3.1 Stroke (CVA) Rehabilitation
Key Takeaways
- Left-hemisphere cerebrovascular accident (CVA) typically produces right hemiparesis with aphasia, apraxia, and a cautious, slow processing style; right-hemisphere CVA typically produces left hemiparesis with unilateral neglect, impulsivity, and poor safety awareness.
- Brunnstrom motor recovery has seven stages, moving from flaccidity (stage 1) through obligatory synergy and spasticity (stages 2-4) to isolated, near-normal movement (stages 6-7).
- Motor return after stroke generally follows a proximal-to-distal and gross-to-fine sequence, and synergy patterns must be broken before isolated selective movement returns.
- Neurodevelopmental treatment (NDT) emphasizes normalized handling and tone, while task-specific and repetitive training emphasizes high-repetition functional practice; current evidence favors task-specific, high-intensity practice for motor outcomes.
- The PTA implements the physical therapist (PT) plan of care, drives carryover through consistent cueing and repetition, and reports plateaus or new deficits rather than redesigning the program.
Why Stroke Recovery Dominates Neuromuscular Items
A cerebrovascular accident (CVA), or stroke, interrupts blood flow to the brain through ischemia (clot) or hemorrhage (bleed). The Federation of State Boards of Physical Therapy (FSBPT) content outline allots 27-35 items to the neuromuscular and nervous systems domain, and stroke recurs because the physical therapist assistant (PTA) delivers most of the repetitive gait, balance, transfer, and upper-extremity practice that drives recovery. The exam tests whether you can recognize a recovery stage, match an intervention to it, and adapt your approach to the patient's hemisphere-specific behavior.
Hemisphere Differences
The brain controls the opposite side of the body, so the side of the lesion predicts the side of the weakness — and the cognitive-behavioral profile.
| Feature | Left-Hemisphere CVA | Right-Hemisphere CVA |
|---|---|---|
| Side of hemiparesis | Right | Left |
| Communication | Aphasia (expressive, receptive, or global) | Usually intact speech |
| Praxis | Apraxia common | Generally intact |
| Behavioral style | Cautious, anxious, slow, hesitant | Impulsive, quick, poor judgment |
| Visual-perceptual | Generally intact | Unilateral (left) neglect, spatial deficits |
| PTA implication | Use demonstration and visual cues; allow extra processing time | Add safety supervision; cue the patient to scan the neglected side |
A practical rule: the right-CVA patient overestimates ability and needs closer guarding, while the left-CVA patient underestimates ability and needs encouragement plus nonverbal instruction.
Brunnstrom Stages of Motor Recovery
Brunnstrom described a predictable seven-stage sequence of motor return after stroke. Recovery does not always reach stage 7, and a patient may plateau at any stage.
| Stage | Motor Status |
|---|---|
| 1 | Flaccidity — no voluntary movement |
| 2 | Synergies begin to appear; spasticity develops; minimal voluntary movement |
| 3 | Synergies performed voluntarily; spasticity peaks |
| 4 | Movement combinations deviate from synergy; spasticity decreases |
| 5 | More difficult movement combinations; synergy influence declines further |
| 6 | Isolated joint movements, near-normal coordination; spasticity minimal |
| 7 | Normal motor function restored |
Synergy Patterns
An obligatory synergy is a stereotyped, linked movement pattern the patient cannot break voluntarily. The two classic upper-extremity patterns:
- Flexion synergy (UE): scapular retraction/elevation, shoulder abduction and external rotation, elbow flexion, forearm supination, wrist and finger flexion.
- Extension synergy (UE): scapular protraction, shoulder adduction and internal rotation, elbow extension, forearm pronation.
The lower-extremity extension synergy (hip extension/adduction/internal rotation, knee extension, ankle plantarflexion/inversion) can actually assist a patient into standing early in recovery — a useful, not always undesirable, pattern.
Motor Recovery Sequence and Treatment Progression
Motor return typically moves proximal to distal and gross to fine, and synergy dominance must be reduced before isolated selective movement returns. Hemiparesis treatment generally progresses through:
- Early/flaccid stage: positioning to prevent contracture and shoulder subluxation, PROM, weight-bearing through the affected limb, trunk control, sensory input.
- Synergy/spasticity stage: facilitate movement out of synergy, scapular mobility, pelvic control, sit-to-stand, guarded gait.
- Recovery stage: task-specific gait and balance training, isolated control, fine-motor and dexterity practice, community-mobility tasks.
NDT vs Task-Specific Training
- Neurodevelopmental treatment (NDT) uses hands-on handling and key points of control to normalize tone and guide more typical movement patterns.
- Task-specific / repetitive training prioritizes high-repetition, functionally meaningful practice (e.g., repeated sit-to-stand, treadmill gait) and is strongly supported by current motor-learning and neuroplasticity evidence.
Most plans of care blend both. The PTA's role is to maximize repetitions, consistency, and carryover — using the same cues each session, training in functional contexts, and reinforcing the home program — while reporting plateaus, new deficits, or safety concerns to the supervising PT.
A PTA is performing gait training with a patient who had a right-hemisphere CVA two weeks ago. The patient repeatedly tries to stand and walk without waiting for the gait belt and consistently bumps the left side of the doorway. What is the MOST appropriate PTA approach?
A PTA notes that a post-CVA patient can voluntarily perform the upper-extremity flexion and extension synergies but cannot yet combine movements outside those patterns. Which Brunnstrom stage BEST describes this patient?