The flaccid arm — protecting the shoulder
| Patient | 71M, acute phase |
|---|---|
| LesionLeft MCA, dense right hemiplegia | |
| Severity | NIHSS 14 |
| Days since onset | 4 |
| Before the strokeIndependent. Retired carpenter, right-handed. | |
| Also on the chartAtrial fibrillation (anticoagulated); Ischaemic heart disease | |
| PrecautionsCardiac monitoring; Orthostatic hypotension — gradual verticalisation; Nil by mouth — dysphagia, NG feeding; Fall risk | |
Test yourself
Day 4. Before any mobilisation, what do you check first?
The teaching
Day 4 with a dense hemiplegia is not about chasing movement — it is about not losing the arm to positioning injury while the brain sorts itself out. Subluxation first, standardised baseline (Fugl-Meyer), a positioning and NMES plan, family hands trained. The two traps are the pulley and the promise: one injures the shoulder, the other injures the family’s trust.
- SAFE 0/10 puts this arm on the poor-potential pathway of PREP2 — set the team’s expectations early and write the prognosis into the notes.
- Dysphagia and drowsiness cap the session length — frequent short bouts are a medical constraint here, not a preference.
- He is anticoagulated — report any shoulder bruising or swelling before anyone assumes a handling injury.
Read next
The full sequence
This page carries the case’s first decision. The full sequence — every decision, the five-domain examination, and the debrief that grades you — is in the drill, and the library is included with membership.
Sources on this page: Winstein CJ et al. Guidelines for Adult Stroke Rehabilitation and Recovery. Stroke. 2016;47(6):e98–e169. · Moore JL et al. A core set of outcome measures for adults with neurologic conditions undergoing rehabilitation. J Neurol Phys Ther. 2018;42(3):174–220. · Winstein CJ et al. Stroke. 2016;47(6):e98–e169.