NCS Prep Program

Case Excerpt

A 76-year-old male is admitted to an inpatient rehabilitation hospital 20 days after a left middle cerebral artery ischemic cerebrovascular accident (CVA). He underwent tissue plasminogen activator (TPA) treatment, but his hospital course was complicated by the emergence of shingles on his left flank, and MRSA in his urine. His past medical history includes atrial fibrillation, degenerative joint disease, osteoporosis, coronary artery disease, hypertension, myocardial infarction, peripheral vascular disease (PVD), coronary artery bypass graft x2, abdominal aortic aneurysm repair, and a history of smoking 1 pack per day for many years. He currently has a 2-cm unstageable ulcer on his right heel. He lives with his wife in a 2-story home and has 2 sons who live in a neighboring town. He is a retired police officer. Prior to his stroke, he walked with a cane and was able to walk 10-15 minutes before tiring. He enjoys puzzles of any kind—crossword, word search, jigsaw, etc. His wife is 10 years younger than he is, works part-time at a discount store, and is in good health.

Question

An initial examination of this patient’s ambulation reveals the following:

• assistance required: minimal
• HR changes: 72–96 bpm after 100'
• distance at which motor components of gait begin to deteriorate: 100'
• walking speed: 0.3 m/s
• qualitative analysis: lack of R push-off and reduced R foot clearance during R swing phase; R hip flexion and mild knee hyperextension during R stance phase; asymmetrical step length R > L

Impairment in which muscle group is the most likely contributor to this patient’s slow walking speed?