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Outpatient physical therapy for a young adult post-cerebellar stroke presenting with balance and gait impairments

A 22-year-old patient following a left cerebellar hemorrhagic stroke was seen for physical therapy treatment for 8 sessions from 4/3/15 to 5/22/15 at an outpatient physical therapy clinic. Treatment was provided by a student physical therapist under the supervision of a licensed physical therapist. At the initial encounter, the patient was evaluated using the Modified Clinical Test of Sensory Interaction on Balance, Five Times Sit to Stand, Dynamic Gait Index, 10 Meter Walk Test, 6 Minute Walk Test, and the Falls Efficacy Scale-International, and a plan of care was established. The primary goals for the patient were to improve static and dynamic balance and postural control, lower extremity strength and walking endurance, motor control during functional activities, gait speed, independence with an assistive device, and to decrease fall risk. All interventions utilized were task-specific and included sensory integration training, fall prevention and recovery training, balance and motor control training, strength training, over-ground gait training, and body weight supported treadmill training. The patient improved static balance, motor control during gait and functional activities, walking endurance, and fear of falling relating to improved independence when ambulating with an assistive device in the community. The patient was discharged to continue living at home with a progressive home exercise program and with follow up home health physical therapy.

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