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 (a clot, roughly 87% of strokes) or hemorrhage (a bleed). The Federation of State Boards of Physical Therapy (FSBPT) builds the National Physical Therapy Examination for the Physical Therapist Assistant (NPTE-PTA) as a 200-item, 4-hour test (four 50-question sections; 180 scored, 20 unscored pretest items; passing scaled score 600 out of 200-800).
The neuromuscular and nervous systems domain is a large slice of that test, 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, the language profile, and the cognitive-behavioral profile.
| Feature | Left-Hemisphere CVA | Right-Hemisphere CVA |
|---|---|---|
| Side of hemiparesis | Right | Left |
| Communication | Aphasia (expressive/Broca, receptive/Wernicke, or global) | Usually intact speech; flat affect |
| 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 exam rewards: the right-CVA patient overestimates ability and needs closer guarding (a gait belt and hands-on contact), while the left-CVA patient underestimates ability, frustrates easily with verbal commands, and responds best to nonverbal demonstration plus encouragement.
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. Spasticity is the giveaway: it appears in stage 2, peaks in stage 3, and declines thereafter.
| Stage | Motor Status | Spasticity |
|---|---|---|
| 1 | Flaccidity — no voluntary movement | None |
| 2 | Synergies begin; minimal voluntary movement | Developing |
| 3 | Synergies performed voluntarily | Peak |
| 4 | Movement combinations deviate from synergy | Decreasing |
| 5 | More difficult combinations; synergy influence fades | Waning |
| 6 | Isolated joint movements, near-normal coordination | Minimal |
| 7 | Normal motor function restored | None |
Synergy Patterns
An obligatory synergy is a stereotyped, linked movement pattern the patient cannot break voluntarily. The two classic upper-extremity (UE) patterns are high-yield:
- Flexion synergy (UE): scapular retraction/elevation, shoulder abduction and external rotation, elbow flexion, forearm supination, wrist and finger flexion. (Elbow flexion is the strongest component.)
- Extension synergy (UE): scapular protraction, shoulder adduction and internal rotation, elbow extension, forearm pronation. (Shoulder adduction is strongest.)
The lower-extremity (LE) extension synergy — hip extension/adduction/internal rotation, knee extension, ankle plantarflexion/inversion — can actually assist a patient into standing early in recovery, so it is not always undesirable. The LE flexion synergy (hip flexion/abduction/external rotation, knee flexion, ankle dorsiflexion) helps with limb advancement in swing.
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 progresses through three broad phases:
- Early/flaccid stage: positioning to prevent contracture and shoulder subluxation, passive range of motion (PROM), weight-bearing through the affected limb, trunk control, and sensory input.
- Synergy/spasticity stage: facilitate movement out of synergy, scapular mobility, pelvic control, sit-to-stand, and guarded gait.
- Recovery stage: task-specific gait and balance training, isolated control, fine-motor and dexterity practice, and community-mobility tasks.
Shoulder Subluxation and Hemiplegic Shoulder
In the flaccid stage, the unsupported humeral head can drift inferiorly, producing glenohumeral subluxation and a painful hemiplegic shoulder. The PTA prevents it with proper positioning, supporting the arm during transfers, lap trays or arm troughs in the wheelchair, and avoiding pulling on the affected arm. Never use overhead pulleys on a flaccid hemiplegic shoulder — uncontrolled abduction can impinge tissues and cause pain.
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 (repeated sit-to-stand, treadmill gait, constraint-induced movement therapy) 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 common exam trap: when motor return stalls or a new deficit appears, the PTA reports to the PT; the PTA does not redesign or discontinue the plan of care independently.
Pusher Syndrome and Aphasia Communication
A subset of patients, more often after right-hemisphere strokes, develop contraversive pushing (pusher syndrome) — they actively push toward the hemiplegic side and resist correction toward midline, perceiving "upright" as tilted. The PTA does not fight the push; instead, use visual vertical references (a doorframe, a mirror, vertical lines) and have the patient self-correct toward the stronger side.
For aphasia, match strategy to type: an expressive (Broca) aphasic understands but cannot produce speech, so allow time and yes/no or gestural responses; a receptive (Wernicke) aphasic speaks fluently but does not comprehend, so rely on demonstration, gestures, and tactile cues rather than verbal commands.
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, and tone is at its highest. Which Brunnstrom stage BEST describes this patient?