Physical Therapy Initial Evaluation Note: Post-Stroke Patient with Left-Sided Weakness

PATIENT INFORMATION

Date of Evaluation: [Insert Date]
Diagnosis: Cerebrovascular Accident (CVA) with left hemiparesis
Onset Date: [Insert stroke date]
Referral Source: [Physician name]

CHIEF COMPLAINT

Patient reports difficulty with left-sided movement and functional activities following stroke.

HISTORY OF PRESENT ILLNESS

Patient sustained [ischemic/hemorrhagic] stroke on [date], resulting in left-sided weakness. Currently [X] days/weeks post-stroke. Medical management included [specify: thrombolysis, thrombectomy, conservative management]. Patient reports difficulty with [specific functional limitations: walking, transfers, ADLs, upper extremity use].

Prior Level of Function: Independent with all mobility and ADLs
Current Living Situation: [Home/facility, alone/with family]
Goals: Patient wishes to [specific functional goals: walk independently, use left arm for daily tasks, return to work/hobbies]

PAST MEDICAL HISTORY

Stroke (current)
[Other relevant conditions: hypertension, diabetes, atrial fibrillation, prior stroke]
[Medications relevant to rehabilitation]

SYSTEMS REVIEW

Cardiovascular: [Heart rate, blood pressure, endurance limitations] 1
Musculoskeletal: Left-sided weakness, [presence/absence of contractures]
Neuromuscular: Left hemiparesis, [sensory deficits, visual field cuts, neglect]
Integumentary: Intact, no pressure injuries
Communication: [Intact/aphasia present]
Cognition: [Alert and oriented x3/cognitive deficits noted]

OBJECTIVE EXAMINATION

Vital Signs

Blood Pressure: [value] mmHg (target <130/80 mmHg for secondary prevention per AHA guidelines) 1
Heart Rate: [value] bpm
Respiratory Rate: [value] breaths/min
Oxygen Saturation: [value]%

Range of Motion (ROM)

Left Upper Extremity:

Shoulder flexion: [degrees] (normal 180°)
Shoulder abduction: [degrees] (normal 180°)
Elbow flexion/extension: [degrees] (normal 0-150°)
Wrist extension: [degrees] (normal 0-70°)
Finger flexion/extension: [degrees]

Left Lower Extremity:

Hip flexion: [degrees] (normal 120°)
Knee flexion/extension: [degrees] (normal 0-135°)
Ankle dorsiflexion: [degrees] (normal 0-20°)
Ankle plantarflexion: [degrees] (normal 0-50°)

ROM limitations noted in [specify joints] secondary to [weakness/spasticity/pain] 1

Manual Muscle Testing (MMT) - Modified 0-5 Scale

Left Upper Extremity:

Shoulder flexors: 4/5 (good strength, able to move against gravity and moderate resistance)
Shoulder abductors: 4/5 2
Elbow flexors: 4/5 (strong predictor of functional recovery) 3
Elbow extensors: 4/5
Wrist extensors: 4/5 (critical for functional hand use) 2
Finger flexors: 4/5 2
Finger extensors: 4/5 (important predictor of upper extremity function) 3

Left Lower Extremity:

Hip flexors: 4/5
Hip extensors: 4/5
Hip abductors: 4/5
Knee flexors: 4/5
Knee extensors: 4/5
Ankle dorsiflexors: 4/5 (assess for foot drop requiring AFO) 1
Ankle plantarflexors: 4/5

Right Side (Unaffected): 5/5 throughout

Patient demonstrates good strength (4/5) throughout left side with ability to move against gravity and moderate resistance, indicating favorable prognosis for functional recovery 2, 3

Tone Assessment - Modified Ashworth Scale

Left upper extremity: [0-4 rating for each joint]
Left lower extremity: [0-4 rating for each joint]
[Specify if spasticity present and location] 1

Sensation

Light touch: [Intact/impaired] left upper and lower extremity
Proprioception: [Intact/impaired] left side
[Sensory deficits may impact motor learning and functional recovery] 4

Balance Assessment

Sitting Balance: [Static: independent/requires supervision/contact guard; Dynamic: able to reach in all directions/limited reach]

Standing Balance: [Static: independent/requires assistive device/contact guard; Dynamic: weight shift ability, single-leg stance time]

Patient requires balance training program per AHA Class I recommendation for fall prevention 1

Functional Mobility

Bed Mobility: [Independent/requires minimal/moderate/maximal assistance] for rolling, supine-to-sit transitions

Transfers: [Independent/requires assistance level] for sit-to-stand, bed-to-chair, toilet transfers
[Specify assistive device used if applicable]

Gait:

Assistive Device: [None/cane/walker/AFO]
Distance: Ambulates [X] feet with [device] and [assistance level]
Gait Speed: [X] meters/second (normal >1.0 m/s for community ambulation)
Gait Deviations: [Foot drop, circumduction, decreased stance time on left, decreased step length, trunk lean, etc.]
Endurance: Limited to [distance/time] due to [deconditioning/weakness/balance concerns]

Patient demonstrates remediable gait impairments requiring intensive mobility training per AHA Class I recommendation 1

Functional Assessment - Barthel Index or FIM Score

[Document specific scores for:]

Feeding: [score]
Bathing: [score]
Grooming: [score]
Dressing: [score]
Bowel control: [score]
Bladder control: [score]
Toilet use: [score]
Transfers: [score]
Mobility: [score]
Stairs: [score]

Total Score: [X]/100 (Barthel) or [X]/126 (FIM)

Standardized functional assessment used per AHA recommendation to track rehabilitation progress 1, 5

ASSESSMENT

Rehabilitation Diagnosis: Left hemiparesis secondary to CVA with impairments in strength (4/5 MMT left side), balance, gait, and functional mobility limiting independence with ADLs and community ambulation.

Prognosis: Good for continued functional improvement based on:

4/5 strength indicating preserved motor control 2, 3
[Early post-stroke timing: <6 months optimal for recovery] 5, 4
[Patient motivation and cognitive status]
[Medical stability]

Rehabilitation Potential: Excellent for achieving independence with mobility and ADLs with intensive, task-specific rehabilitation.

Safety Concerns: Fall risk due to left-sided weakness and balance deficits; requires [supervision/contact guard] for mobility 1

PLAN OF CARE

Frequency and Duration

Recommended: 3 hours per day, 5 days per week of multidisciplinary rehabilitation (PT, OT, Speech as indicated) per AHA Class I recommendation for optimal functional outcomes 5

Duration: [X] weeks with reassessment every 2-3 weeks to evaluate treatment effectiveness 5

Short-Term Goals (2-4 weeks):

Patient will demonstrate improved left lower extremity strength to 4+/5 to enhance gait stability 1
Patient will ambulate 150 feet with [assistive device] and supervision, demonstrating improved gait speed and reduced deviations 1
Patient will perform sit-to-stand transfers independently with [assistive device] in 3/5 trials 1
Patient will demonstrate improved standing balance with ability to maintain single-leg stance on right leg for 10 seconds 1
Patient will demonstrate improved left upper extremity function with ability to reach forward 12 inches while seated 1

Long-Term Goals (6-12 weeks):

Patient will ambulate 300+ feet independently with [assistive device if needed] at speed >0.8 m/s for community ambulation 1
Patient will ascend/descend 12 stairs with railing and supervision 1
Patient will perform all transfers independently without assistive device 1
Patient will demonstrate independence with basic ADLs (dressing, grooming, bathing) with adaptive equipment as needed 1, 5
Patient will demonstrate functional use of left upper extremity for bimanual tasks in daily activities 1

Interventions (Evidence-Based per AHA/ASA Guidelines):

Lower Extremity and Mobility Training (Class I, Level A):

Intensive, repetitive mobility-task training focusing on functional activities: sit-to-stand, transfers, walking, stairs 1
Task-specific gait training with progressive difficulty and intensity, 20-60 minutes per session 1, 5
Overground walking practice emphasizing step length symmetry, weight shift, and gait speed 1
Treadmill training (with or without body-weight support) may be incorporated to increase training intensity and duration 1, 5
Cardiovascular exercise at 40-70% heart rate reserve or 50-80% max heart rate, 20-60 minutes per session, using walking, stationary cycling, or combined arm-leg ergometry 1, 5

Strengthening Program (Class IIa, Level A/B):

Lower extremity resistance training 2-3 times per week to improve gait speed and walking distance 1, 5
- 1-3 sets of 10-15 repetitions of 8-10 exercises targeting major muscle groups 5
- Focus on hip flexors, extensors, abductors, knee extensors, and ankle dorsiflexors 1
Upper extremity strengthening as adjunct to task-specific training when time permits 1, 5
- 1-3 sets of 10-15 repetitions with lighter loads for safety 5

Balance Training (Class I, Level A):

Static and dynamic balance activities in sitting and standing 1, 5
Weight-shifting exercises in multiple directions 1
Functional reach training 1
Single-leg stance practice (on unaffected side initially) 1
Dual-task training combining balance with cognitive or motor tasks 1

Upper Extremity Training (Class I, Level A):

Task-specific training with repetitive, challenging practice of functional, goal-oriented activities 1, 5
Functional task practice emphasizing activities patient needs to perform in daily life 1, 5
Trunk restraint during reaching tasks to limit compensatory movements and enhance proximal control 5
Bilateral upper limb training for functional bimanual tasks 1

Stretching and ROM (Class IIa, Level B):

Stretching program 2-3 times per week, holding each stretch 10-30 seconds 5
Focus on left upper and lower extremity to maintain joint mobility and prevent contractures 5
Passive and active-assisted ROM as needed for limited joints 1

Orthotic/Assistive Device Prescription (Class I, Level A):

Ankle-Foot Orthosis (AFO) evaluation if foot drop present to improve mobility and gait biomechanics 1, 5
Appropriate assistive device (cane, walker) to improve balance and safety during gait 1

Adjunctive Modalities (Class IIa, Level A):

Neuromuscular Electrical Stimulation (NMES) may be considered as alternative to AFO for foot drop or as adjunct to upper extremity training 1, 5
Group circuit training may be incorporated as cost-effective approach to improve walking and enhance social engagement 1, 5

Patient and Family Education (Class IIa, Level B):

Home exercise program instruction for strengthening, balance, and functional activities 5
Fall prevention strategies and environmental modifications 1, 5
Stroke education regarding recovery expectations and secondary prevention 5
Caregiver training for safe assistance with mobility and ADLs as needed 5

Contraindications/Precautions:

Monitor blood pressure during exercise (target <130/80 mmHg) 1
Avoid intensive mobilization if within first 24 hours post-stroke 5
Monitor for signs of overexertion: excessive fatigue, shortness of breath, chest pain 1
Fall precautions during all mobility activities 1

Physical Therapist Signature: ___________________________
Date: ___________________________
License Number: ___________________________

Note: This evaluation note is based on American Heart Association/American Stroke Association Guidelines for Adult Stroke Rehabilitation and Recovery (2016) 1 and AHA/ASA Physical Activity and Exercise Recommendations for Stroke Survivors (2014) 1, which provide Class I (strongest) evidence-based recommendations for intensive, repetitive task-specific training as the foundation of stroke rehabilitation to optimize functional recovery, reduce disability, and improve quality of life.

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