Two mechanisms, one clinical picture
You cannot reliably tell an ischaemic from a haemorrhagic stroke at the bedside. That is exactly why imaging comes before thrombolysis, and it is a favourite reasoning trap in exam cases.
Blood supply is blocked
- Thrombotic — clot forms on an atherosclerotic plaque, often large-vessel or lacunar.
- Embolic — clot travels from elsewhere. Atrial fibrillation is the classic source.
- Hypoperfusion — global drop in flow, watershed infarcts.
Onset is often sudden and may be noticed on waking. Deficit reflects the territory starved of blood.
Blood supply is spilled
- Intracerebral — bleeding into brain tissue. Chronic hypertension is the leading cause.
- Subarachnoid — bleeding into the subarachnoid space, usually a ruptured aneurysm.
More likely to feature sudden severe headache, vomiting, falling level of consciousness, and rapid deterioration. Mass effect and raised intracranial pressure drive the picture.
Recognition in the community: FAST
Onset time is the single most valuable piece of history you can hand the medical team. It determines eligibility for thrombolysis and endovascular therapy.
Click a territory. Predict the presentation.
Almost every "why does this client present this way" question resolves to vascular anatomy. Learn the territory, and the sign list writes itself.
Schematic, not anatomical. Tap or use Tab plus Enter to explore.
Left hemisphere, right hemisphere, two different clients
Motor loss is contralateral. The behavioural picture is what actually changes your treatment style, your cueing, and your safety plan. Flip each card.
Homonymous hemianopia
A lesion behind the optic chiasm removes the same visual field in both eyes, on the side opposite the lesion. This is a field loss, not an attention problem.
Hemianopia or neglect? Screen the difference
They coexist, but they are managed differently, and the exam wants you to name the distinction.
| Feature | Hemianopia | Neglect |
|---|---|---|
| Aware of loss | Usually yes | Usually no |
| Turns head to compensate | Yes, spontaneously | No |
| Reads a page | Loses end of line, self-corrects | Ignores half the page entirely |
| Screen with | Confrontation fields | Line bisection, cancellation, clock drawing |
Manage hemianopia by teaching scanning. Manage neglect by drawing attention into the neglected side and structuring the environment. Both need occupational therapy involvement.
What you gather, and the order you gather it in
Examiners score the reasoning, not the list. Lead with screening and safety, then impairment, then activity, then participation.
Chart and subjective
- Stroke type, territory, imaging findings
- Date and time of onset, thrombolysis or thrombectomy
- Comorbidities: atrial fibrillation, hypertension, diabetes, previous stroke
- Anticoagulation status and blood pressure parameters
- Swallowing screen status, cognition, continence
- Prior level of function, home setup, supports, goals
Body structure and function
- Cognition and communication screen before you test anything
- Tone, using the Modified Ashworth Scale
- Voluntary movement and synergy patterns
- Sensation, proprioception, stereognosis
- Coordination, dysmetria, dysdiadochokinesia
- Glenohumeral alignment and shoulder pain
- Range of motion and soft tissue length
Activity and participation
- Bed mobility, sitting balance, sit to stand
- Transfers and standing balance, static then dynamic
- Gait, endurance, stairs, outdoor surfaces
- Upper limb reach, grasp, manipulation
- Falls history and falls risk
- Role, work, driving, community access
Motor recovery follows a pattern
Spasticity typically emerges as flaccidity resolves, peaks in the middle stages, then declines as isolated movement returns. Recovery can arrest at any stage. The Chedoke-McMaster Stroke Assessment stages this formally and is widely used in Canada.
Outcome measures worth naming out loud
In an oral case, naming a measure earns a mark. Naming the measure and what score would change your plan earns the reasoning mark on top.
| Measure | What it captures | Score range | Interpretation anchor |
|---|---|---|---|
| Berg Balance Scale | Static and dynamic sitting and standing balance | 0–56 | Lower scores indicate higher falls risk; commonly flagged below the mid-40s |
| Timed Up and Go | Functional mobility, transfer plus turn | Seconds | Slower times associate with falls risk; compare against the client's own baseline |
| 10 Metre Walk Test | Comfortable and fast gait speed | m/s | Roughly below 0.4 household, 0.4 to 0.8 limited community, above 0.8 community ambulation |
| 6 Minute Walk Test | Walking endurance and cardiorespiratory capacity | Metres | Track change over time; pair with rating of perceived exertion |
| Chedoke-McMaster | Impairment and activity, staged recovery | Stages 1–7 | Canadian, maps directly to stage-based treatment selection |
| Fugl-Meyer Assessment | Sensorimotor impairment, upper and lower limb | Motor 0–100 | Research standard for motor impairment; sensitive to synergy emergence |
| Modified Ashworth Scale | Resistance to passive movement | 0, 1, 1+, 2, 3, 4 | Measures tone, not function. Never justify treatment on tone alone |
| Postural Assessment Scale for Stroke | Postural control including lying and sitting | 0–36 | Useful early, when Berg has a floor effect |
| Action Research Arm Test / Box and Block | Upper limb function and dexterity | Varies | Pick one and use it consistently for reassessment |
| Stroke Impact Scale | Participation and quality of life | 0–100 per domain | The client-reported measure that lifts you out of impairment-only reasoning |
Always confirm current cut-off and minimal detectable change values against the source manual and Canadian best practice recommendations before you rely on them clinically.
The plan changes with the phase of recovery
The same client needs different physiotherapy at day two, week six, and year two. Say which phase you are in, and the marker knows you are reasoning rather than reciting.
Interventions with the strongest support
- Task-specific, repetitive practice at high dose. Repetitions matter. Practising standing up builds standing up.
- Strength training. It improves function and does not worsen spasticity. Say this if a case tries to bait you.
- Aerobic and fitness training for endurance, mood, and secondary prevention.
- Constraint induced movement therapy where there is some active wrist and finger extension.
- Mirror therapy and mental practice as adjuncts for the upper limb.
- Functional electrical stimulation for dorsiflexion and shoulder subluxation.
- Body weight supported treadmill training and overground walking practice.
- Early supported discharge with a coordinated team, where the client is suitable.
Goal setting that scores
- Written with the client, not for them. Involve family where the client consents.
- Specific and measurable. Not "improve balance". Rather, "stand at the kitchen counter for two minutes without upper limb support, within three weeks".
- Anchored to participation, because that is what the client came for.
- Reviewed and revised as status changes, and documented each time.
- Realistic against prognosis, without extinguishing hope.
The section that fails candidates
This domain appears in every oral case. In a stroke case it is nearly always about mobilisation limits, swallowing, blood pressure, and falls.
Red flags during a session
- New or worsening neurological deficit
- Sudden severe headache, vomiting, or falling level of consciousness
- Seizure activity
- Chest pain, marked dyspnoea, new arrhythmia
- Unilateral calf pain, swelling, warmth, suggesting deep vein thrombosis
- Blood pressure outside the parameters set by the medical team
- Coughing, wet voice, or choking with oral intake
Stop the session, position the client safely, take vital signs, do not leave them alone, and contact the medical team. Then document.
Your pre-session checks
- Confirm medical clearance and any blood pressure or activity parameters in the chart.
- Check whether the client has been screened for dysphagia. Nothing by mouth until they pass, including water.
- Screen for orthostatic hypotension as you progress from lying to sitting to standing.
- Note anticoagulation. Bruising and bleeding risk changes how you handle and how you interpret a fall.
- Check lines, catheters, oxygen, and telemetry before you move anyone.
- Plan the number of people you need. Ask for the second person. Nobody has ever failed for asking.
Complications you are expected to prevent
Each of these is a plausible curveball in a case. Each has a physiotherapy answer and a referral answer, and the exam wants both.
Hemiplegic shoulder pain and subluxation
The flaccid shoulder loses its rotator cuff and deltoid support. The humeral head drops, and a palpable gap appears below the acromion.
- Support the limb in sitting, lying, and standing. Lap tray, arm trough, pillow.
- Never pull on the affected arm during transfers. Educate every person who handles the client.
- Avoid overhead pulley exercise. It is associated with shoulder pain.
- Do not force abduction or flexion without external rotation and scapular movement.
- Consider taping, strapping, and functional electrical stimulation. Evidence supports delaying pain onset.
The rest of the list
- Aspiration pneumonia. No oral intake until the dysphagia screen is passed. Refer to speech-language pathology.
- Deep vein thrombosis and pulmonary embolism. Mobilise, position, and watch for calf signs.
- Pressure injury. Turning schedule, offloading, skin checks, especially over insensate areas.
- Falls. Highest risk where there is neglect, impulsivity, and poor insight.
- Spasticity and contracture. Range of motion, positioning, splinting, and medical management with botulinum toxin where indicated.
- Post-stroke depression. Common, under-recognised, and it will blunt your rehabilitation gains. Screen and refer.
- Central post-stroke pain. Neuropathic. Does not respond to the usual musculoskeletal approach. Refer for medical management.
- Pusher behaviour. The client actively pushes toward the hemiplegic side and resists correction. Do not push back. Use visual vertical references and let the client find midline themselves.
Who you refer to, and exactly why
"I would refer to the team" earns nothing. Name the professional and name the reason. That is the whole mark.
Speech-language pathology
Dysphagia assessment before any oral intake. Aphasia assessment, and the supported communication strategies you will use in your own sessions.
Occupational therapy
Activities of daily living, upper limb function, cognition, perception, neglect retraining, home assessment, equipment, driving readiness.
Nursing
Continuous observation, skin integrity, continence, medication timing. Schedule your session around peak function, not the ward routine.
Physician or physiatrist
Blood pressure parameters, spasticity management, mood, pain, seizure risk, medical clearance for activity, driving fitness.
Dietitian and social work
Modified texture diets and nutrition. Discharge destination, funding, caregiver strain, return to work.
Support personnel
You may assign a stable, repetitive task with appropriate supervision. You may never assign assessment, interpretation, or the decision to progress.
Talking with a client who has aphasia
Aphasia affects language, not intelligence. If you remember one line from this section, make it that one, and then say it in your case.
Do
- Speak to the client, not the family member beside them.
- Use short sentences, one idea at a time, and normal adult tone.
- Offer closed or yes and no questions when needed, and verify with a second question.
- Write key words, draw, gesture, and demonstrate.
- Allow long pauses. Silence is processing.
- Reduce background noise and distraction.
- Confirm understanding and consent before you touch or move anyone.
Do not
- Raise your voice. This is not a hearing problem.
- Finish their sentences by default, unless they have asked you to.
- Assume a nod means comprehension. Check it.
- Assume that a client who cannot speak cannot consent. Capacity is presumed. Find a way to communicate before you conclude otherwise.
- Talk about the client over their bed as though they are absent.
Consent, capacity, and the awkward questions
Consent and capacity
- Capacity is presumed and is decision specific. A client may consent to physiotherapy while being unable to manage finances.
- Aphasia is a communication barrier, not automatic incapacity. Exhaust supported communication first.
- If the client lacks capacity, work with the substitute decision maker, and still involve the client to the extent they are able.
- Consent is ongoing. It can be withdrawn mid-session, including non-verbally.
Situations that show up in cases
- Driving. Do not clear anyone yourself. Report your functional findings, and direct the client to the physician and the provincial licensing authority, which sets the restriction period.
- Family pushing for more therapy. Acknowledge, explain the reasoning and the evidence, offer a home programme, and document the conversation.
- Client refuses treatment. Explore the reason, provide information, respect the decision, document it, and inform the team.
- Outside your competence. Say so. Seek supervision, consult, or refer. Practising beyond your competence is the fastest way to fail a professional responsibility question.
- Documentation. Objective, timely, and it records what you did, what you found, and what you decided next.
Answer out loud, then reveal
Speak your answer for sixty seconds before you open the card. Reading a model answer feels productive and teaches you almost nothing.
Your client had a right middle cerebral artery infarct four days ago. Describe your initial physiotherapy assessment and justify your prioritisation.
Structure to hit: Chart review and medical stability first, including blood pressure parameters, dysphagia screen status, and anticoagulation. Then screen cognition, perception, and neglect, because a left neglect will invalidate everything I measure afterwards if I ignore it.
Then impairment: tone, voluntary movement, sensation, and glenohumeral alignment on the left. Then activity: bed mobility, sitting balance, sit to stand, transfers, standing balance, gait if safe. Then participation and prior function and home setup.
Justification: I prioritise safety and screening because a right hemisphere client is likely to be impulsive with poor insight, which makes them a high falls risk, and because I need a valid picture before I set goals. I would use the Postural Assessment Scale for Stroke early if Berg has a floor effect.
Midway through standing practice the client develops a sudden severe headache and becomes drowsy. What do you do?
Immediate: Stop the activity. Return the client safely to a supported sitting or lying position. Do not leave them unattended. Call for help.
Then: Take vital signs including blood pressure, assess level of consciousness, and perform a rapid neurological screen comparing to baseline. Escalate urgently to the medical team or emergency services, because I am concerned about a haemorrhagic event or extension of the stroke.
After: Hand over onset time and exactly what changed. Document objectively. Do not resume therapy without medical clearance.
The client's daughter asks whether her father will walk again. He has dense flaccid hemiplegia at day five. How do you respond?
Consent first. Confirm the client is comfortable with me discussing his care with his daughter, and involve him in the conversation.
Be honest without removing hope. Explain that it is too early to give a definite answer, that recovery is most rapid in the first weeks to months, that gains continue beyond that, and that a number of factors influence the outcome.
Redirect to what is controllable. Describe the plan, the short-term goals, and how she can help. Offer to revisit the conversation as we reassess. Involve the physician and the team for the prognostic discussion. Document what was discussed.
What loses marks: Promising he will walk. Or flatly saying he will not.
The client complains of left shoulder pain during transfers. Explain the likely mechanism and your management.
Mechanism: With a flaccid or weak deltoid and rotator cuff, the humeral head loses superior support and subluxes inferiorly. Pain is provoked by traction on the joint, by soft tissue impingement when the arm is moved without scapular rotation and external rotation, and by being pulled on during handling.
Assess: Palpate for a subluxation gap, screen range of motion, and check how the arm is being handled by staff and family.
Manage: Support the limb at all times. Educate all handlers not to pull on the arm, and to use a safe transfer technique. Avoid overhead pulleys. Consider taping and functional electrical stimulation. Maintain pain-free range with correct scapulohumeral mechanics. Escalate for pain management if it persists.
The team wants to discharge home in a week. The client lives alone with three stairs to the entry. What is your role?
Assess against the destination. Test the actual demands: transfers, gait with any aid, stairs with the real step height and rail configuration, endurance for the distance from the car, and falls risk.
Collaborate. Occupational therapy for a home assessment and equipment. Social work for supports and funding. Physician for medical readiness. Speech-language pathology if eating alone is a concern.
Prepare the client. Home exercise programme, education on falls prevention and stroke recognition, what to do if they fall, and a clear plan for follow-up or outpatient therapy.
Advocate. If discharge is unsafe, state the objective findings that support that position, propose what would make it safe, and document the recommendation.
A colleague suggests you avoid strength training because it will increase the client's spasticity. How do you respond?
Respectfully and with evidence. Strength training in stroke improves strength and function, and current evidence does not support the belief that it increases spasticity. Weakness, not spasticity, is the greater contributor to functional limitation in most clients.
I would share the evidence, discuss it collegially, and continue to monitor tone objectively using the Modified Ashworth Scale so that our decision rests on measurement rather than assumption. This also demonstrates incorporating best available evidence into clinical decision-making.
Can you do all fourteen of these?
Tick honestly. Anything unticked is your next study block.
0 of 14 complete