Note: The image provided is a lateral (sagittal) view, not a frontal (coronal) view. The assessment below is based on the lateral view that is actually visible.

---

Lateral (Sagittal Plane) Postural Assessment

Plumb Line Reference

• External auditory meatus (ear lobe)
• Tip of the shoulder (acromion)
• Greater trochanter of the hip
• Just anterior to the lateral malleolus of the ankle

---

Findings by Region

---

Key Deviations Identified

---

Summary

• Marked forward head posture
• Thoracic hyperkyphosis
• Reduced lumbar lordosis
• Global anterior lean of the trunk

1. PostureScreen Mobile or PostureCo apps — designed specifically for this purpose; auto-draw plumb lines on patient photos
2. PowerPoint / Google Slides — insert the image, then draw a vertical line from head to feet using the shapes tool
3. Paint / Preview (Mac) — open image, draw a straight vertical line using the line tool

• The vertical line should pass through:
  • Midpoint of the skull
  • Nose/chin midline
  • Sternal notch
  • Navel/umbilicus
  • Pubic symphysis midpoint
  • Midpoint between both feet

---

ICF Checklist — Right Side Stroke (Left Hemiplegia)

ICF Qualifier Scale: 0 = No problem (0–4%) | 1 = Mild (5–24%) | 2 = Moderate (25–49%) | 3 = Severe (50–95%) | 4 = Complete (96–100%) | 8 = Not specified | 9 = Not applicable

---

PART 1: BODY FUNCTIONS (b)

b1 — Mental Functions

---

b2 — Sensory Functions & Pain

---

b3 — Voice & Speech Functions

---

b4 — Functions of the Cardiovascular, Haematological, Immunological & Respiratory Systems

---

b5 — Functions of the Digestive, Metabolic & Endocrine Systems

---

b7 — Neuromusculoskeletal & Movement-Related Functions

---

PART 2: BODY STRUCTURES (s)

---

PART 3: ACTIVITIES & PARTICIPATION (d)

d1 — Learning & Applying Knowledge

---

d2 — General Tasks & Demands

---

d3 — Communication

---

d4 — Mobility

---

d5 — Self-Care

---

d6 — Domestic Life

---

d7 — Interpersonal Interactions & Relationships

---

d8 — Major Life Areas

---

d9 — Community, Social & Civic Life

---

PART 4: CONTEXTUAL FACTORS

Environmental Factors (e) — Barriers (−) / Facilitators (+)

---

Personal Factors (non-coded in ICF)

---

Key Right Hemisphere Stroke-Specific Highlights

---

Clinical Note: Right hemisphere strokes are often underestimated in severity because language (aphasia) is absent. However, neglect, anosognosia, and impaired safety awareness make rehabilitation significantly more challenging. Caregiver education and environmental modification (e310, e155) are critical facilitators.

---

Physiotherapy Management

60-Year-Old Male | MCA Stroke | UL Spasticity + LL Weakness

---

PATIENT PROFILE

---

PROBLEM LIST

Impairment Level

Activity Limitation Level

Participation Restriction Level

---

SHORT-TERM GOALS

---

LONG-TERM GOALS

---

ADVANCED PHYSIOTHERAPY TREATMENT PLAN

---

PHASE 1 — ACUTE/EARLY SUBACUTE (Week 1–2)

A. Positioning & Handling

• Antispasticity positioning: UL in shoulder abduction, elbow extension, wrist/finger extension using splints
• Avoid traction on subluxed shoulder
• Proper hemiplegic positioning in bed (avoid shoulder internal rotation, hip external rotation)
• Use of Bobath handling techniques for tone normalization

B. Passive & Active-Assisted ROM

• Gentle passive ROM all joints 2× daily
• Shoulder: scapular mobilization before glenohumeral movement
• Wrist/finger extension stretching for spastic flexors
• Neural mobilization — median nerve (for UL spasticity)

C. Respiratory Physiotherapy

• Diaphragmatic breathing, trunk expansion exercises
• Positioning for optimal ventilation

---

PHASE 2 — SPASTICITY MANAGEMENT (Ongoing)

1. Stretching & Inhibitory Techniques

• Prolonged static stretching of spastic muscles (≥20 min sustained stretch)
• Reflex Inhibiting Patterns (RIPs) — Bobath NDT approach
• Rhythmic Rotation — slow, rhythmic passive movement to reduce tone
• Weight bearing through affected UL — inhibits flexor spasticity (neurodevelopmental technique)

2. Neuromuscular Facilitation

• Proprioceptive Neuromuscular Facilitation (PNF)
  • D1 extension pattern (UL): shoulder flexion/abduction/ER + elbow extension
  • D2 flexion/extension patterns for LL strengthening
  • Hold-Relax and Contract-Relax techniques for spastic muscles

3. Splinting & Orthotic Management

• Resting hand splint (night) — maintain wrist/finger in extension
• Lycra arm sleeve — proprioceptive input, tone normalization
• AFO (Ankle Foot Orthosis) — for foot drop and safe ambulation during LL weakness phase

4. Extracorporeal Shock Wave Therapy (ESWT)

• Radial ESWT over spastic UL muscles (biceps, wrist flexors)
• Protocol: 1500–2000 shocks, 0.1 mJ/mm², 3–5 sessions weekly
• Evidence: Significant MAS reduction at short, mid, and long-term follow-up (Management of Stroke Rehabilitation, p. 73)

5. Botulinum Toxin (Adjunct — coordinated with physician)

• Injection into: biceps brachii, brachialis, flexor carpi radialis/ulnaris, finger flexors
• Post-injection physiotherapy within 2 weeks mandatory
• Effect lasts 12–16 weeks; combine with intensive PT (Management of Stroke Rehabilitation, p. 68)

6. Functional Electrical Stimulation (FES)

• FES to wrist/finger extensors — reduces flexor spasticity, facilitates active extension
• Cyclic FES during task practice for neuroplastic effect
• NMES to shoulder stabilizers for subluxation prevention

---

PHASE 3 — LOWER LIMB STRENGTHENING & GAIT TRAINING

A. Strengthening Program (Progressive Resistance)

B. Balance Training (Progressive)

• Level 1: Supported standing — parallel bars
• Level 2: Standing weight shift — lateral, anterior-posterior
• Level 3: Single leg stance (unaffected side support)
• Level 4: Tandem standing, perturbation training
• Level 5: Dynamic balance — stepping, reaching tasks
• Balance Board / Wobble Board — proprioceptive training
• Virtual Reality Balance Training — evidence-based; interactive, motivating

C. Gait Rehabilitation

• Parallel bars → walking frame → tripod/quad stick → independent
• Pre-gait activities: weight shifting, step-up, stepping over obstacles

---

PHASE 4 — ADVANCED UPPER LIMB REHABILITATION

1. Constraint-Induced Movement Therapy (CIMT)

• Restrain unaffected UL with mitt/sling for 90% waking hours
• Intensive shaping tasks with affected UL — 6 hours/day × 2 weeks
• Modified CIMT (mCIMT): 3–5 hours/day for patients with moderate function
• Best evidence for UL recovery in stroke — drives neuroplastic cortical reorganization

2. Mirror Therapy

• Affected UL placed behind mirror; patient views reflection of unaffected limb moving
• 30 min sessions, 5 days/week × 4 weeks
• Activates motor cortex via visual feedback; effective in spasticity + weakness

3. Mental Practice / Motor Imagery

• Patient mentally rehearses UL movements
• Combine with physical practice — additive neuroplastic effect
• Protocol: 20 min imagery × 5 sessions/week

4. Task-Specific Training

• Repetitive, goal-directed functional tasks:
  • Reaching for objects at various heights
  • Opening jars, turning door handles
  • Typing, folding clothes
  • Pouring water — graded task difficulty

5. Robotic-Assisted UL Therapy

• Armeo Spring / MIT-MANUS — gravity-compensated UL robotic training
• High-repetition, low-effort reaching in gamified environments
• Indicated when active movement is minimal

6. Electromyographic (EMG) Biofeedback

• Surface EMG on target muscles (wrist extensors, biceps antagonists)
• Real-time visual/auditory feedback of muscle activity
• Improves voluntary motor control, reduces co-contraction

7. Transcranial Magnetic Stimulation (TMS) — Adjunct

• Inhibitory rTMS to contralesional (unaffected) hemisphere — reduces interhemispheric inhibition
• Excitatory TMS to ipsilesional hemisphere — facilitates motor cortex
• Combine with physiotherapy immediately after session

---

PHASE 5 — FUNCTIONAL & COMMUNITY REHABILITATION

---

OUTCOME MEASURES

---

SUMMARY TREATMENT ALGORITHM

Acute Phase
    ↓
Positioning + Passive ROM + Respiratory PT
    ↓
Spasticity Management (Stretching + FES + ESWT + Splinting ± Botox)
    ↓
Trunk Control + Sitting Balance
    ↓
LL Strengthening (PNF + Progressive Resistance)
    ↓
Standing Balance + Pre-gait Activities
    ↓
Gait Training (BWS-TT → Overground → Community)
    ↓
Advanced UL (CIMT + Mirror Therapy + Robotics + Task-Specific)
    ↓
Community Reintegration + HEP + Caregiver Education

Clinical Note: The distinct pattern of UL spasticity with LL weakness only (without LL spasticity) suggests the corticospinal tract lesion may be incomplete or that lower motor neuron pathways to the LL are relatively preserved. This is a favorable prognostic sign for LL functional recovery. Priority should be aggressive spasticity management in UL combined with high-intensity strengthening and gait retraining for the LL. (Management of Stroke Rehabilitation, pp. 68, 73)

---

Short-Term Physiotherapy Treatment Plan

Old (Chronic) CVA Case — Week 1 to Week 4

---

Key Considerations for Chronic CVA

In an old/chronic CVA (>6 months post-stroke), neuroplasticity is still present but slower. The focus shifts from spontaneous recovery to skill relearning, compensatory strategies, spasticity/contracture management, and preventing secondary complications. Intensity of practice remains the strongest driver of improvement.

---

WEEK 1 — ASSESSMENT & BASELINE ESTABLISHMENT

Day 1–3: Comprehensive Evaluation

---

Day 1–7: Initial Treatment Priorities

1. Pain & Spasticity Control (UL)

• Prolonged passive stretching of spastic muscles — 20–30 min
  • Elbow extensors stretch, wrist/finger extension stretch
  • Hold each stretch 60 seconds × 3 sets
• Reflex Inhibiting Patterns (RIP) — Bobath technique
  • Key pattern: Shoulder ER + abduction + elbow extension + wrist extension
• Ice/cold pack over spastic UL muscles — 10–15 min before stretching
• Resting hand splint application — nights + 2 hrs daytime
• Proper antispasticity positioning in sitting and lying

2. Passive & Active-Assisted ROM

• All joints — upper and lower limb
• Shoulder: scapular mobilization first, then glenohumeral
• Hip, knee, ankle — full range daily
• Prevents contracture (primary risk in chronic CVA)

3. Trunk Activation

• Supported sitting — active trunk holding 30 sec × 5 reps
• Lateral weight shift in sitting — active
• Anterior-posterior weight shift with therapist support
• Deep breathing + trunk expansion exercises

4. Positioning Education

• Caregiver training on:
  • Correct hemiplegic lying positions (supine, side-lying)
  • Seated posture with arm support
  • Avoid prolonged elbow/wrist flexion postures

---

WEEK 2 — FUNCTIONAL ACTIVATION & STRENGTHENING

1. Continued Spasticity Management

• Progress stretching — increase duration to 30–45 min
• Neurodevelopmental Technique (NDT):
  • Weight bearing through affected UL (elbow extended, palm flat on plinth)
  • Inhibits flexor spasticity reflexively
• Slow, rhythmic rotation of limb segments — tone reduction
• FES/NMES to wrist and finger extensors (antagonists of spastic muscles)
  • 20 min sessions, 5 days/week

2. Lower Limb Strengthening (Progressive)

3. Sitting Balance — Progressive

• Static: Unsupported sitting 1–3 min
• Dynamic: Reaching tasks in sitting — forward, lateral, diagonal
• Perturbation in sitting — gentle manual destabilization → reactive balance
• Ball rolling on plinth — weight shift facilitation

4. Sitting to Standing Practice

• Assisted sit-to-stand with verbal cues
• Focus: equal weight bearing through both lower limbs
• Mirror feedback for symmetry correction
• Repeat 10–15 times per session

---

WEEK 3 — STANDING BALANCE & PRE-GAIT TRAINING

1. Standing Balance Program

2. Pre-Gait Activities

• Pelvic tilting in standing — anterior/posterior
• Hip hiking exercises — prepares for swing phase
• Stepping over lines/obstacles on floor
• Marching in place with parallel bar support
• Weight shifting to affected LL — crucial for stance phase preparation
• Ankle rocking — heel to toe weight transfer

3. UL Functional Activation

• Mirror therapy — 20–30 min daily
  • Mirror placed sagittally; patient watches unaffected hand move
  • Facilitates motor cortex activation of affected side
• Bilateral arm training — symmetric reaching tasks
  • Unaffected side guides affected side
• Gravity-eliminated UL exercises:
  • Shoulder flexion/abduction in side-lying
  • Elbow flexion/extension in supported position
• Wrist extension facilitation — tapping, brushing, quick stretch

4. Sensory Re-education

• Tactile stimulation — different textures on affected limb
• Proprioceptive training — joint repositioning tasks
• Weight bearing on affected UL for deep pressure input
• Vibration therapy over affected muscles

---

WEEK 4 — GAIT INITIATION & ADL TRAINING

1. Gait Training

• Parallel bars → Walking frame → Quad stick
• Therapist: manual guidance at pelvis and affected knee
• Gait cues:
  • "Lift the knee"
  • "Push off with the toes"
  • "Heel first"
• Rhythmic auditory stimulation (RAS) — metronome at comfortable cadence
• AFO fitting if foot drop present — for safe ambulation
• Walk 10–15 metres × 3–5 repetitions per session

2. Stair Training (if appropriate)

• Step-up/step-down on single step
• Rail support — unaffected side
• Principle: "Good goes up, bad goes down"

3. ADL Integration

4. Home Exercise Program (HEP) Initiation

• Teach patient + caregiver:
  • Daily stretching routine (UL spastic muscles)
  • LL strengthening exercises
  • Balance practice — safe standing at kitchen counter
  • Walking practice indoors
• Written illustrated HEP provided

---

SHORT-TERM TREATMENT SUMMARY TABLE

---

SHORT-TERM GOALS ACHIEVED BY WEEK 4

---

Clinical Note: In chronic CVA, intensity and repetition are the most critical factors for neuroplastic recovery — even years post-stroke. A minimum of 45 minutes of active task practice per session is recommended. Passive modalities alone are insufficient; every session should include active patient participation wherever possible. (Management of Stroke Rehabilitation, p. 55)

---

Long-Term Physiotherapy Treatment Plan

Old (Chronic) CVA Case — Month 2 to Month 6

---

KEY PRINCIPLE

Intensity of training is the most critical determinant of sustained long-term improvement in chronic stroke. Activity-dependent neuroplasticity drives cortical motor map reorganization and functional recovery even in old CVA cases. Technology-assisted high-repetition training maximizes this potential. (Harrison's, p. 13833)

---

LONG-TERM GOALS (Month 2–6)

---

MONTH 2 — ADVANCED SPASTICITY MANAGEMENT & GAIT CONSOLIDATION

1. Advanced Spasticity Management

Extracorporeal Shock Wave Therapy (ESWT)

• Radial ESWT over biceps, brachialis, wrist/finger flexors
• Protocol: 1500–2000 shocks, 0.1 mJ/mm², 3 sessions/week × 4 weeks
• Significant MAS reduction at short, mid, and long-term follow-up (Management of Stroke Rehabilitation, p. 73)

Botulinum Toxin (Coordinated with Physician)

• Injection sites: biceps brachii, brachialis, flexor carpi radialis, flexor carpi ulnaris, finger flexors
• Mandatory: intensive physiotherapy within 2 weeks post-injection
• Effect window: 12–16 weeks — maximize therapy during this period
• Repeat cycle every 3–4 months as needed (Management of Stroke Rehabilitation, p. 68)

Serial Casting

• Progressive plaster casting of elbow/wrist in increasing extension
• Changed every 5–7 days — gradual lengthening of spastic muscles
• Best for fixed or near-fixed contractures developing from chronic spasticity

Sustained Mechanical Stretch

• Dynasplint or Ultraflex splint — prolonged low-load stretch overnight
• 6–8 hours wear — biomechanical remodeling of soft tissue

---

2. Gait Consolidation Program

---

MONTH 3 — ADVANCED UL REHABILITATION & BALANCE MASTERY

1. Constraint-Induced Movement Therapy (CIMT)

• At least 10° active wrist extension
• At least 10° active finger extension in 2 fingers

• Picking up objects of varying size/weight
• Stacking blocks, turning pages
• Opening jars, door handles, taps
• Feeding, grooming, dressing activities

CIMT is appropriate only for those with some active movement in the paretic limb. mCIMT (≤3 hours/day) is suitable for patients who cannot tolerate full CIMT intensity. (Management of Stroke Rehabilitation, p. 47)

---

2. Mirror Therapy

• Mirror placed sagittally on midline
• Affected UL behind mirror; patient views reflection of unaffected UL
• Protocol: 30 min × 5 days/week × 4 weeks
• Tasks: wrist flexion/extension, finger movements, grasp/release
• Activates mirror neuron system — facilitates ipsilesional motor cortex

---

3. Mental Practice / Motor Imagery

• 20 min imagery sessions × 5 days/week
• Patient mentally rehearses specific UL tasks (reaching, grasping)
• Combine with physical practice immediately after — additive neuroplastic effect
• Use audio-guided imagery scripts for compliance

---

4. Advanced Balance Training

---

MONTH 4 — TECHNOLOGY-ASSISTED REHABILITATION

1. Robotic-Assisted Upper Limb Training

• Sessions: 45–60 min × 5 days/week
• High repetition (500–1000 movements/session) — drives neuroplasticity

---

2. Body Weight Supported Treadmill Training (BWSTT)

• 20–40% body weight support via overhead harness
• Treadmill speed: start slow (0.2–0.5 km/h) → progress to comfortable speed
• Therapist manually facilitates hip/knee during swing if needed
• Benefit: safe high-repetition stepping — activates spinal locomotor CPGs
• Progress: reduce body weight support by 5–10% every 2 weeks

---

3. Lokomat / Robotic Gait Trainer

• Exoskeleton-guided treadmill walking
• Precise joint kinematics — hip and knee guidance
• High-intensity, high-repetition gait practice
• Indicated when: unable to walk on treadmill independently or fear of falling

---

4. Virtual Reality (VR) Rehabilitation

• UL: VR reaching, grasping, manipulation tasks
• Balance/Gait: VR obstacle avoidance, community navigation simulation
• Immersive environment — high motivation, reduces perceived effort
• Wearable sensor-based systems (e.g., Leap Motion, Nintendo Switch) for home VR

---

5. Neuromuscular Electrical Stimulation (NMES) / FES

---

MONTH 5 — COMMUNITY REINTEGRATION & FUNCTIONAL INDEPENDENCE

1. Community Ambulation Training

---

2. Advanced ADL Training

---

3. Cardiovascular Conditioning

• Aerobic exercise: walking, cycling, swimming — 3–5 days/week
• Target: 40–70% heart rate reserve (moderate intensity)
• Duration: build to 30–45 min continuous activity
• Reduces stroke recurrence risk — secondary prevention
• Monitor BP before/after exercise (target: <130/80 mmHg)

---

4. Falls Prevention Program

---

MONTH 6 — MAINTENANCE, REVIEW & DISCHARGE PLANNING

1. Reassessment of All Outcome Measures

• Compare Month 6 values to baseline (Week 1)
• Document functional gains across all domains
• Identify residual deficits requiring ongoing therapy

2. Maintenance Exercise Program

---

3. Discharge Planning Checklist

---

LONG-TERM TREATMENT SUMMARY

---

OUTCOME MEASURES — BASELINE vs. MONTH 6 TARGETS

---

Core Principle: Neuroplasticity does not have a fixed endpoint — even in chronic stroke, high-intensity, task-specific, repetitive practice continues to drive measurable cortical reorganization and functional improvement. Technology-assisted training (robotics, VR, FES) allows delivery of the required dose when manual therapy alone is insufficient. (Harrison's, p. 13833; Management of Stroke Rehabilitation, p. 47)