---

Physiotherapy Management — Right Hemiplegia Post-Stroke (60-Year-Old, Pacemaker)

---

1. UNDERSTANDING THE MMT GRADES & CLINICAL PICTURE

MMT Grade Interpretation (MRC Scale)

Patient's MMT Summary (Right Side)

Symptoms Explained by MMT & Tightness

• Leg dragging in external rotation: Weak hip flexors (2−) cannot lift the leg, so patient circumducts; hip external rotation deformity from piriformis tightness + external rotator dominance
• External rotation deformity: Piriformis tightness rotates femur externally; weak hip abductors/internal rotators cannot counteract
• Adductor tightness: Common post-stroke due to spastic tone in adductors, leads to scissor gait tendency; here combined with external rotation creates characteristic hemiplegic drag
• Trendelenburg gait tendency: Weak hip abductors (2−) → pelvis drops on swing phase
• Poor push-off: Hip extensor grade 1 + plantar flexor 2− → no propulsion
• Foot drop risk: Dorsiflexors 2− → foot may catch ground
• Poor upper limb function: Shoulder muscles grade 1 prevents overhead function; wrist 2+ is the strongest segment — focus for early UL rehab
• Inability to walk independently: Hip flexors insufficient to clear limb; no hip extension for propulsion; piriformis tightness locks ER position

---

2. PACEMAKER PRECAUTIONS

• Avoid strong electromagnetic fields — no TENS, IFT, ultrasound, diathermy, or electrical stimulation near the chest/pacemaker site
• Heart rate monitoring — note the pacemaker-set rate (typically 60–70 bpm lower limit); use Rate of Perceived Exertion (RPE) scale (Borg 6–20), target RPE 11–13 (light to somewhat hard)
• No upper limb exercises with shoulder abduction > 90° in early weeks (pacemaker lead stability — confirm with cardiologist)
• Avoid Valsalva maneuver during exercises
• Electrotherapy allowed only distal to pacemaker (e.g., hand/wrist) with bipolar electrode placement
• Coordinate with cardiologist for exercise intensity clearance

---

3. GOAL SETTING

Short-Term Goals (0–4 Weeks)

1. Prevent secondary complications (contractures, pressure sores, DVT)
2. Improve passive and active range of motion
3. Stretch tight structures (piriformis, adductors)
4. Progress MMT grades by 0.5–1 grade in key muscles
5. Improve standing balance and weight-bearing tolerance
6. Safe sit-to-stand with reduced support

Long-Term Goals (4–12+ Weeks)

1. Independent ambulation with walking aid (at minimum)
2. Eliminate external rotation drag pattern
3. Functional upper limb use (at least gross grasp)
4. Community-level mobility
5. Improved pelvic control and core stability

---

4. DETAILED PHYSIOTHERAPY MANAGEMENT PLAN

---

A. POSITIONING & SPASTICITY MANAGEMENT

• Right upper limb: shoulder protracted (slight forward), elbow extended, wrist neutral, fingers extended with thumb abducted (anti-spastic position)
• Right lower limb: hip in neutral rotation (pillow between knees to prevent ER), knee slight flexion, ankle in neutral with foot splint/AFO

• Weight-bearing equally through both buttocks
• Right foot flat on floor
• Trunk upright, no lateral lean

---

B. RANGE OF MOTION (ROM) EXERCISES

Passive ROM (All joints, 2× daily, 10 repetitions each)

• All shoulder motions (within pacemaker precaution limits)
• Elbow, wrist, finger — full ROM, focus on finger extension
• Hip: flexion, extension, internal rotation (counteracts piriformis/ER tightness)
• Knee flexion/extension
• Ankle dorsiflexion (sustained stretch)

Active Assisted ROM

• Wrist flexion/extension (grade 2+ — patient can assist)
• Knee extension (grade 2 — gravity eliminated position, horizontal)
• Hip flexion (gravity eliminated, side-lying — grade 2−)

---

C. STRETCHING (Priority: Piriformis + Adductors)

Piriformis Stretch

• Right hip flexed 60°, right ankle resting on left knee
• Gentle pressure on right knee downward (figure-4 stretch)
• Hold 30–60 seconds × 3 repetitions, 2× daily
• Goal: Reduce external rotation deformity, normalize gait pattern

Adductor Stretch

• Both hips flexed, feet flat — allow right knee to fall outward (butterfly position)
• OR: Side-lying with right hip abducted gently with support
• Hold 30–60 seconds × 3 reps, 2× daily

Plantarflexor/Calf Stretch

• Sustained dorsiflexion stretch with towel or standing stretch at wall
• 30–60 seconds × 3 reps (prevents equinus)

Wrist/Finger Extensors

• Sustained gentle extension of fingers and wrist to counteract flexor tone

---

D. STRENGTHENING PROGRAM

Lower Limb (Gravity Eliminated Positions First — Grades 2)

Upper Limb

Core & Pelvic Stability

• Pelvic tilting (anterior/posterior) — supine
• Pelvic bridging (patient can do 10s) → progress to marching in bridge
• Trunk side-bending in seated — right lateral flexion activation
• Dead bug exercise (supine, legs and arms moving alternately) — when tolerated

---

E. NEURODEVELOPMENTAL TECHNIQUE (NDT/BOBATH)

1. Weight-bearing through affected limb — facilitates tone normalization
2. Key point of control (KPC):
   • Proximal KPC: shoulder girdle, pelvic girdle
   • Distal KPC: wrist, hand
3. Inhibition of spastic patterns:
   • Trunk rotation in sitting (inhibits limb spasticity)
   • Weight shifting in standing
4. Facilitation of normal movement:
   • Reaching tasks (UL), stepping tasks (LL)
   • Rhythmic initiation for hip flexion during gait

---

F. TRANSFER & FUNCTIONAL MOBILITY TRAINING

Sit-to-Stand (Patient Currently Able With Frame)

1. Ensure equal weight through both feet before rising
2. Lean trunk forward ("nose over toes") before extending hips
3. Cue right hip extension during rise
4. Progress: from higher surface → standard height → lower surface
5. Work toward frame → quad cane → standard cane

Standing Program

• Standing with frame: weight shift side-to-side (5 min → 15 min)
• Weight transfer onto right leg: controlled unilateral standing 5–10 seconds
• Mini-squats in standing (with frame): activates quads and hip extensors
• Toe tapping and heel raises in standing

---

G. GAIT RETRAINING (Most Critical Goal)

• Insufficient hip flexion to clear limb
• Piriformis/ER tightness blocking neutral rotation
• No propulsion from hip extensors
• Risk of foot catch/fall

Gait Re-Education Sequence:

• Pelvic bracing and pelvic rocking (patient has 10s pelvic bracing — good foundation)
• Standing hip flexion practice (lift right knee while holding frame — gravity eliminated → against gravity progression)
• Weight shifting forward/backward/lateral in standing
• Marching in place (with frame)

• Therapist facilitates hip internal rotation manually during swing phase
• Cue patient: "Turn your right foot inward / forward"
• Step practice with frame: right leg — emphasize heel strike (not toe drag)
• Parallel bars if available — stepping practice

• Instruct patient to actively internally rotate hip during swing (counteract piriformis)
• Use floor markers (tape lines) to guide step placement
• Rhythmic auditory cueing (metronome) — improves stride regularity
• Mirror feedback — patient observes gait pattern

• Walking frame (current) → wheeled walker → quad cane → single-point cane
• Outdoor walking when indoor is safe

Ankle Foot Orthosis (AFO) Consideration

• Dorsiflexors 2− → foot drop risk during swing phase
• A rigid or hinged AFO prevents foot-drop, improves heel-strike, and improves safety
• Refer to orthotist for assessment

---

H. BALANCE TRAINING

---

I. ELECTRICAL STIMULATION (Pacemaker-Safe)

• Neuromuscular Electrical Stimulation (NMES) to right dorsiflexors and wrist extensors (distal electrodes only, bipolar, not near chest)
• NMES for dorsiflexors during gait = Functional Electrical Stimulation (FES) — improves foot clearance
• Confirm with pacemaker manufacturer/cardiologist re: safe parameters (typically 1–5 mA, short pulse, well away from chest)

---

J. ACTIVITIES OF DAILY LIVING (ADL) & OCCUPATIONAL THERAPY LIAISON

• Right arm used as assist limb for bilateral tasks (wrist 2+ is functional)
• Wrist extension splint to facilitate hand function
• Practice: reaching, object transfer hand-to-hand, weight-bearing on right palm
• Home modification: grab bars, raised toilet seat, non-slip mats

---

K. HOME EXERCISE PROGRAM

1. Piriformis stretch × 3 daily
2. Adductor stretch × 3 daily
3. Ankle pump/dorsiflexion × 20 reps hourly (DVT prevention + muscle activation)
4. Pelvic bridging × 10 reps (patient already achieving 10s hold — maintain and progress)
5. Seated wrist curls and extensions × 15 reps
6. Standing at kitchen counter for 5–10 minutes (weight bearing)

---

5. OUTCOME MEASURES TO TRACK PROGRESS

---

6. SUMMARY OF CLINICAL PRIORITIES

---

---

Complete Physiotherapy Assessment & Management

60-Year-Old | Right Hemiplegia | Pacemaker

---

PART 1 — MMT GRADE INTERPRETATION & SYMPTOMS

Understanding the MRC Manual Muscle Test Scale

---

Patient's Complete MMT Profile & Symptoms

UPPER LIMB (Right)

• The arm hangs limp at rest in the classic hemiplegic posture: shoulder adducted and internally rotated, elbow slightly flexed, wrist and fingers flexed (flexor synergy pattern)
• Risk of shoulder subluxation — the rotator cuff and deltoid (grade 1) cannot maintain the humeral head in the glenoid against gravity
• No functional hand use — cannot hold objects, write, or perform fine motor tasks
• Wrist at 2+ is the brightest spot — early functional training target

LOWER LIMB (Right)

• Cannot lift leg freely — leads to the circumduction gait (swinging leg out in a wide arc to clear the floor)
• No propulsion from hip extensors or plantar flexors → slow, effortful gait
• Weak knee flexors prevent normal swing — knee stays stiff during walking
• Dorsiflexor weakness → foot drop tendency (toe drags ground during swing)
• Abductor weakness → Trendelenburg lurch (trunk sways right during left stance)
• Patient needs to drag right leg because hip flexors cannot clear it

---

Symptoms from Soft Tissue Tightness

Piriformis Tightness

• The piriformis muscle externally rotates and abducts the hip
• When tight: hip is locked in external rotation and slight abduction
• Walking symptom: the right foot points outward (toe-out posture) and the leg swings in an externally rotated arc — exactly what this patient shows
• On clinical examination: positive piriformis test, pain/restriction with passive internal rotation of hip, possible sciatic nerve irritation (piriformis syndrome)
• During gait: the right foot contacts ground with lateral border → risk of ankle inversion sprain
• Combined with weak hip internal rotators (grade 1 gluteus medius) — no muscle to counteract the ER deformity

Adductor Tightness

• The adductors (gracilis, adductor longus/brevis/magnus) shorten post-stroke due to spastic tone and disuse positioning
• Symptoms: thighs tend to cross toward each other (scissor posture in severe cases)
• Restricts hip abduction — cannot separate legs for stable base of support
• During standing: narrow base of support → poor balance
• During gait: limits step width, creates mediolateral instability
• On clinical examination: restricted passive hip abduction (<20°), palpable tightness in medial thigh, positive Ober's variant for adductors

Combined Effect (ER + Adductor Tightness + Weak Muscles):

The right leg is pulled into external rotation by tight piriformis, held medially by adductor tightness, with weak muscles unable to counteract either force. Result: the patient drags the right leg in a fixed externally rotated position — the most energy-inefficient, unsafe gait pattern possible.

---

PART 2 — PACEMAKER PRECAUTIONS (Non-Negotiable)

---

PART 3 — PHYSIOTHERAPY GOALS

Short-Term Goals (Weeks 1–4)

1. Prevent contractures, pressure injury, and shoulder subluxation
2. Achieve Grade 2 in hip flexors and hip extensors (minimum for assisted gait)
3. Fully stretch piriformis and adductor tightness — restore neutral hip rotation
4. Progress from frame-assisted standing to frame-assisted stepping
5. Improve pelvic bracing from 10 seconds to 30 seconds
6. Improve wrist/hand volitional control for functional grasp

Long-Term Goals (Weeks 4–12+)

1. Independent ambulation with walking aid (minimum: frame → quad cane)
2. Eliminate external rotation drag — achieve heel-toe gait pattern
3. Functional upper limb use (gross grasp at minimum)
4. Safe community mobility (step over obstacles, manage uneven terrain)
5. Independent sit-to-stand without support frame

---

PART 4 — DETAILED PHYSIOTHERAPY PLAN

---

A. POSITIONING & ANTI-SPASTICITY POSTURES

• Right shoulder: slight protraction, arm supported on pillow in slight abduction and external rotation (anti-spastic for flexor synergy)
• Right elbow: extended, wrist neutral, fingers extended over a rolled towel, thumb abducted
• Right lower limb: hip in neutral rotation (pillow placed under right buttock and lateral thigh — prevents external rotation), knee in slight flexion (5–10°)
• Ankle: maintained at 90° with foot splint/AFO to prevent equinus

• Right shoulder forward with arm extended
• Right hip slightly flexed, knee flexed
• Avoid prolonged side-lying on right — pressure injury risk over greater trochanter

• Both buttocks equally weight-bearing
• Right foot flat on floor (not externally rotated)
• Hips and knees at 90°
• Trunk upright — no lateral lean toward right

---

B. RANGE OF MOTION (ROM) PROGRAM

Passive ROM

• Shoulder: flexion (0–90° within pacemaker precautions), abduction (0–90°), internal/external rotation, horizontal adduction
• Elbow: flexion/extension
• Forearm: pronation/supination
• Wrist: flexion/extension, radial/ulnar deviation
• Fingers: MCP, PIP, DIP — flexion/extension; thumb opposition

• Hip: flexion/extension, abduction/adduction, internal rotation (critical — counteracts piriformis tightness), circumduction
• Knee: flexion/extension
• Ankle: dorsiflexion/plantarflexion, inversion/eversion
• Toes: extension (prevents flexion contracture)

Active Assisted ROM

• Wrist flexion/extension (grade 2+ — can do actively)
• Knee extension in gravity-eliminated position
• Hip flexion in side-lying (gravity eliminated)
• Hip abduction in side-lying

---

C. STRETCHING PROGRAM (Priority: Piriformis + Adductors)

1. Piriformis Stretch — PRIORITY #1

• Patient supine; right hip flexed to 60°, right ankle rested on left knee
• Therapist (or patient with hands) gently presses right knee down toward the bed
• Simultaneously, slight overpressure on right ankle (pushing it toward chest)
• Hold: 30–60 seconds | Sets: 3 | Frequency: 3× daily

• Patient seated; right ankle placed on left knee
• Lean trunk forward — feel stretch in right buttock
• Hold 30–60 seconds

2. Adductor Stretch — PRIORITY #2

• Both hips flexed, soles of feet together
• Allow right knee to fall outward gently (gravity-assisted)
• Overpressure: gentle downward press on right medial knee
• Hold: 30–60 seconds | Sets: 3 | Frequency: 3× daily

• Patient left side-lying; therapist slowly abducts right hip to end range
• Sustained stretch at barrier
• Hold 30 seconds × 3

• When able to sit on floor: spread legs apart as far as possible
• Lean forward gently to increase stretch
• Hold 60 seconds

3. Calf / Plantarflexor Stretch

• Towel stretch: loop towel around right foot, pull toes toward shin (supine)
• Standing wall stretch: right foot back, heel flat on floor, lean into wall
• Hold 30–60 seconds × 3 × daily
• Goal: Prevent equinus contracture; improve heel-strike in gait

4. Hamstring Stretch

• Supine straight leg raise (passive) to point of hamstring resistance
• Hold 30 seconds × 3
• Improves knee flexion during gait

5. Wrist/Finger Extensor Sustained Stretch

• Right hand palm-down on flat surface, gently press down to extend wrist and fingers
• Hold 20–30 seconds × 5 (inhibits flexor spasticity)

---

D. STRENGTHENING PROGRAM

LOWER LIMB STRENGTHENING

PELVIC/CORE STRENGTHENING

UPPER LIMB STRENGTHENING

---

E. NEUROLOGICAL FACILITATION TECHNIQUES

Bobath / Neurodevelopmental Technique (NDT)

• Normalize tone before movement — do not work against strong spasticity
• Use key points of control (KPC) to influence tone throughout the limb:
  • Proximal KPC: shoulder girdle, pelvic girdle
  • Distal KPC: wrist, thumb web-space (UL); heel, foot (LL)
• Weight-bearing through the affected limb facilitates tone normalization
• Trunk rotation inhibits limb spasticity

1. Pelvic mobilization in sitting — hands on pelvis, rotate and tilt pelvis rhythmically → inhibits LL spasticity, prepares for gait
2. Seated trunk rotation with arm swing — arms clasped together, rotate right and left → inhibits whole-body spasticity, activates trunk rotators
3. Right heel weight-bearing — standing, ensure right heel is fully on floor; therapist facilitates right knee extension → normalizes extensor tone in LL
4. Shoulder protraction in sitting — therapist moves right shoulder forward and slightly down → inhibits shoulder retraction pattern
5. Hip internal rotation facilitation — therapist cups right knee and internally rotates during walking → teaches brain correct hip position during swing

Proprioceptive Neuromuscular Facilitation (PNF)

• D1 Flexion pattern: Hip flexion + adduction + external rotation (already dominant — modify)
• D2 Flexion pattern: Hip flexion + abduction + internal rotation → this is the therapeutic pattern to train (counteracts ER deformity)
  • Patient in supine; therapist resists/guides right limb in D2 flexion diagonal
  • Use rhythmic initiation: passive → active-assisted → active → resisted

• D2 Extension: Shoulder extension + abduction + internal rotation → facilitates shoulder control
• Rhythmic initiation for wrist/forearm: Passive pronation/supination → active with facilitation

Electrical Facilitation (Pacemaker-Safe)

• NMES to right dorsiflexors (electrodes on tibialis anterior, below knee — safe distance from pacemaker)
  • Bipolar electrode placement, short pulse width
  • Combine with attempted voluntary dorsiflexion — biofeedback + electrical facilitation
  • 20 minutes/session, 5× week
• NMES to wrist extensors — electrodes on forearm (extensor compartment)
  • Stimulate during attempted wrist extension → strengthens, inhibits flexor dominance
• Confirm safe parameters with pacemaker cardiologist

---

F. TRANSFER & FUNCTIONAL TRAINING

Sit-to-Stand (Patient Currently Able With Frame)

1. Move buttocks to edge of chair
2. Right foot slightly behind left (active hip flexion practice)
3. Lean trunk forward ("nose over toes") — weight shifts over feet
4. Push up through frame; therapist cues right hip extension
5. Achieve upright standing: hips fully extended, right foot pointing forward (not externally rotated — therapist corrects foot placement manually)

• From higher surface (raised toilet seat height) → standard chair → lower surface
• Reduce frame to one hand → then fingertip touch → unsupported sit-to-stand

Bed Mobility

• Rolling to right: patient clasps hands, swings arms right with momentum
• Rolling to left: therapist facilitates via pelvic rotation
• Sitting up from lying: via side-lying, push up with left arm

---

G. STANDING BALANCE TRAINING

---

H. GAIT RETRAINING — MOST CRITICAL SECTION

Analysis of Current Gait Fault:

• Right leg drag in external rotation = combination of:
  • Piriformis tightness (ER deformity)
  • Hip flexor grade 2− (insufficient limb clearance)
  • Knee flexor grade 2− (stiff knee during swing)
  • Dorsiflexor grade 2− (foot drop tendency)
  • No propulsion from hip extensor/plantar flexors
  • No hip ER correction from weak internal rotators

Phase 1 — Pre-Gait Foundation (Weeks 1–2)

1. Pelvic dissociation in standing: Hold frame; shift weight right → left repeatedly; right pelvis forward and back (simulates gait pelvic rotation)
2. Standing hip flexion (marching): Right knee lift with frame — even if only partial, repeat 3×10 — trains hip flexors in functional position
3. Hip internal rotation drill standing: Therapist manually rotates right foot to neutral while standing — patient holds position 5s × 10
4. Weight acceptance practice: Step sideways — left foot leads, right foot follows — right leg accepts weight for 3 seconds

Phase 2 — Assisted Stepping (Weeks 2–4)

1. Therapist-facilitated stepping: Therapist stands right side, right hand guides right pelvis forward, left hand guides right knee into flexion + internal rotation during swing phase
2. Floor targets: Place tape marks on floor; patient aims right foot to step on tape (trains step length and direction)
3. Forward step practice with frame: Right leg steps forward first — ensure heel-strike, not toe-drag — therapist corrects foot position
4. Stairs/step-ups: Step up and down a single step with frame (excellent hip flexor, quadriceps, and hip extensor strengthening in functional context)

Phase 3 — Gait Pattern Correction (Weeks 4–8)

1. Verbal cueing: "Turn your right foot straight ahead" before each step
2. Mirror biofeedback: Large mirror in front — patient watches foot position during gait and corrects in real time
3. Rhythmic auditory stimulation (RAS): Metronome at patient's natural cadence + 5% — improves stride regularity and reduces compensatory patterns
4. Treadmill walking (slow speed, hand rails): Forces reciprocal stepping pattern; reduces opportunity for external rotation drag
5. Hip internal rotation taping: Kinesio tape in IR facilitation pattern on right hip — proprioceptive cue for IR during swing
6. PNF gait facilitation: As described above — D2 flexion diagonal during swing phase

Phase 4 — Walking Aid Progression

• Independent stepping without dragging at previous aid level
• Single-limb stance right ≥5 seconds
• Consistent heel-strike pattern

---

I. ANKLE FOOT ORTHOSIS (AFO) PRESCRIPTION

• Prevents toe-drag during swing phase
• Improves heel-strike pattern
• Reduces energy expenditure during gait
• Improves safety and walking speed

---

J. SHOULDER SUBLUXATION PREVENTION

1. Arm sling during ambulation and standing — prevents downward subluxation and protects shoulder joint
2. Broad arm support in seated position — do not allow arm to hang free
3. NEVER lift patient by right arm — subluxation and brachial plexus injury risk
4. Glenohumeral strapping: Theraband or kinesio tape supports humeral head in glenoid
5. Regular passive shoulder ROM maintains capsule flexibility despite muscle weakness

---

K. ADJUNCT MODALITIES (Pacemaker-Safe Only)

---

L. PATIENT AND CAREGIVER EDUCATION

1. Correct handling: Never drag by right arm; support under armpit and forearm
2. Positioning at home: Anti-spastic postures in bed, sitting, and standing
3. Fall prevention: Clear home pathways, non-slip mats, grab bars in bathroom
4. Stretching routine: Piriformis and adductor stretch 3× daily
5. Recognition of shoulder subluxation: Visible gap above humeral head — report immediately
6. Pacemaker awareness: Avoid magnets, airport security wands — carry pacemaker ID card
7. Exercise compliance: Daily home exercises as prescribed below

---

M. HOME EXERCISE PROGRAM

---

PART 5 — OUTCOME MEASURES (Baseline + Weekly Monitoring)

---

PART 6 — TREATMENT SCHEDULE SUMMARY

---

PART 7 — PROGNOSIS & CLINICAL HIGHLIGHTS

• Pelvic bracing 10 seconds → good core activation; strong foundation for gait
• Sit-to-stand with frame → adequate quadriceps and core for weight-bearing
• Wrist flexors/extensors at grade 2+ → best UL function to capitalize on
• Knee extensor grade 2 → sufficient for weight-bearing with facilitation

1. Piriformis and adductor tightness — the single biggest mechanical barrier to correct gait; resolve this first and gait will improve rapidly
2. Hip flexors must reach grade 2 (full gravity-eliminated) minimum before independent stepping is possible
3. Hip extensors need to reach grade 2+ for any propulsion — bridging and step-training are essential
4. AFO fitting should happen early — foot drop is a major fall risk during all gait training

---

12-WEEK FUNCTIONAL REHABILITATION PROTOCOL

Right Hemiplegia | 60-Year-Old | Pacemaker

Target: Assisted Community Ambulation + Functional Upper Limb + Independent ADLs

---

PROTOCOL OVERVIEW

---

PACEMAKER SAFETY RULES (ALL PHASES)

These apply throughout all 12 weeks without exception.

• No TENS, IFT, shortwave diathermy, or ultrasound near chest or device
• NMES/FES electrodes: below elbow (UL) or below knee (LL) only, bipolar
• No shoulder abduction > 90° until week 6 (cardiologist clearance)
• Exercise intensity by Borg RPE only — target 11–13 ("light to somewhat hard")
• Stop session immediately if: chest pain, dizziness, palpitations, syncope
• Carry pacemaker ID card; emergency defibrillation protocols noted for gym staff

---

PHASE 1 — FOUNDATION PHASE

Weeks 1–2 | 5 sessions/week | 60 min/session

---

SESSION STRUCTURE — PHASE 1 (60 minutes)

---

WEEK 1 — DAILY PROTOCOL

Day 1, 3, 5 (Monday/Wednesday/Friday Pattern)

• Full passive ROM: shoulder (0–90°), elbow, wrist, fingers — 10 reps each
• Full passive ROM: hip (all planes), knee, ankle — 10 reps each
• Emphasis: Hip internal rotation — 10 slow reps, end-range hold 3 seconds
• Set anti-spastic positioning for rest of session

• Standing with frame: 2 × 5 minutes bilateral weight-bearing
• Weight shift side-to-side: 2 × 10 reps (therapist ensures right heel contact)
• Sit-to-stand × 5 (frame): therapist corrects right foot position (neutral rotation)

Day 2, 4 (Tuesday/Thursday Pattern)

• Same structure but replace hip IR strengthening with hip abduction (side-lying)
• Add pelvic bracing in standing: 3 × 10 seconds (progress from current 10s)
• Add Codman's shoulder pendulum: 2 minutes (activate shoulder muscles)
• Add tendon gliding fingers: hook fist → full fist → straight fist — 3×5 each

---

WEEK 2 — PROGRESSION

• Hip internal rotation passive ROM improved ≥ 10° from baseline
• Hip flexor MMT progressed to grade 2 (full gravity-eliminated range)
• Pelvic bracing 3 × 15 seconds in standing
• Standing tolerance 15 minutes continuous with frame
• Right knee lift (hip flexion in standing) — partial range × 10 reps

---

PHASE 2 — ACTIVATION & PRE-GAIT PHASE

Weeks 3–4 | 5 sessions/week | 60 min/session

---

SESSION STRUCTURE — PHASE 2 (60 minutes)

---

WEEK 3 — DAILY PROTOCOL

• Piriformis × 2 × 90 sec (therapist maintained stretch)
• Adductor × 2 × 60 sec
• Calf × 2 × 45 sec
• Total: maintain gains from Phase 1 — done quickly, not dwelt upon

• NDT trunk rotation in sitting: Clasped hands, rotate right and left × 20 — inhibits limb spasticity
• PNF D2 flexion diagonal (LL): Therapist guides right limb — hip flexion + abduction + internal rotation → trains correct swing phase movement
• Hip IR facilitation: Therapist internally rotates hip during active hip flexion — 10 reps, bimanual guidance
• Weight-bearing right arm (palm on plinth beside hip): 2 × 30 seconds lean through right arm — activates shoulder

1. Therapist places right foot in neutral (0° rotation) before each step
2. Patient instructed: "Point your right toes straight"
3. Aim for heel-strike — not toe-drag
4. 5 steps → rest → 5 steps: quality over distance

---

WEEK 4 — PROGRESSION

• Hip flexor MMT: grade 2+ (moves against gravity, partial range)
• Hip extensor MMT: grade 2 (full gravity-eliminated range)
• Walks 10 meters × 3 sets with frame and therapist guidance
• Right foot placed in <15° external rotation (down from presenting ER)
• Heel-strike achieved on ≥5/10 steps
• Pelvic bracing 3 × 30 seconds
• AFO fitted and tolerated (minimum 2 hours wear)

---

PHASE 3 — GAIT RETRAINING & STRENGTHENING PHASE

Weeks 5–8 | 4–5 sessions/week | 60 min/session

---

SESSION STRUCTURE — PHASE 3 (60 minutes)

---

WEEKS 5–6 PROTOCOL

External Rotation Elimination Protocol:

1. Manual correction: Therapist positions right foot at 0° before each step until patient does it independently
2. Floor tape lines: Two parallel tape strips 10cm apart — patient must keep right foot within the lines
3. Kinesio taping (hip IR facilitation): Applied from greater trochanter inferiorly in spiral toward medial knee — proprioceptive IR cue
4. Verbal + visual feedback loop: "Knee forward, toes straight" + mirror
5. Success criterion: Right foot ≤5° ER independently, 8/10 steps

---

WEEKS 7–8 — PROGRESSION

• Walks 20 meters with frame or rollator — no therapist hand guidance
• Right foot ER ≤ 10° for majority of steps
• No toe-drag (AFO or active dorsiflexion maintaining foot clearance)
• Single-leg stance right: 10 seconds with frame
• Hip flexor MMT: grade 3 (against gravity full range) — OR grade 2+ minimum
• Sit-to-stand from standard chair × 5 repetitions independently
• Gross grasp: can pick up 200g object with right hand
• Stairs: 5 steps up and down with railing

---

PHASE 4 — FUNCTIONAL INDEPENDENCE PHASE

Weeks 9–12 | 3–4 sessions/week | 60 min/session

---

SESSION STRUCTURE — PHASE 4 (60 minutes)

---

WEEKS 9–10 PROTOCOL

---

WEEKS 11–12 — CONSOLIDATION & DISCHARGE PREPARATION

---

HOME EXERCISE PROGRAMME — ALL 12 WEEKS

Morning Routine (20 minutes)

Afternoon Routine (15 minutes)

Evening Routine (10 minutes)

---

INTERDISCIPLINARY COORDINATION

---

DISCHARGE CRITERIA (END OF WEEK 12)

• Walks 50 meters with quad cane — no drag, no ER deformity beyond 5°
• TUG < 20 seconds
• Berg Balance Scale > 45/56
• Independent sit-to-stand from standard chair
• Manages 5+ steps with railing (stair access)
• Can perform basic ADLs with affected arm as assist limb
• HEP understood and demonstrated independently
• Caregiver trained in handling, positioning, and HEP supervision
• Community follow-up physiotherapy arranged (1–2×/week maintenance)
• Pacemaker monitoring schedule confirmed with cardiologist

---

PROTOCOL DECISION TREE

START PHASE 1
     ↓
Week 2 Milestones Met?
     YES → Move to Phase 2
     NO  → Extend Phase 1 by 1 week, reassess

Phase 2 → Week 4 Milestones Met?
     YES → Move to Phase 3
     NO  → Repeat Week 3–4 protocol, identify bottleneck

Phase 3 → Week 8 Milestones Met?
     YES → Move to Phase 4
     NO  → Extend Phase 3, address specific deficit

Phase 4 → Week 12 Discharge Criteria Met?
     YES → Community discharge + outpatient maintenance
     NO  → Extend to Week 14–16, reassess goals

---

KEY CLINICAL PRINCIPLE UNDERLYING THIS PROTOCOL

Neuroplasticity drives recovery. The brain rewires fastest when:

1. Movements are repetitive (high volume — aim 50–100 repetitions of key movements per session)
2. Movements are task-specific (functional, not just isolated muscle work)
3. Movements are performed at the edge of capability (challenging but achievable)
4. Feedback is immediate and accurate (mirror, therapist cues, RAS)
5. Practice happens outside of clinic (HEP compliance = neuroplasticity every day)