intensive care unit, such as

this patient, MMT has been shown to have adequate to excellent interrater reliability (r=.66-1.00)

for the muscles in the lower extremity.24 The patient’s left lower extremity strength was grossly

4/5, meaning that the patient was able to withstand moderate resistance from the clinician.23

There was more variability of the patient’s right lower extremity in muscle grades. In the supine

position, with gravity eliminated, the patient was able to initiate hip flexion and knee flexion for

the full range of motion (ROM) when performing both motions together, but the patient had

difficulty with isolating individual joint motions. The patient was not able to initiate dorsiflexion

12
active range of motion (AROM) in supine or in sitting. Because the patient had full AROM in

supine, he was moved to sitting at the edge of the bed. Seated at the edge of the bed, the patient

also had difficulty with initiating isolated joint movements for hip flexion and knee flexion but

was able to achieve close to full range for both of these movements when they were performed

together. In sitting, patient able to initiate active right knee extension for half of the range of

motion when performing active knee extension at the same time on the left lower extremity. The

patient was not able to withstand any resistance for any of these joint motions. When assessing

strength, there was no obvious tone of the patient’s lower extremities, so a formal tone

assessment was not performed. See Table 2 for full assessment of muscle strength for this patient

throughout treatment.

Sensation. At time of reexamination, light touch sensation of the right lower extremity was found

to not be intact. Light touch sensation was assessed by the therapist gently touching dermatomal

patterns on the patient’s lower extremities. The therapist first tested the touching sensation on the

patient’s left arm, an area that was known to have intact sensation so that the patient knew what

the sensation should feel like it.23 As each area was being touched, the patient was asked if he

could feel the area that was being touched.23 In the literature there is not information regarding

the reliability and validity of these testing procedures. However, it has been found that there is

excellent interrater reliability for this method of sensation testing.25

Cognition. The patient was asked questions regarding the current date, his current location, the

reason why he was in the hospital, and his birthdate.26 The patient was able to identify himself by

his name and other familiar people that work at the hospital. He was able to identify that he was

at the SNF for rehab but could not identify name of the hospital. He knew the city that he was in.

13
Additionally, he was not able to identify the correct day of the week, current month, or year.

There has been no reliability or validity data found for these cognition questions.

Clinical Impression #2

Based on the patient’s progress thus far, it seems as though the decision to transfer him to

a SNF was the right decision. The patient was taking longer to reach his physical therapy goals,

and still had deficits in cognition. While the patient was receiving OT, SLP, and PT for almost 3

hours in total, he had difficulty with being able to tolerate this amount of therapy in one day, and

would not have been able to tolerate the intensive therapy that is required when being transferred

to an inpatient rehabilitation center.

At the time of the reexamination, the most limiting factor for the patient was his dislike to

get into the position of supine to perform the FIST.16 The patient had difficulty on this day, and

he had exhibited tolerance issues in the past for positions such as supine and performing bed

mobility, which are positions that are required for this test. He had some hesitancy when trying

new things and needs to be encouraged to try something new for the first time. When given time

to adapt to the activity, the patient is willing to try it and puts forth good effort. This is something

that was also seen with the therapists that were treating the patient prior to the current author.

Based on the patient’s progress since the time of the initial examination, he should be able to

continue to improve upon his functional mobility and become more independent. The patient has

the potential to be able to ambulate with an assistive device of least restriction, transfer

independently, and improve his balance in both sitting and standing.

One of the therapy goals for the patient is to be able to transfer from the bed to and from

the wheelchair, without an assistive device, with stand by assistance. Other goals are for the

14
patient to be independent in performing bed mobility and supine to sit and sit to supine transfers.

Additionally, the goal is for the score of the PASS to improve to at least 28 out of 36, and for the

FIST to improve to 50 out of 56, so that the patient is as close as possible to independent. For

ambulation, the goal is for the patient to be able to walk for 25 feet with the use of a large base

quad cane with stand by assistance so that he could walk in a living environment alone following

discharge. A variety of different treatment approaches including electrical stimulation, PNF, and

lower extremity strengthening will be used to facilitate the patient to be able to reach these goals,

along with conventional physical therapy methods of gait training and transfer training. Physical

therapy at the SNF was being planned for an extended period until the patient would be able to

return to his mother’s home at a level close to independent as possible per the current discharge

plan. This patient is a good candidate for a case report because he still has multiple impairments,

even after 4 weeks of physical therapy intervention, and has the ability to improve upon his

current level of function.

Interventions

The plan of care was for the patient to be treated 5 times per week for 4 weeks for 55

minutes at each session with the patient being treated by the same therapist at each session.

During this time, the patient was also receiving OT that was primarily focusing on the patient’s

right upper extremity and his ability to do functional activities of daily living (ADLs) such as

bathing and dressing, as well as receiving SLP treatment for dysphagia and aphasia. Physical

therapy treatment consisted of therapeutic exercises, therapeutic activities, gait training,

electrical stimulation, and neuromuscular re-education. The therapy sessions were split between

performance in the therapy gym or in the patient’s room based on what type of interventions

were being performed on a given day. Interventions were selected to improve transfers

15
independently, to progress towards ambulation independently with the least restrictive assistive

device, and to improve function of the patient’s right lower extremity. Treatment provided in this

case report is being reported from the time of reexamination. Please refer to Table 3 for a list of

treatments provided during each session.

Therapeutic Exercises. Therapeutic exercises were selected to facilitate weight-bearing through

the patient’s right lower extremity and to strengthen both lower extremities. Exercises were

primarily done in standing with the patient in the parallel bars so that the patient had upper

extremity support while standing. He was then progressed to using therapist support for standing

upright and then support from an assistive device to maintain standing upright while performing

exercises. Support from the therapist was utilized because it caused the patient to rely on a more

unstable surface and it challenged him to be less reliant on an external surface for support while

standing. These exercises started out as the patient performing mini squats to facilitate weight

bearing in both lower extremities with patient progressively being able to perform deeper squats

with less assistance and with weight bearing distributed more equally between the right and left

lower extremities. The patient also performed toe taps and step-ups onto steps of different

heights as it takes more strength to raise the leg onto a higher surface and more weight bearing

for the opposite extremity to support the non-weight bearing limb.14 Over the course of

treatment, when hip abduction and adduction exercises were being performed, the patient

demonstrated increased AROM with the patient being able to actively control more of the range.

When the therapist gave resistance manually to the patient, the patient demonstrated decreased

ability to move against the resistance on the right compared to the left side. Resistance was given

at the lateral or medial aspect of the distal thigh depending on if abduction or adduction was

16
being performed. During times when the patient practiced stepping with the right lower

extremity, he would lean his trunk posteriorly to advance the right leg forward.

Therapeutic Activities. Transfers were also included in the plan of care for this patient. The

patient needed minimum assistance for transfers and was using a slideboard to complete most of

his transfers at the onset of this case report. He was first progressed to using a hemi-walker for a

stand pivot transfer from his wheelchair to other surfaces such as his bed, commode, or a mat

table in the therapy gym. He was then progressed to performing the stand-pivot transfer without

an assistive device, but with assistance from the therapist. The decision to progress the patient to

not using an assistive device for the transfer was made when the patient when not actively using

the hemi-walker for support. He was able to maintain good upright standing balance without loss

of balance and did not need increased assistance from the therapist to complete the transfer. At

the time of the 12th session, caregiver education was provided to the nursing staff for stand pivot

transfers with the patient so that the use of the slideboard could be discontinued for transfers. It

had been reported to the therapy staff that the patient was refusing to use the slideboard with

nursing staff after he had been practicing the stand pivot transfer during therapy so the decision

was made at this point to teach the nursing staff how to complete the transfer with the patient.

Over the course of treatment, the patient was also able to remove and place his right arm onto

and off of the platform walker while completing sit to and from standing transfers.

Gait Training. Gait training was also performed as part of the plan of care for this patient. Due to

the patient not liking using the TRAM, gait training was started in parallel bars with the patient

needing minimum assistance18 of one person for trunk control while another therapist facilitated

the patient in initiating right step length because the patient was not able to actively do this on his

own. At first, the patient used left upper extremity support on the parallel bars and then he used

17
support on the therapist. With support from the therapist, the patient had decreased gait speed,

smaller step lengths on both sides, and a less reciprocal gait pattern. The patient was then

progressed to using a hemi-walker for ambulation. Progression was made on the observation that

the patient was not relying on the therapist as much for support during ambulation, and when

trialing the hemi-walker, he did not need more support to maintain balance than he did while in

the parallel bars. He needed the same amount of assistance for both his trunk and the right lower

extremity as he did in the parallel bars. During this time, the occupational therapist wanted to

work on facilitating weight bearing through the right upper extremity, so a front-wheeled

platform walker was used with the patient needing the same level of assistance. During therapy,

the patient was also able to progress towards walking longer distances as well as completing

turns during ambulation. The patient would become frequently distracted during therapy sessions

in the therapy gym, and gait training was frequently done in a quiet hallway to help the patient to

focus on the gait training task. During ambulating longer distances the patient, at times, became

frustrated and would take standing rest breaks. At these times, the patient was encouraged to use

deep breathing to help calm himself down as well as refocusing on a target that was placed for

the patient to have a visual representation of where his goal was to how far that the therapist

wanted him to walk.

During the 4 treatment sessions when gait training was not done it was due to the patient

refusing to complete gait training usually due to the patient being too tired. During his course of

physical therapy, the patient was also receiving OT and SLP treatment sessions. If these sessions

took place before PT sessions, then the patient at times would have difficulty participating and

treatment had to be provided based on what the patient was willing to do each day. When starting

to ambulate with the platform walker, the patient required assistance with weight shifting to both

18
the right and left sides to help clear the opposite leg during its swing phase. As the patient

progressed, less assistance was needed for this weight shifting to occur. The patient also needed

assistance for initiating and moving the right leg through the swing phase of gait. During the 16th

session, the patient was starting to initiate right swing phase on his own, so tactile cuing was

given on the patient’s gastrocnemius as well as auditory cuing for taking a step with the right

foot. With this cuing the patient was able to take steps with the right foot, but quickly became

fatigued and the patient was able to only ambulate shorter distances. Minimum assistance18 was

needed to help place the patient’s foot to the right of midline after he took some steps due to his

right step being irregular and sometimes crossing midline. Over the course of gait training, the

patient’s cadence became more regular, and his step length on the left side was starting to

become longer. The patient had a step-to gait pattern. At the time of the 5th treatment session, the

orthotist was present at the session. She casted the patient for a custom AFO and gave the

therapy team a trial solid AFO to use with the patient for the course of treatment until the time

his custom one was delivered. The AFO was used for all of the treatment sessions on this day

and the rest afterward on the right ankle. The patient was fitted for the AFO to help to prevent

hyperextension of the knee during stance phase of ambulation, and to help facilitate dorsiflexion

motion to initiate swing phase for the right lower extremity and to help clear the foot during the

start of swing phase. Ankle foot orthoses have been shown to be effective in preventing ankle

contractures following stroke as well as improving gait quality and safety.4

Neuromuscular Re-education. Neuromuscular re-education for the treatment of this patient

consisted of PNF and balance exercises. Proprioceptive neuromuscular facilitation was used for

this patient to help facilitate activation of the pelvis to help improve functional mobility.3 Pelvic

PNF was combined with lower extremity movement to help activate more musculature and

19
active movement from the patient. In left sidelying, rhythmic initiation into anterior elevation

into posterior depression was used on the right pelvis. Rhythmic initiation uses passive range of

motion (PROM) then active assisted range of motion (AAROM) then AROM to facilitate active

movement by the patient.27 Once the patient was able to start initiating movement of the pelvis

on his own into anterior elevation and posterior depression, distal handling of the right leg was

used to move the right hip and knee in and out of hip and knee extension. After there were

palpable contractions noticed of the right leg musculature, alternating isotonics were used with

the therapist giving resistance to the patient as he moved through the motion. Resistance was

given at the patient’s foot as he moved into extension. Alternating isotonics are when there is

first a contraction of the agonist muscle and then there is contraction of the antagonist muscles

against resistance.27 This was able to be done for treatment sessions 3 and 7 during the 4 weeks

of treatment. In supine, the patient was taken through right lower extremity flexion and extension

with the patient needing demonstration on the left lower extremity for him to understand the

motion he was supposed to be performing. For the demonstration, the therapist moved the

patient’s left lower extremity through the motion and then had the patient actively perform the

motion, and then he was able to understand what he was supposed to be doing with the right

lower extremity. The patient was taken through the first couple of repetitions passively by the

therapist before he was able to start initiating movement actively. After the patient went through

the motion repeatedly, moderate resistance, at the foot, from the therapist was added when the

patient moved into the extension range of motion. This was done for treatment sessions for

treatments sessions 3 and 18. These exercises were done as ideas taken from Ribeiro and

associates.3 Other exercises that were performed (similar to those used in Ribeiro’s3 research)

included: weight shifting onto the right and lower extremities and giving resistance to the patient

20
for hip abduction and adduction to improve hip and pelvis mobility and activation for gait.

Resistance for hip abduction and adduction was given at the lateral or medial thigh depending on

if hip abduction or adduction was being performed. When weight shifting was first performed,

the patient was apprehensive about putting weight on his right leg; however, as this exercise was

performed more frequently he was able to distribute more weight onto his right leg and was able

to do it without being cued to do so. Another exercise commonly used was single leg stance on

the right leg to help facilitate weight bearing through the leg and improving the patient’s

confidence to stand on the right leg for stance phase during gait due to the patient commonly

being apprehensive about bearing weight fully through the right lower extremity. The patient

needed to be able to balance and facilitate weight through this right leg in order to improve his

gait mechanics. Performing these PNF type exercises more frequently would have been

beneficial for this patient, but the patient often refused to do exercises in supine or sidelying due

to not liking to be in these positions. On days when PNF treatment was done, it took a lot of

persuasion for the patient to do these exercises, but once the patient got the movement of the

exercises down, he was okay with doing further exercises.

Electrical Stimulation. Electrical stimulation was another form of treatment that the patient

received as part of his plan of care. Neuromuscular electrical stimulation (NMES) has been

found to have positive effects following stroke, in helping to prevent foot drop and improving

gait mechanics.28,29 Electrical stimulation works by improving voluntary muscle activation,

reducing spasticity of muscles, improving coordination outside of synergy patterns, and reducing

con-contraction that is abnormal.30 Russian electrical stimulation, which is similar to NMES, was

applied to the patient’s right vastus medialis muscles. Russian electrical stimulation is used to

produce an isometric contraction of a muscle and is commonly used for muscle strengthening

21
and activation.31 Parameters for Russian electrical stimulation were as follows: duty cycle 50%,

cycle time 10 seconds on:20 seconds off, burst frequency 50 bursts per second, ramp time 2

seconds, duration 15 minutes. The amplitude that was used for this patient ranged from 65 to 100

milliamps depending on the level in which a muscle contraction was able to be elicited as well as

how high of an intensity the patient was able to tolerate on a given day. During electrical

stimulation of the vastus medialis, AAROM was performed during the on time, the time when

the amplitude is increasing to the set amplitude, for knee extension to help facilitation activation

of the quadriceps muscle group.

Outcomes
The patient was treated 18 times for 55 minutes for each session and treated by the same

therapist or physical therapist assistant at each session. The full planned duration of 20 treatment

sessions was not able to be completed due to the current author being suspended from the clinic

due to the COVID-19 pandemic that was taking place. Over the course of treatment, that was

performed for this case report, the patient had a change in his FIST score of 9 points, scoring

45/56 at reexamination and 54/56 at the end of treatment. For the FIST, a minimal detectable

change (MDC) of 5.6 points is necessary for those with an acute stroke, a stroke that occurred

less than 3 months ago for significant clinical improvement.16 The MDC represents the smallest

amount of change in a score that shows functional improvement in the patient’s abilities.

Because the patient showed an increase in score of 9 points, it indicates that he was able to show

functional improvement in his abilities which was noticed in the patient through the course of his

treatment. For the PASS a MDC of 2.22 points has been established for those who have had a

stroke and are in the subacute phase.32 The patient scored 23/36 points at the time of

reexamination and 27/36 points at the end of treatment, indicating that the patent met the MDC

22
for this functional outcome measure as well. At the end of treatment, the patient had met his goal

for the score of the FIST, reaching 54/56, and was 1 point away from reaching his goal for the

PASS of 28/36.

Throughout the course of treatment, the patient showed improved functional mobility

although his need for assistance at the end of treatment do not necessarily show this as

documented in Table 1. The patient required minimum assistance18 for sit to and from stand and

sit to and from supine both at the start and end of treatment. While there was no change in the

amount of assistance needed, the patient showed improved body awareness throughout treatment

with the patient being able to use correct hand placement and moving his legs on his own, and

less verbal cuing was needed for body positioning while completing the transfers. For sit to stand

transfers, the patient was able to use correct hand placement on the wheelchair without needing

cuing to do so. When performing transfers to and from the platform walker used for ambulation,

he was able to place his right arm on and off of the walker after being given cuing. The patient

was able to progress from using a slideboard transfer for transfers from a bed to and from the

wheelchair with minimum assistance18 to being able to complete stand pivot transfers with

minimum assistance18 with no assistive device. The patient showed improved postural control

with completing the transfer that he was progressed to not needing the assistive device. The

patient demonstrated proper hand placement when completing the transfer as well as improved

knowledge of the transfer and awareness that he was able to complete the transfer with nursing

staff as well.

The biggest area of improvement throughout the time of treatment for the patient was in

ambulation. He started off with being able to ambulate in the parallel bars, only 8 feet, with

minimum assistance for trunk control and moderate to maximum assistance18 for the patient’s

23
right step. At the end of treatment, the patient was able to ambulate at most 40 feet with the use

of the TRAM. Using the TRAM, the patient was able to initiate the right step independently after

given tactile cuing at the gastrocnemius and verbal cuing for the patient to take the right step.

Without the use of the TRAM, and the patient using the platform walker, the patient was able to

ambulate shorter distances taking the right step independently and having minimum assistance18

for trunk control. Throughout the course of treatment, the patient was able to ambulate up to 70

feet with minimum assistance for the right step length and minimum assistance18 for trunk

control. As the patient gained endurance, he was able to ambulate further although he still

needed some assistance for the right step. The patient was given an AFO that may have played a

part in assisting him in being able to initiate the right step. The patient also showed improved

sequencing ability between the right and left steps, and his gait speed and quality improved as

well. Overall, the patient showed a great improvement in his ambulation ability and was his

greatest achievement throughout treatment. The patient did not meet his goals of progressing to

be independent in supine to and from sitting and standing to and from sitting. He also did not

meet his ambulation goals of being able to ambulate 25 feet with a cane with standby assistance.

Please refer to Tables 1 and 2 for measurements as of the last day of treatment. In Table 2, the

strength measurements had not been re-evaluated in a recent time but based on observations

when performing interventions there had not been substantial change over the course of

treatment.

Discussion
The purpose of this case report was to determine if the addition of PNF and lower

extremity exercises to a plan of care that used other usual physical therapy treatment was

beneficial in improving functional mobility in a patient who had a basal ganglia hemorrhage. The

24
outcomes of this case report support the research that PNF and lower extremity strengthening can

help to improve ambulation and functional mobility following a stroke.3,14,15

The frequency of the PNF and lower extremity strengthening exercises may have

influenced the outcomes positively. While either of these exercises were performed during most

treatment sessions, a greater majority of the time was spent working on gait training and other

mobility skills such as transfers. In the study done by Ribeiro and associates,3 PNF was done 3

times per week, 30 minutes each time for 4 weeks. Kumar and associates12 also performed PNF

exercises for this same duration. In our case report, PNF exercises were only done during 5

sessions for about 30 minutes at each time. It is also known, that with mobility training, the

exercises needs to have sufficient frequency, intensity, and duration so it can be inferred that the

same would be held true for other types of exercises.4,7 While either PNF or strengthening

exercises were performed at most sessions, they were not likely performed for 30 minutes of the

session and they each may have not been done 3 times per week. While the patient did make

progress throughout the course of treatment, there is a chance that the patient may have

experienced more progress if these exercises has been performed more frequently or with higher

intensities for longer durations. The same idea could be applied to the gait training and other

functional mobility, transfers and bed mobility, that were worked on with the patient during this

time. While the patient did perform gait training on all but 4 of the sessions, the training may

have been more beneficial if it would have been of higher frequency and intensity as it has been

that these variables have positive effects on mobility training.4,7

Before the interventions of this case report were started, the patient had done some trials

of gait training in the TRAM device to decrease the amount of body weight to help improve gait

for this patient. Due to the patient not liking this device and refusing it after a couple trials it was

25
not further used for these reasons. As the patient progressed in physical therapy, the idea to use

the TRAM was brought up again and the patient was willing to try the device once more. When

using the TRAM, the patient was able to walk longer distances while initiating the right step on

his own which is something he had not been able to do while not in this device. There is much

evidence to support body weight supported treadmill training as well as body weight supported

flat ground training with devices such as the TRAM. Flat ground training with body weight

support has been found to improve the scores of the Berg Balance Scale, the 10-meter

comfortable walk velocity, as well as the Functional Ambulation Category.33 There is evidence

that body weight supported treadmill training increase walking ability more in those who are less

than 3 months post-stroke compared to over ground training.34 In addition, when using body

weight supported training evidence suggests that those who are less than 3 months post-stroke

have better gait recovery outcomes if they are unable to walk following the stroke.34 With

knowledge of this research it may have been more beneficial to try using the TRAM earlier in

the treatment, or to incorporate it more frequently to see if it could have helped the patient to

improve upon his ambulation abilities.

One of the limiting factors for the patient of this case report in improving his ambulation

and functional mobility skills was his motivation and ability to participate in each session.

Following a stroke, there is an increase in incidence of depression and anxiety, and these are

associated with poorer functional outcomes and increased mortality.4 While this patient had not

been diagnosed with either of these disorders, there was evidence from his behavior that he may

have had some of the behaviors associated with these diagnoses, anxiety in particular. This may

hinder a patient’s ability to participate in rehabilitation therapies.35 When a patient has both

general anxiety disorder in addition to poststroke depression, Shimoda and Robinson36 found that

26
these patients have delayed activities of daily living recovery, a reduction in social functioning,

and a decreased rate of recovery from depression. In a qualitative study, performed by Maclean

and associates37, rehabilitation professionals, that work with patients who have had a stroke, were

interviewed with questions regarding motivation in their patients and the effects it had on their

outcomes. Fourteen of the 32 professionals that were interviewed stated that they felt motivated

patients were compliant with their rehabilitation.37 The patient of this case report frequently

refused different types of treatment, such as PNF, when they were given to him and the other

therapists, OT and SLP, also had problems with getting the patient to do some of the treatments.

Many of those interviewed in Maclean’s study stated that they thought increasing age was

associated with lower motivation, but the patient in this study was only 45-years-old so it seems

as though based on this his motivation should have been higher because he should have more to

look forward to and have better functional outcomes.37 On the other hand, those interview in this

study stated that those who are older do not respond as well to encouragement compared to

younger patients.37 When encouraging this patient, he often took well to the encouragement and

his performance often improved. During gait training, the patient was encouraged by taking

breaks to remind him of the goals of ambulation, having the patient focus on a target for how far

he was to walk, and using words of encouragement to keep the patient motivated. This patient

was not unmotivated, but there were times in which extra external encouragement and

motivation was needed to help remind the patient the benefits of physical therapy and the

purpose behind that activities that the therapist wanted him to do.

Based on the patient’s ability to participate in treatment sessions, and the patient quickly

fatiguing after three kinds of therapies each day, it seems that it was the right decision to send

him to a SNF instead of an IRF. These two types of rehabilitation centers are the most common

27
following the patient’s stay in the acute care hospital. Part of the decision-making process of

where the patient will be discharged to is up to the therapy team.4 Currently, there is not an

outcome measure or functional assessment that can be used throughout the entire course of care,

following a stroke, as the patient moves from acute care to inpatient rehabilitation and then to

outpatient care. In the acute care hospital, the FIM was commonly used, as well as the Barthel

Index that is still used, to guide the decision-making process by the acute care therapists based

on the patient’s functional abilities.38,39 Jette and associates40 found that therapists feel that the

patient’s level of disability and function were the top considerations used when making a

decision regarding discharge planning. Another consideration that is often taken into effect is the

patient’s ability to participate in therapy. Therapists stated that they thought about how much

therapy the patient would be able to tolerate. They considered if the patient could participate in 3

hours of therapy a day, as that is what is needed to discharge to a IRF. If they thought that the

patient would tolerate less than 3 hours, they would need to be discharged somewhere with less

intensive requirements such as a SNF.40 Other considerations that therapists use when making

decisions, in regard to discharge planning, include support that the patient has, the environment

that they will be discharging to, and the patient’s needs and wants.40 Other factors to consider

when thinking about the decisions that have to be made for patients by acute care therapists

include how much experience the therapist has, the health care team’s collaboration in making a

decision, and health care regulations such as insurance.40 Based on the patient’s progress and the

amount of therapy he was able to tolerate; it seems as though the SNF was the right discharge

location for this patient.

While this case has many positive aspects to it, there are also limitations that can be

addressed. First, there was only patient in this report, so the results are harder to generalize to a

28
greater population. Another limitation is that there was not a set frequency for the interventions

that were performed during this case. Interventions were performed based on the patient’s

tolerance each day and therefore, exercises were not always able to be performed as frequently as

they would have liked to be. This particularly goes for the PNF exercises as the patient did not

like to be in positions such as supine or sidelying to perform these types of exercises. Not having

a set frequency makes these interventions hard to be reproduced with another patient. One other

limitation of this study is that the full planned duration of interventions was not able to be

performed, and therefore full final measurements were not able to be taken, due to the current

author not being able to finish at the clinic due to the COVID-19 pandemic. If there had been

more time to complete interventions further progress may have been made and formal

measurements of his functional mobility and strength could have been assessed.

Based on the findings from this case report there is evidence that supports that further

research in this area can be warranted. For this future research, a randomized controlled trial may

be formed to compare the effects of PNF and lower extremity strengthening exercises on a set

schedule for frequency and duration in addition to best physical therapy practices for gait

training and functional mobility. This group would be compared to a controlled group that only

received gait and functional mobility training. Future research may also look at using body

weight supported gait training with the additional exercises of PNF and lower extremity

strengthening to see if there are improvements as well. While the patient showed improvements,

further research could be beneficial to figure out what parameters of PNF and lower extremity

strengthening exercises are best to be able to add them to best practice guidelines for patients

following a stroke.

29
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doi:10.1016 /s1836-9553(10)70020-5
35. Chollet F, Acket B, Raposo N, Albucher JF, Loubinoux I, Pariente J. Use of antidepressant
medications to improve outcomes after stroke. Curr Neurol Neurosci Rep. 2013;13:318. doi:
10.1007/s11910-012-0318-z.
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analysis of stoke professionals’ attitudes. Stroke. 2002;33:444-448. doi:10.1161/hs0202.102367.
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recommending-discharge-placement-from-acute-care-setting.

33
Table 1.
Transfer and Outcome Measure Results for Patient’s Time in Therapy
Test or Measure Initial Examination* Reexamination** End of
Interventions***
Sit to/from Standa Maximum Assist x2 Minimum Assist Minimum Assist
Therapists
Supine to/from Sita Maximum Assist x2 Minimum Assist Minimum Assist
Therapists
Transfer Bed to/from Maximum Assist x2 Minimum Assist with Stand Pivot Transfer
Wheelchaira Therapists use of Slideboard with Minimum Assist
Ambulationa Unable to Attempt 8 feet in parallel bars 40 feet with TRAMc
with use of LUEb with patient able to
support and minimum take right step on his
assistance for trunk own with cuing, 70
control and moderate feet with platform
to maximum walker and minimum
assistance for right assistance for right
step step and minimum
assist for trunk
control
d
FIST 29/56 45/56 54/56
e
PASS 8/36 23/36 27/36
*At initial evaluation, patient was evaluated by another therapist. These results represent initial
examination baseline data for reference.
** These results represent baseline date for the episode of care as described in this case report.
***These results represent data for the patient at the end of the episode of care as described in
this case report.
a
FIM = Functional Independence Measure: Levels of Assistance: dependent= patient performs
<25% of effort, maximum assistance= patient performs 25-50% of effort, moderate assistance=
patient performs 50-75% of effort, minimal assistance= patient performs 75% or more of effort,
supervision or standby assistance= cueing required or setting up items for use, independent=
patient performs 100% of effort safely and without cueing
b
LUE = left upper extremity
c
TRAM, Community Products, LLC, Rifton, NY
d
FIST = Function in Sitting Test
e
PASS = Postural Assessment Scale for Stroke

a
Guide for the Uniform Data Set for Medical Rehabilitation Adult Functional Independence
Measure (FIM), Version 4.0. Buffalo, NY 14214: State University of New York at Buffalo,
1993.
Table 2.
Manual Muscle Test Strength Grades for Episode of Carea
Initial Reexamination** End of
Examination* Interventions***
Hip Flexion 0/5 3-/5 3-/5
Knee Flexion 0/5 3-/5 3-/5
Knee Extension 0/5 2+/5 2+/5
Ankle Dorsiflexion 0/5 1/5 1/5
*At initial evaluation, patient was evaluated by another therapist. These results represent initial
examination baseline data for reference.
** These results represent baseline date for the episode of care as described in this case report.
***These results represent data for the patient at the end of the episode of care as described in
this case report.
a
Manual Muscle Testing Gradesa: 0/5 = No muscle contraction (cannot be palpated or
visualized), 1/5 = No motion but slight contraction, 2-/5 = Moves through partial range of motion
(ROM) with gravity eliminated, 2/5 = Moves through complete ROM with gravity eliminated,
2+/5 = Moves through complete ROM with gravity eliminated and through ½ of ROM against
gravity 3-/5 = Moves through greater than ½ but less than full range of motion against gravity,
3/5 = Moves through full ROM against gravity, 3+/5 = Moves through full ROM against gravity
and can withstand minimal resistance, 4/5 = Moves through full ROM against gravity and can
withstand moderate resistance, 5/5 – Moves through full ROM against gravity and can withstand
maximal resistance

a
Reese NB. Muscle and Sensory Testing. 3rd ed. St. Louis, Missouri: Elsevier Saunders; 2012.
Table 3.
Interventions Performed During Each Therapy Session1
Sessio Gait Training Therapeutic Therapeutic Neuromuscular Electrical
n Activities Exercises Re-education Stimulation
1 Parallel Bars Rolling in Right Vastus
8 feet x22 Bed: Medialis
Moderate Minimum Intensity: 92-
3
assist x1 for assist x13 100 milliamps
4
RLE swing Sideboard
phase Transfer (Bed
Minimum to/from WC6):
3
assist x1 for Minimum
trunk control assist x13 and
LUE support pt using LUE5
5

on parallel bar support on

parallel bar
2 Parallel Bars Stand pivot Mini Squats
8 feet x12 transfer WC6 1x202 LUE on
LUE5 support to/from mat parallel bar
on parallel bar table with 1x202 with no
3,5,6 feet x12 hemi-walker LUE5 support
5
with LUE Minimum Toe Taps
3
support on assist x1 2 and 4 inch
therapist Sit to stand step 1x102
2
Moderate 1x8 in parallel each by the
3
assist x1 for bars LLE6
4
RLE swing Minimum 6 inch step
phase assist 2x102
Minimum LUE5 on
assist x13 for parallel bar for
trunk control all repetitions
3 Bed Right steps L8 sidelying
Supine to sit forward and Rhythmic
Minimum backward with initiation for
assistance 1x22 RUE10 support anterior
Rolling to R7 on therapist elevation and
Minimum 1x152, posterior
2
assistance 3x1 minimum depression of
Rolling to L8 assist x13 for R7 pelvis
9
SBA and trunk control Alternating
positioning of isotonics for
RLE4 R7 hip & knee
Sit to Stand flexion in/out
4x12 with of hip & knee
minimum extension
assist Supine
 Stand pivot Rhythmic
WC11 to/from initiation for
bed, no AD12, RLE4 flexion
Minimum and extension
assist with moderate
resistance
given from
therapist
4 Gym Seated
11, 18, 27 feet AAROM13 for
x12 with R7 knee
platform extension
walker 3x102
minimum
assist x13
trunk control,
moderate
assist x13 for
RLE4 swing
5 Parallel Bars Toe taps by
8 feet x22 LLE6
LUE5 on 6-inch step
parallel bar for 1x102, 1x152
1 trial and on with LUE5
therapist for 1 support on
trial parallel bar
6 Gym Mini squats
32 and 34 feet 2x102, LUE5
x12 with support on
platform parallel bar for
walker, 1st trial and on
minimum therapist for
assist x13 for 2nd trial
weight shifting
to the R7 and
L8 to facilitate
swing phase
on opposite
side, moderate
assist x13 for
RLE4 swing
7 Stand pivot Mini squats PNF14 for
transfers 4x12 2x202 with anterior
WC11 to/from LUE5 support elevation and
mat table with on therapist posterior
moderate Toe taps on 6- depression of
 assist x13 inch step with R7 pelvis
Sit to L8 LUE5 support 1x152, anterior
sidelying with on parallel elevation with
minimum bars hip and knee
assist to bring flexion and
RLE4 onto posterior
table, depression
sidelying to sit with hip and
with minimum knee extension
assist 4x102
8 Hallway Sit to stand to Repeated sit to
27 & 33 feet platform stands 1x52,
x12 with walker with Mini squats
platform minimum 1x102
walker, assist x23,
minimum Sit to stand in
assist for trunk parallel bars
control, with SBA9
minimum to
moderate
assist for RLE4
swing phase
9 Stand pivot Mini squats Hip abduction R7 Vastus
3x12, 2x152 and adduction Medialis
Minimum in sitting 2x102 Intensity: 65
assist x13 with moderate milliamps
WC11 to/from resistance from
mat table therapist
10 Hallway Sit to stands Standing at
32 & 60 feet 4x12 with platform
x12 with minimum walker,
platform assist to reached for
walker, platform cones in
minimum walker, midline, up &
assist x13 for maximum down, R7 & L8
weight assist to place of midline, in
shifting, RUE10 on and out of pt’s
minimum platform BOS15,
assist x13 for walker minimum
RLE4 swing assist for trunk
phase control
11 Hallway Sit to stands Mini Squats
70 feet x12, 2x12 with 2x202 with no
minimum minimum LUE5 support,
assist x13 for assist to stepping
weight platform forward &
 shifting, walker, back to neutral
minimum maximum with RLE4
assist x13 for assist to place 2x102 with
RLE4 swing RUE10 on LUE5 support
phase, used platform on parallel bar
platform walker
walker
12 Hallway Sit to stands Static standing
71 feet x12 90° 2x12 with with no AD
turn to the L, minimum 2x12 min
minimum assist to Weight
assist x13 for platform shifting to the
trunk control walker, R7 & L8 with
and minimum maximum no AD12 with
assist x13 for assist to place minimum
RLE4 swing RUE10 on assist x13
phase, used platform
platform walker
walker Stand pivot
transfer
2x12 with
minimum to
moderate
assist x13
13 Hallway Sit to/from Standing at
40 feet x12 stands platform
with 3-90° 1x12 with walker, weight
turns with minimum shifting onto
minimum assist to RLE4 with
assist for trunk platform reaching at the
control and walker, same time for
minimum to maximum beanbag and
moderate assist to place tossing bean
assist for RLE4 RUE10 on bags 1x5:45
swing phase, platform minutes2 &
used platform walker, pt able 1x3:22
walker to remove his minutes2,
RUE10 for minimum
stand to sit assist for
steadying
14 Sit to/from Right Standing at
stand to hamstring & platform
platform gastrocnemius walker, weight
walker 3x12 stretching shifting onto
with minimum 4x452 seconds RLE4 with
assist for trunk each same side and
 and maximum RLE4 cross midline
assist to place extension in reaching at
RUE10 sitting with knee to above
moderate shoulder level
resistance 1x4:43
from therapist minutes2 and
2x152 1x3:552
minutes with
minimum
assist to shift
onto RLE4
15 Hallway Sit to/from Platform
1 x 70 feet2 stand 4x12 walker
Minimum with minimum Weight
assist for trunk assist x13, with shifting to R7
control x13 cuing pt able and L8 with
and minimum to place RUE10 minimum
assist x13 for on/off walker assist for
RLE4 swing for sit & stand steadying 2x3
phase minutes2
Weight
shifting onto
RLE4 and
taking step
forward & to
neutral with
LLE6 1x152
with minimum
assist x13
Single leg
stance on
RLE4 5x2,
5x3, 3x7, 3x5,
1x10 seconds2
with minimum
assist for trunk
control,
minimum
assist x13 for
possible RLE4
knee buckling
but did not
occur
16 Hallway Stand pivot
1x70, 20, and bed to/from
15 feet2, WC11 with
 minimum minimum
assist x13 for assist
trunk control, Sit to/from
minimum stand 4x12
assist x13 for with minimum
RLE4 swing assist x13,
phase maximum
assist x13 to
place RUE10
on walker
16
17 Rifton Tram Sit to/from Standing at
1x15 and x40 stand 3x12 platform
feet2. with minimum walker weight-
Minimum to assist for trunk shifting to the
moderate control and R7 and L8 with
assistance for maximum minimum
4
RLE swing assist to place assist 2x102
phase for 15 RUE10 on
feet walk, for walker or
40 feet walk pt Rifton Tram16
able to do
RLE4 swing
phase
independently
after given
verbal &
tactile cuing
18 Hallway, Stand pivot Bent knee Standing at
1x10 feet2, transfer to L8 fallouts, tactile platform
platform side WC11 and verbal walker weight-
walker, tactile to/from mat cuing for shifting to the
and verbal table with correct R7 and L8 with
cuing given minimum motion, 2x102 minimum
4
for RLE assist Moderate assistance
swing phase, Supine to/from resistance 2x102, single
needs sit with given for leg stance on
minimum moderate fallout motion RLE4 5x10
assist for RLE4 assist to bring 2x102 seconds2, 2x12
swing phase RLE4 on/off seconds2 with
table minimum
assist for
steadying,
Supine
completed hip
flexion and
extension with
 initiation from
therapist for
movement,
AROM17 3x102
moderate
resistance
given by
therapist
during range
1
FIM = Functional Independence Measure: Levels of Assistance: dependent= patient performs
<25% of effort, maximum assistance= patient performs 25-50% of effort, moderate assistance=
patient performs 50-75% of effort, minimal assistance= patient performs 75% or more of effort,
supervision or standby assistance= cueing required or setting up items for use, independent=
patient performs 100% of effort safely and without cueing
2
#x# = sets x repetitions
3
x# = number of people needed to perform task
4
RLE = Right Lower Extremity
5
LUE = Left Upper Extremity
6
LLE = Left Lower Extremity
7
R = Right
8
L = Left
9
SBA= Standby Assistance
10
RUE = Right Upper Extremity
11
WC = Wheelchair
12
AD = Assistive Device
13
AAROM = Active Assisted Range of Motion
14
PNF = Proprioceptive Neuromuscular Facilitation
15
BOS = Base of Support
16
TRAM, Community Products, LLC, Rifton, NY
17
AROM = active range of motion

1
Guide for the Uniform Data Set for Medical Rehabilitation Adult Functional Independence
Measure (FIM), Version 4.0. Buffalo, NY 14214: State University of New York at Buffalo,
1993.
Figure 1.
Timeline of Episode of Care for Patient