Eight months out — the plateau that isn’t
| Patient | 60F, chronic phase |
|---|---|
| LesionLeft capsular infarct, 8 months ago | |
| Severity | NIHSS 4 |
| Days since onset | 240 |
| Before the strokeIndependent. Primary school teacher, hopes to return part-time. | |
| Also on the chartDepression — engaged with GP; Hypertension | |
| PrecautionsTwo falls in the past year — review the environment | |
Test yourself
First re-evaluation in three months. What do you check first?
The teaching
Eight months out, the failure mode is resignation — the patient’s, the family’s, the team’s. The discipline: re-map what is still changeable (spasticity vs contracture first), measure the two goals directly, prescribe aerobic and task practice at real doses, and replace the plateau story with a four-week experiment she can watch herself win.
- Modified Ashworth 2 with full passive range argues spasticity, not contracture — the distinction that decides whether stretching or task practice leads.
- Low mood and a plateau story travel together. The goal-setting conversation is partly a mood intervention; her GP is already in the loop.
- 0.6 m/s is household ambulation. The community goal is a real, measurable step up — say the number, not ‘a bit better’.
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. Billinger SA et al. Physical activity and exercise recommendations for stroke survivors. Stroke. 2014;45(8):2532–2553. · 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. · Billinger SA et al. Stroke. 2014;45(8):2532–2553. French B et al. Cochrane Database Syst Rev. 2016;11:CD006073. Winstein CJ et al. Stroke. 2016. · Billinger SA et al. Stroke. 2014;45(8):2532–2553. Winstein CJ et al. Stroke. 2016.