Stepping Forward: A Case Report on Innovative Rehabilitation in Hemorrhagic Stroke

Case Diagnosis: Left anterior cerebral artery (ACA) infarct with hemorrhagic conversion

Case Description or Program Description: A 49-year-old hypertensive male presented with right-sided weakness and aphasia. Imaging revealed left intracerebral hemorrhage and left internal carotid artery thrombus with possible dissection. During inpatient rehabilitation, mirror therapy (MT) was implemented for gait training, supplemented by neuromuscular electrical stimulation (NMES). Sinemet was initiated and uptitrated to promote motor recovery.

Setting: Grady Inpatient Rehabilitation Unit

Assessment/Results: Initially, manual muscle testing (MMT) showed 0/5 strength in the right lower extremity (RLE). Despite this severe motor deficit, the patient demonstrated functional ambulation with a walker and ankle-foot orthosis under close guarding. By discharge, he exhibited proximal RLE improvement and maintained stride and cadence without MT for the first time. He achieved independence in ambulation up to 150 feet on even surfaces, setup assistance for uneven surfaces, and supervision for stairs.

Discussion (relevance): This case highlights several unique aspects that contribute significantly to the existing literature on stroke rehabilitation. The remarkable functional recovery despite severe initial deficits demonstrates a striking disconnect between traditional impairment measures and functional outcomes. This challenges conventional thinking and emphasizes the importance of function-focused rehabilitation approaches.

The combined use of MT and NMES for lower extremity rehabilitation is relatively uncommon, especially in cases with such severe initial impairments. Recent meta-analyses, albeit with small sample sizes, suggest this combination elicits greater improvement in walking speed, balance, and other gait parameters compared to conventional therapy alone. Our case provides real-world evidence supporting this emerging approach, particularly in the context of severe initial motor deficits.

Conclusions: This case is among the first documented instances of using combined MT and NMES for significant functional recovery in a patient with such severe initial motor deficits. It adds valuable insights to the growing body of evidence supporting innovative, multifaceted approaches in stroke rehabilitation, particularly for patients with severe initial impairments.