9.1 Stroke and TIA: Acute Considerations

Quick Answer: Treat new FAST/BE-FAST features as a medical emergency. Start physiotherapy intensity only after medical stability and protocol clearance (including post-thrombolysis windows). Early mobilisation is valuable when safe and monitored—not when vitals, consciousness, or restrictions say stop. Assume swallow risk until formal clearance; position upright for approved oral intake and never improvise casual water tests.

Stroke (cerebrovascular accident, CVA) and transient ischaemic attack (TIA) sit at the centre of neurological cases on the APC Written Assessment. You are not expected to run a stroke unit or prescribe thrombolysis. You are expected to recognise time-critical neurology, respect medical stability before aggressive rehabilitation, mobilise early when safe, monitor cardiovascular and neurological response, and manage dysphagia-related positioning and oral-intake risks as part of the multidisciplinary team in Australian public, private, and community settings.

Stroke vs TIA: Working Definitions for Physiotherapy Reasoning

Ischaemic stroke is focal brain infarction from arterial occlusion (thrombus or embolus). Haemorrhagic stroke is bleeding into brain parenchyma or the subarachnoid space. Both can produce sudden focal deficits: unilateral weakness, sensory loss, aphasia or dysarthria, visual field cuts, neglect, ataxia, or altered consciousness. TIA is a transient episode of neurological dysfunction caused by focal ischaemia without permanent infarction on imaging, with symptoms typically resolving within minutes to hours. For bedside and exam purposes, treat any new or fluctuating focal neurological deficit as a medical emergency until medical teams have assessed it. Do not wait for symptoms to “prove” permanence before escalating.

Public and clinical recognition tools matter because delayed presentation worsens outcomes. FAST (Face, Arm, Speech, Time) remains a common public message. BE-FAST adds Balance and Eyes (vision) to capture posterior circulation and ataxia presentations that FAST can miss. Physiotherapists in community, ED, ward, and private settings may be the first clinician to notice new facial asymmetry, arm drift, speech change, sudden unsteadiness, or monocular/binocular visual change. Your first action is not a detailed gait scale—it is activate emergency medical response (call emergency services or the hospital stroke pathway) and keep the person safe while waiting (airway protection, prevent falls, nil by mouth if swallow uncertain).

Why “Medical Stability Before Aggressive Rehab” Is Exam Gold

Hyperacute and early acute stroke care prioritises reperfusion (where eligible), blood-pressure management according to stroke type and local protocol, glucose control, temperature management, secondary prevention (antiplatelet/anticoagulation decisions, statin, risk-factor work-up), and prevention of complications (aspiration, DVT, pressure injury, infection, shoulder subluxation). Physiotherapy is integral, but intensity and timing are constrained by medical status.

“Aggressive rehab” means high-dose, high-effort task practice, long upright sessions, and progressive endurance loading. That is appropriate later for many survivors; it is not automatic in the first hours after arrival when the person may still be within a reperfusion window, may have unstable blood pressure, evolving haematoma risk, new atrial fibrillation with rate issues, or fluctuating consciousness. Entry-level reasoning is: screen safety → clarify medical parameters → plan the lightest effective early intervention that prevents harm and begins recovery → escalate intensity as stability improves.

Red and amber medical flags that should slow or stop aggressive upright work (until clarified) include: new or worsening neurological deficit, reduced conscious state, uncontrolled arrhythmia or chest pain, SpO2 below target with increased work of breathing, fever with systemic instability, and blood pressure outside the unit’s agreed parameters for that stroke type. Haemorrhagic stroke often has tighter blood-pressure targets early; ischaemic stroke post-thrombolysis or thrombectomy has specific monitoring protocols. You do not need to memorise every mmHg for every protocol on the APC exam, but you must recognise that vitals and protocol parameters trump a generic “early mobility is always good” slogan.

Early Mobilisation Principles with Safety

Modern stroke care supports early mobilisation when medically appropriate: getting people out of bed, sitting, standing, and walking as soon as safety allows. Benefits include reduced deconditioning, improved orientation, earlier task practice, better respiratory toilet, and lower risk of pressure injury and DVT compared with prolonged bed rest. The key is individualised timing, not a race to day zero for every patient.

Practical principles for exam cases:

1. Confirm medical clearance parameters with the team or pathway (BP range, post-thrombolysis restrictions, intracranial pressure concerns, DVT prophylaxis status, lines/drains).
2. Assess baseline: conscious level, ability to follow commands, motor strength (including trunk), sensory and proprioceptive status, sitting balance, orthostatic symptoms, and any neglect or impulsivity that increases fall risk.
3. Start with the least demanding upright task that meets the goal (supported sitting edge of bed before unsupported standing; standing with two-person assist and gait belt before free walking).
4. Monitor response: symptoms (dizziness, nausea, headache, chest pain, increased confusion), heart rate and rhythm, blood pressure, SpO2, and neurological change. Stop and rest or return to bed if response is adverse.
5. Dose early sessions short and frequent when fatigue and cardiovascular reserve are limited; quality and safety beat heroic single sessions that end in collapse or aspiration.

Post-thrombolysis or endovascular treatment periods often include bed-rest or limited-mobility windows and puncture-site precautions. Do not invent a walk around the ward during an active restricted period. After the window, reassess and progress using the same safety framework.

Blood Pressure and Heart-Rate Caveats at Exam Level

Stroke cases commonly test whether you notice cardiovascular limits:

• Hypotension or orthostatic drop on sitting/standing can cause syncope, falls, and reduced cerebral perfusion—especially in older adults on antihypertensives or with dehydration. Measure and act: lie down or sit, legs elevated as appropriate, notify medical staff if symptomatic or outside parameters.
• Hypertension is common after stroke. Acute management is medical; physiotherapy should avoid unnecessary isometric straining, Valsalva, and extreme effort while BP is far outside target, and should report symptomatic hypertension (severe headache, visual change, chest pain, neurological deterioration).
• Heart rate: relative tachycardia, new irregularly irregular pulse suggesting AF, or bradycardia with dizziness all change risk. Do not progress aerobic-style walking trials without addressing new arrhythmia symptoms.
• RPE and symptom-limited progression are safer than rigid speed targets in the first days when autoregulation and reserve are uncertain.

Remember comorbidity: many stroke patients have ischaemic heart disease, heart failure, diabetes, or COPD. A “neuro” case is often a cardiorespiratory–neuro hybrid. If the vignette gives chest pain, SpO2 88% on air, or acute pulmonary oedema signs, treat those as stop/escalate cues even if the hemiparesis is your main interest. This integration mirrors APC case design across cardiorespiratory and neurology domains.

Dysphagia Awareness: Positioning and Oral Intake

Dysphagia is common after stroke, especially with brainstem, bilateral, or large hemispheric lesions, reduced alertness, or facial/bulbar weakness. Aspiration can be silent. Until a competent swallow screen or speech pathology assessment clears oral intake, nil by mouth (except care directed by the team) is the safe default in many pathways. Physiotherapists influence aspiration risk through:

• Upright positioning for any oral intake or oral medications once cleared—avoid feeding someone fully supine.
• Avoiding rushed mobility immediately after meals when aspiration risk is high and fatigue is peaking (coordinate with nursing/speech pathology).
• Recognising red flags: coughing/choking with intake, wet voice, recurrent chest infections, desaturation with feeding, delayed swallow, and pocketing of food.
• Airway and secretion management collaboration: positioning to optimise ventilation, assisted cough if indicated and safe, and escalation when chest status worsens.

Never “test the swallow yourself” with water as a casual experiment when formal screening is required. Scope and local protocol matter; APC reasoning favours safety and team process over improvisation.

Positioning, Shoulder Protection, and Pressure Care (Acute Layer)

Even before intensive motor rehab, acute physiotherapy contributes to:

• Hemiplegic shoulder protection: support the arm in sitting and lying; avoid traction on the flaccid shoulder during transfers; educate staff and family not to pull on the affected arm.
• Alignment and awareness: position to reduce neglect of the affected side where possible, and to maintain length without painful end-range forcing.
• Pressure injury prevention: turn schedules, offloading bony prominences, early sitting out when safe.
• Respiratory base: deep breathing and mobilisation to reduce atelectasis, within medical limits.

TIA-Specific Physiotherapy Angles

After TIA, motor recovery may appear “normal,” but risk of early stroke is elevated. Physiotherapy roles include screening residual subtle balance or dual-task deficits, educating on secondary prevention lifestyle factors within scope, ensuring the person understands urgent return if FAST symptoms recur, and not falsely reassuring someone who has not completed medical work-up (carotid imaging, cardiac rhythm monitoring, risk-factor optimisation). If symptoms return during your session, treat as acute stroke pathway—not as a physiotherapy technique failure. Australian community and private-practice vignettes often test this recognition outside the stroke unit.

APC Case Pattern: How to Choose the Best Option

Typical multi-choice traps:

• Choosing intensive gait training before medical stability or during post-thrombolysis restrictions.
• Ignoring new facial droop/speech change as “just fatigue.”
• Offering food or fluid to a drowsy post-stroke patient to “encourage energy for physio.”
• Pushing upright mobility despite symptomatic hypotension because “early mobilisation guidelines say day one.”
• Focusing only on the weak arm while the patient is hypoxic or in AF with rate 150.

Best answers usually: recognise emergency features → escalate → stabilise/liaise → then plan graded early rehab with monitoring, dysphagia-safe positioning, and clear goals.

Integration with Thresholds Competencies

This content maps to assessment and planning (collect relevant data, prioritise safety), collaborative practice (medical, nursing, speech pathology), and professional judgment (know when not to treat aggressively). Document neurological baseline, vital signs around mobility, assistance level, and any adverse response. Reassess frequently in the first 72 hours because stroke deficits can evolve. Cultural safety matters in communication about sudden disability, family roles, and consent for hands-on assistance—especially when language barriers or interpreter needs are present in Australian case stems.

Closing Exam Anchor

If you remember only one sentence from this section: time-critical recognition and medical stability set the ceiling for physiotherapy intensity; early mobilisation is powerful when protocol-safe, monitored, dysphagia-aware, and stopped when the body says stop.