¶ Stroke at the Allen
Sources: "Physical Therapy for the Acute Stroke Patient" inservice (Gerstenhaber, 2025); Allen OT Orientation Packet (2021); Neuro Team Cheat Sheet. NYP Columbia is a Joint Commission comprehensive stroke center — ~2,000 stroke patients/year across CUIMC/WCMC.
🚨 Suspected new/evolving stroke on an inpatient unit Call 212-305-3333 to activate the Acute Stroke Page and RRT. Give building, unit, room, patient demographics, and your name.
¶ Evaluation timing
- Stroke patients should be evaluated within 24 hours of the therapy order.
- Tenecteplase (TNK) — the single-dose thrombolytic that replaced tPA: wait 24 hours before the therapy evaluation. With clearance from the provider you may evaluate after 12 hours, but proceed with caution — the patient is at higher risk of hemorrhagic conversion.
- Antiplatelet therapy / DAPT (aspirin + clopidogrel): increased bleeding risk — extra vigilance for falls, gentle handling, pressure relief.
- Thrombectomy candidates: last known well within 24 hours, NIHSS >5.
¶ Blood pressure and precautions by stroke type
Watch BP closely and take it often — this is the core vital for every stroke session.
| Type | Typical parameters & precautions |
|---|---|
| Ischemic | Typically <180/105; early permissive hypertension is common — confirm the goal in the chart. Focal deficits follow the vascular territory. |
| Intracerebral hemorrhage (ICH) | Initial SBP >150 → goal 130–150; if initial <150, treat when >150. Avoid acute lowering below 130 — potentially harmful. HOB 30°; NPO until dysphagia screen; SpO2 ≥94%; glucose kept 100–180; Venodynes from day of admission; may have A-line, EVD, ICP monitor. |
| Subarachnoid hemorrhage (SAH) | SBP goal <140. HOB 30° — unless post-angiography, then reverse Trendelenburg at 30°. Initial bedrest; get clearance before mobilizing. Seizure precautions. SpO2 >94%. |
| General (cheat sheet) | Hemorrhagic strokes typically SBP <160 — always defer to the ordered parameters. |
¶ Decompressive hemicraniectomy
- Skull flap replaced ~1–3 months later; protect the defect until then.
- In the NICU: helmet not required for out-of-bed to chair if low fall risk; short helmeted periods for chair/ambulation with MD clearance.
- On the stroke unit and beyond: helmet on whenever out of bed; dangling without the helmet only in a controlled environment with adequate assistance.
¶ Evaluation essentials
- Chart review: time of onset, mechanism, territory/hemisphere, comorbidities; provider outcome scores — NIHSS (mild 1–5, mod-severe 5–14, severe 15–24, very severe >25), GCS, ICH score, Hunt-Hess.
- Assessment: arousal, cognition, communication (establish reliable yes/no with objective questions if non-verbal), vitals with orthostatic screen, cranial nerves as indicated, motor (bulk/tone/strength), sensation and extinction, coordination (dysmetria, dysdiadochokinesia, truncal ataxia), reflexes, sitting/standing balance — watch for contraversive pushing and midline orientation.
- OT domains (dept packet): strength, sensation, balance, fine and gross coordination, proprioception, vision (tracking, fields, convergence/divergence), cognition, and neglect (spatial, body).
- Functional mobility: limit cues and assistance at first to find the true baseline; allow processing time; identify the limiting factor (motor control, balance, apraxia, cognition).
¶ Outcome measures
| Measure | Key numbers |
|---|---|
| Berg Balance Scale | <50/56 → increased fall risk in stroke |
| PASS | >12.5 predicts independent ambulation at IRF discharge |
| Orpington |  .2 home · 3.2–5.2 rehab · >5.2 institutional care |
| 10-Meter Walk | <0.4 household · 0.4–0.8 limited community · 0.8–1.2 community; <1.0 m/s benefits from fall-prevention training |
| FGA | ≤22/30 correlates with fall risk |
| Also used at the Allen | 5xSTS, TUG, DGI, 6MWT (dept list) |
¶ Dysphagia and NPO
- All suspected stroke/TIA patients are NPO — including medications — until the dysphagia screen is performed and interpreted (usually provider or RN).
- OT: check swallow precautions and avoid liquids until SLP clears.
¶ Treatment and prognosis notes
- Ground treatment in the neuroplasticity principles (use it or lose it; specificity, repetition, intensity, salience) and motor-learning choices (practice type, feedback schedule, recovery vs. compensation).
- Early-mobilization tools: Combolizer, stretcher chair, Sara Plus; position for contracture prevention; train caregivers.
- Screen for post-stroke depression and report symptoms/medication response to the team — depression management improves participation.
- Skin safety: mobility-impaired patients need pressure management; check the Braden score.
- Prognosis favors: younger age, hemorrhagic type, continence, intact sitting balance, early consciousness. Dysphagia and severe initial disability are negative indicators.
- Patient education: BEFAST warning signs (RÁPIDO in Spanish); 5 modifiable risk factors — BP, diet, inactivity, smoking, abdominal obesity — drive 80–90% of stroke risk.