Use of a Task-Oriented Approach in the Physical Therapy Management of a Patient Following a
Posterior Inferior Cerebellar Artery Stroke: A Case Report
Erika Derks, DPT Student
Department of Physical Therapy, University of New England, Portland, ME
Background
• 3.4% of the 600,000 strokes that occur annually in the
United States are cerebellar strokes.
1
• Despite the rarity of cerebellar strokes, their impact can
cause severe acute neurological morbidity.
2
• The posterior inferior cerebellar artery (PICA) supplies the
inferior portion of the cerebellum.
3
• PICA infarct can lead to deficits in:
o Gait and postural stability
o Coordination
o Cognition and attention
• The task-oriented approach has been demonstrated as an
effective intervention for patients with cerebrovascular
accidents, but limited research has been done on its use in
patients with cerebellar stroke.
Left picture: http://corticalchauvinism.com/2013/03/14/key-players-in-autism-ii-the-cerebellum/
Right picture: https://en.wikipedia.org/wiki/Posterior_inferior_cerebellar_artery
Purpose
To provide an overview of the physical therapy management
in the acute inpatient rehabilitation setting for a patient
following a PICA stroke, with the use of a task-oriented
approach
Case Description and Examination
• 78-year-old female
• Right PICA stroke
• Received daily physical therapy over four and a half weeks
in the acute rehabilitation setting
• Prior to admission, she was completely independent.
• During week three of her episode of care, she was
diagnosed with a second stroke.
Outcomes
The patient showed improvements in all categories by the end of
the treatment period. However, due to complications from a
subsequent stroke, the interdisciplinary team recommended
discharge to a skilled nursing facility for continued rehabilitation.
In comparison to the initial evaluation, the patient required less assistance in all
categories of functional mobility by discharge. The largest improvement (greatest
difference in assistance required) was in ambulation, wheelchair mobility, and supine
to sit. For wheelchair mobility and supine to sit, the patient required no assistance at
time of discharge.
Discussion
Physical therapists within the acute rehabilitation setting
commonly utilize the task-oriented approach for patients with
cerebral stroke. A similar intervention approach for this patient
with a cerebellar stroke appears to have been beneficial. The
patient had improved functional mobility at the time of discharge,
despite having a second stroke. This may warrant future studies
on this intervention method.
Acknowledgements
Special thanks to Rachel Emery, DPT, for supervision and
assistance with photo footage, Amy Litterini, PT, DPT for
assistance with case report conceptualization, and the patient for
participation in the case report.
Outcome
Measures
Admission
Discharge
Berg
Balance Scale
5/56 =
high fall risk
13/56 = high
fall risk
Functional Independence
Measure (FIM)
Total FIM
score = 44 (18 lowest
possible
– 126 highest possible)
Total FIM level = 2.44 (Maximal
assistance)
Total
FIM score = 72 (18 lowest
possible
– 126 highest possible)
Total FIM level = 4 (Minimal
assistance)
Interventions
Interventions were performed using a multidimensional approach, with an emphasis on
task-oriented rehabilitation. Interventions were progressed over time, including more
complex neuromuscular re-education activities, increased ambulation distances, and
decreased assistance.
0 10 20 30 40 50 60 70 80
Ambulation
Stand to Sit
Sit to Stand
Supine to Sit
Sit to Supine
Wheelchair Mobility
Percentage of Assistance Given (%)
Mobility Measure
Functional Mobility Progression
Initial Evaluation Discharge
Image A shows the patient mid-ambulation with no visual cues. She demonstrated an ataxic gait pattern,
including scissoring of her lower extremities. Image B shows the patient ambulating with visual cues.
Parallel lines of blue tape were applied to the floor and the patient was encouraged to place her feet on
the lines during ambulation. This improved her foot placement and decreased the scissoring of her lower
extremities.
Neuromuscular
Re-education
Therapeutic
Exercise
Gait Training
Transfer Training
Bed Mobility
Wheelchair
Mobility
Initial Plan of Care
Neuromuscular
Re-education
Therapuetic
Exercise
Gait Training
Transfer Training
Bed
Mobility
Wheelchair
Mobility
Modified Plan of Care
References:
1. Prevalence of Stroke - United States. Centers for Disease Control and Prevention Web site.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6120a5.htm?s_cid=mm6120a5_w. Accessed June 26, 2015
2. Kase CS, Norrving B, Levine SR, et al. Cerebellar infarction: clinical and anatomic observations in 66 cases.
Stroke. 1993;24:76-83. Available at: http://www.medscape.com/medline/abstract/8418555. Accessed July 10, 2015.
3. Dichgans J. Clinical symptoms of cerebellar dysfunction and their topodiagnostical significance. Hum Neurobiol.
1984;2:269-279. Available at: http://www.ncbi.nlm.nih.gov/pubmed/6715211. Accessed June 28, 2015.
Tests and Measures
Results
Manual Muscle Testing
Right LE= 4/5, Left LE = 4
-/5
Coordination: Heel to Shin
Right
= Slow and inaccurate, Left = Slow but
accurate
Sensation: Discriminative Touch
Right UE/LE =
Normal, Left UE/LE = Diminished
Functional Balance Grades
Static Sitting =
Fair, leans to the right
Static Standing = Poor
Dynamic Sitting/Standing = Not tested due to safety
Gait Analysis
Moderate assist
x 2 with rolling walker, max verbal
cues, ataxic gait, scissoring
pattern, unsteady and
uncontrolled foot placement, heavy reliance on
walker, trouble initiating gait
Communication
Dysarthria, word finding difficulties, difficulty
following basic commands and holding conversation
A B
The frequency of the interventions performed across the sessions in
the initial plan of care (A), and the modified plan of care (B) after the
patient had a second stroke.
A B
