What is the best course of treatment for an elderly patient with right-sided hemiparesis (weakness on one side of the body) that occurred 5 days ago, likely due to a stroke?

Management of Elderly Patient with Right-Sided Hemiparesis 5 Days Post-Stroke

At 5 days post-stroke, the acute thrombolytic window has closed, and management should focus on comprehensive stroke rehabilitation including early mobilization, physical therapy with emphasis on eccentric strengthening exercises, antiplatelet therapy (aspirin 162-325 mg daily if not already initiated), and aggressive secondary stroke prevention measures. 1

Immediate Assessment Priorities

Confirm Stroke Diagnosis and Type

• Brain imaging (CT or MRI) should already be completed to differentiate ischemic from hemorrhagic stroke and identify infarct location/extent 1
• If not yet done, vascular imaging (CTA or MRA) of cervical and intracranial vessels should be obtained to identify stenosis, occlusion, or dissection that may guide secondary prevention 1

Airway and Oxygenation Management

• Monitor oxygen saturation continuously with pulse oximetry, maintaining SpO2 ≥92% 1
• Assess for hypoxia risk factors: decreased consciousness, brainstem signs, aspiration risk, or pulmonary comorbidities 1
• Position patient in supine or side-lying position if oxygenation is adequate; elevate head if hypoxic or has significant pulmonary disease 1
• Evaluate swallowing function before oral intake to prevent aspiration pneumonia, which is a leading cause of post-stroke mortality 1

Antiplatelet Therapy

Aspirin 162-325 mg daily should be initiated if not already started, as it provides modest but significant benefit when begun within 48 hours of stroke, primarily through prevention of early recurrent events. 1

• Aspirin reduces death and disability when started within 48 hours, though benefit at 5 days is primarily for secondary prevention 1
• Do NOT initiate anticoagulation for acute stroke treatment, as urgent anticoagulation does not prevent early recurrent stroke or improve outcomes and increases hemorrhagic risk 1
• Avoid combination antiplatelet therapy (aspirin plus clopidogrel) in the acute setting without specific indication 1

Rehabilitation Protocol

Early Mobilization and Physical Therapy

Begin aggressive rehabilitation immediately, as recent evidence demonstrates that intensive therapy beyond the traditional recovery window significantly improves aerobic capacity, sensorimotor function, and functional outcomes. 1, 2

• Initiate active, active-assisted, or passive range of motion exercises immediately to prevent contractures and complex regional pain syndrome 3
• Focus positioning and stretching on increasing external rotation and abduction for upper extremity spasticity 3
• Implement eccentric strengthening exercises for the paretic lower limb, which significantly improves muscle strength (1RM) and gait performance 2
• Eccentric training protocol: three sets of five repetitions of eccentric contraction after determining maximum repetition 2

Gait and Mobility Training

• Begin treadmill training with or without body weight support to improve cardiorespiratory fitness and motor function 1
• Recognize that hemiparetic gait has markedly elevated oxygen cost (up to 50% reduced mechanical efficiency), requiring gradual progression 4
• Implement balance training including trunk training, task-oriented intervention, and force platform biofeedback 3
• Progress from supervised walking programs to home-based training as tolerated 1

Spasticity Management

Assessment and Non-Pharmacological Approaches

• Evaluate tone, strength, soft tissue length, joint alignment, pain, and orthopedic changes 3
• Use functional dynamic orthoses to facilitate repetitive task-specific training 3

Pharmacological Options (if spasticity develops)

• First-line oral agent: Tizanidine, particularly effective for chronic stroke patients with spasticity 3
• Dantrolene for spasticity causing pain, poor skin hygiene, or decreased function 3
• Avoid benzodiazepines during stroke recovery due to negative effects on recovery and sedation 3
• Consider botulinum toxin injections for focal spasticity affecting specific muscle groups 3

Secondary Stroke Prevention

Risk Factor Modification

• Implement aerobic conditioning program to enhance glucose regulation, promote weight loss, reduce blood pressure, and improve lipid profiles 1
• Target modifiable risk factors: hypertension control, diabetes management, lipid optimization, smoking cessation 1
• Regular physical activity reduces stroke risk across all ages and both sexes in multiethnic populations 1

Cardiovascular Assessment

• Perform telemetry monitoring, echocardiography, and carotid imaging as clinically indicated to determine stroke etiology 5
• Recognize that stroke patients have heightened risk of secondary cardiac complications and recurrent stroke 1

Critical Pitfalls to Avoid

• Do not delay rehabilitation waiting for "spontaneous recovery" - aggressive therapy beyond traditional timeframes improves outcomes 1
• Do not reduce muscle tone excessively with spasticity treatments if it compromises functional strength needed for activities 3
• Do not position hypoxic patients flat - they require head elevation despite potential cerebral perfusion benefits of supine positioning 1
• Do not miss alternative diagnoses in atypical presentations, particularly spinal epidural hematoma which can mimic stroke with acute hemiparesis 6
• Regular reassessment is essential to adjust treatment as the patient improves 3

Functional Goals and Prognosis

• Between 25-50% of stroke survivors require assistance with activities of daily living, with half experiencing severe long-term hemiparesis or complete hemiplegia 4
• Functional capacity and mobility improvements (increased gait velocity) are achievable with intensive rehabilitation 1, 2
• Quality of life improvements occur with combined aerobic training and specialized skill training for self-care and leisure activities 1