Physiotherapy Protocol - Traumatic Brain Injury with Right Hemiparesis

Patient Summary (from Clinical Notes)

Clinical Reasoning

• Hypotonia rather than spasticity
• Ataxic gait component
• Cerebellar dyscoordination (Lt side)
• Frontal/temporal lobe-driven behavioral and memory deficits
• Fatigue and motivation issues (thalamic + frontal)
• Left elbow ROM restriction due to myositis ossificans (handle carefully - no aggressive stretching)

PHYSIOTHERAPY PROTOCOL

PHASE 1 - Acute/Early Sub-acute (Weeks 1-4)

1. Positioning and Bed Mobility

• Proper bed positioning every 2 hours to prevent pressure injuries and contractures
• Affected (Rt) side positioning: shoulder protraction, elbow extended, wrist neutral, hip neutral
• Avoid prolonged supine - elevate head 30 degrees
• Passive ROM to all joints of Rt upper and lower limb: 2x daily, 10 repetitions each
• Left elbow: gentle ROM within pain-free range only, no forced stretching (myositis ossificans risk of worsening)

2. Sensory Stimulation

• Multi-sensory stimulation to promote arousal: tactile, auditory, visual input
• Proprioceptive input to Rt limbs: joint approximation, weight bearing through upper limb in sitting

3. Transfers and Positioning Progression

• Supine to sitting via rolling to Rt side (facilitate affected side)
• Supported sitting at edge of bed with trunk stabilization
• Plinth/mat exercises: bridging, trunk rotations

PHASE 2 - Rehabilitation Phase (Weeks 4-12)

A. Trunk Control and Core Stability

• Mat activities: bridging (bilateral, then single leg), sit-ups progression
• Supported trunk exercises in sitting: anterior, posterior, lateral weight shifts
• Ball exercises (Bobath ball): dynamic sitting balance training
• Task-specific trunk challenges: reaching in all planes while seated

B. Lower Limb and Gait Training

• Cerebellar involvement (Lt): Add coordination drills - heel-shin test exercises, tandem standing/walking, Frenkel's exercises for coordination

C. Upper Limb Rehabilitation (Rt side)

• Bilateral symmetrical activities (mirror therapy if available)
• Proprioceptive facilitation: weight bearing through Rt arm in quadruped
• Task-specific training: reaching, grasping, releasing objects
• CIMT (Constraint Induced Movement Therapy) principles - graded tasks
• Fine motor activities: pegboard, putty exercises, stacking cones

D. Left Elbow - Myositis Ossificans Management

• Do NOT apply heat, ultrasound, or aggressive manual therapy to Lt elbow
• Active ROM within pain-free range only
• Gentle active-assisted ROM
• Functional activities that naturally use the elbow without forced motion
• Serial splinting if flexion contracture develops (on physiatrist prescription)
• Monitor for warmth, swelling - signs of active ossification

E. Balance Training

• Static balance: standing on stable surface, eyes open then closed (Romberg test progressively)
• Dynamic balance: stepping responses, perturbation training
• Berg Balance Scale - assess and retest monthly
• Use of foam/wobble board for proprioceptive challenge (progress gradually)

PHASE 3 - Community Reintegration (Months 3-6+)

A. Gait Refinement

• Over-ground gait without parallel bars (with spotter or gait belt initially)
• Dual-task gait training (walk + counting, walk + conversation) - frontal lobe engagement
• Increase cadence, step length, stride symmetry
• Outdoor walking on uneven surfaces

B. Aerobic Conditioning

• Stationary cycling or treadmill walking: 20-30 min, 3x/week at moderate intensity (RPE 11-13)
• Builds endurance, reduces fatigue (thalamic fatigue is significant in this patient)
• Helps mood and motivation (dopaminergic pathway stimulation)

C. Functional Task Training

• ADL training: dressing, grooming, toileting with OT coordination
• Functional reach, stair negotiation, floor transfers

COGNITIVE-BEHAVIORAL INTEGRATION (Mandatory given Frontal + Hippocampal involvement)

• Sessions should be 30-45 minutes maximum due to fatigue and cognitive load
• Use errorless learning approach for motor tasks (demonstrate, guide, repeat)
• Involve family/caregiver as co-therapists - home program with written instructions

ASSESSMENT TOOLS TO USE

PRECAUTIONS AND CONTRAINDICATIONS

1. Left elbow myositis ossificans: No heat, no ultrasound, no aggressive passive stretching, no forced ROM
2. Vision impairment: Ensure safe therapy environment, fall prevention
3. SAH history: Avoid Valsalva maneuvers, excessive straining in early phases
4. Fatigue: Monitor cognitive and physical fatigue; TBI patients tire rapidly - rest breaks every 15-20 min
5. No spasticity currently: Do NOT apply antispasticity stretching protocols - facilitate and strengthen instead
6. Fall risk: Use gait belt, spotter at all times during standing/walking

PROGNOSIS NOTE

PRECISE PHYSIOTHERAPY TREATMENT PROTOCOL

Patient: 39M | TBI (DAI + SAH) | Rt Hemiparesis | No Spasticity | Lt Elbow Myositis Ossificans | Lt Cerebellum involvement

SESSION STRUCTURE (Every Session)

PHASE 1 - ACUTE/EARLY SUBACUTE (Week 1 to Week 4)

STEP 1 - BED POSITIONING (Passive, 24-hour management)

1. Head of bed elevated 30 degrees
2. Rt shoulder: place small pillow under scapula to maintain protraction
3. Rt elbow: extended, wrist neutral, fingers loosely open (roll of bandage in palm)
4. Rt hip: neutral rotation, small pillow under knee (5-10 degree flexion only)
5. Rt ankle: resting splint or pillow positioning to prevent plantarflexion contracture
6. Turn patient every 2 hours - alternate supine/side-lying

1. Head supported in neutral
2. Rt arm forward, elbow extended, forearm supinated
3. Lt knee bent, supported on pillow in front

1. Rt arm resting on pillow in front of chest, shoulder at 90 degrees
2. Rt leg on pillow, hip and knee in 45 degrees flexion

STEP 2 - PASSIVE AND ACTIVE-ASSISTED ROM (2x daily, 10 reps each)

1. Shoulder: Flexion 0-160°, Abduction 0-150°, External rotation 0-60°, Horizontal adduction
2. Elbow: Flexion-extension full range
3. Forearm: Pronation-supination
4. Wrist: Flexion, extension, ulnar/radial deviation
5. Fingers: MCP, PIP flexion-extension, thumb opposition

1. Active ROM ONLY by patient - do not manually move the elbow
2. Ask patient to slowly bend and straighten elbow - only within pain-free range
3. NEVER force beyond comfortable range
4. NEVER apply heat, ultrasound, or massage to the elbow
5. Document available ROM each session

1. Hip: Flexion 0-90°, extension, abduction 0-40°, adduction, IR/ER
2. Knee: Flexion 0-100°, extension
3. Ankle: Dorsiflexion, plantarflexion, inversion/eversion
4. Toes: Extension and flexion

STEP 3 - SENSORY STIMULATION (10-15 min/session)

1. Tactile: Brush/stroke Rt limb skin from distal to proximal using a soft brush
2. Deep pressure: Joint approximation at shoulder, elbow, wrist, hip, knee, ankle (5 compressions at each joint)
3. Proprioception: Passive movement with eyes closed - ask patient "up or down?" to assess and stimulate awareness
4. Temperature: Alternate warm/cold sponge on Rt arm and leg (avoid temperature extremes)
5. Visual: Direct patient's attention to Rt limbs during all passive movements

STEP 4 - MAT EXERCISES (Lying to Sitting Progression)

1. Patient supine, knees bent to 90 degrees, feet flat
2. Place your hands on patient's knees for guidance
3. Cue: "Push your feet down and lift your bottom up"
4. Hold 5 seconds at top, lower slowly
5. Start: 5 reps → Progress to 3 sets of 10
6. Progression: Single-leg bridge when bilateral achieved

1. Start with Rt upper limb assisted by therapist
2. Patient turns head toward rolling direction
3. Guide patient to roll to Rt side first (toward affected side - easier and therapeutic)
4. Progress: rolling to Lt side (harder - requires Rt limb control)
5. Repeat 5x each direction

1. Patient rolls to Rt side
2. Therapist at patient's Rt side for support
3. Patient pushes up with Lt arm while swinging legs off bed
4. Therapist supports Rt shoulder and trunk during transition
5. Progress from maximal assist → moderate assist → minimal assist → independent
6. Practice 5-10 times per session

STEP 5 - SITTING BALANCE TRAINING

1. Patient sits with feet flat on floor, hands on thighs
2. Therapist positioned in front and slightly to Rt side
3. Start with back support → withdraw support gradually
4. Target: 30 seconds unsupported → 1 min → 2 min
5. Watch for trunk lean to Rt (affected side) - correct verbally and manually

1. Patient sitting, feet flat, arms crossed on chest
2. Cue: "Lean forward toward your knees, now come back up straight"
3. 10 reps, 3 sets
4. Therapist guards at Rt shoulder

1. Patient sitting, shift weight onto Rt buttock, then Lt
2. Cue: "Lift your Lt buttock slightly off the seat, hold 3 seconds, come back"
3. 10 reps each side, 2 sets
4. This specifically loads and activates the Rt trunk muscles

1. Place colored cone/cup on table in front - ask patient to reach and return
2. Progress: reach to Rt side, then Lt side, then overhead
3. 10 repetitions each direction
4. Progression: increase distance of object, decrease base of support

PHASE 2 - REHABILITATION (Week 4 to Week 12)

STEP 6 - STANDING PROGRESSION

1. Patient at edge of bed/chair at correct height (hips and knees at 90°)
2. Feet hip-width apart, Rt foot slightly behind if possible
3. Cue: "Lean forward, nose over toes, push through your feet and stand up"
4. Therapist at Rt side, one hand at Rt hip, one at trunk
5. Do NOT allow patient to push up using only Lt arm
6. 10 repetitions, 2-3 sets per session
7. Progression: lower chair height, add timed 30-second STS test

1. Patient holds parallel bar or plinth edge
2. Stand with feet hip-width apart
3. Static hold: 30 sec → 1 min → 2 min as tolerance improves
4. Therapist stands at Rt side with gait belt secured at waist

1. Patient at parallel bars
2. Shift weight onto Rt leg: hold 5 seconds, return to centre
3. Shift weight onto Lt leg: hold 5 seconds, return
4. 10 reps each side
5. Key point: Weight bearing on Rt leg is the priority - it recruits motor neurons and initiates neuroplasticity

1. Patient at parallel bar, holds lightly with Lt hand
2. Lift Lt foot 1-2 cm off floor, balance on Rt leg
3. Target: 5 sec → 10 sec → 30 sec
4. Progress to fingertip hold only, then no hold

STEP 7 - GAIT TRAINING (Step-by-Step)

1. Patient holds parallel bars
2. March in place: lift Rt knee, then Lt knee alternately
3. 30 steps (15 each leg), 2 sets
4. Focus: Rt hip flexion activation

1. Patient at one end of parallel bars
2. Ask to step forward with Rt leg first (affected leg initiating = harder, more therapeutic)
3. Therapist at Rt side, guiding Rt hip into flexion if needed
4. Then bring Lt foot forward to level with Rt
5. Walk full length of parallel bars: 2-3 passes per session

1. Secure gait belt around patient's waist
2. Therapist at Rt side, hand on gait belt and Rt arm
3. Walk on even, clear surface
4. Cue verbal: "Heel down first, then roll to toes"
5. Distance targets: 10m → 20m → corridor length
6. Track: cadence, step length symmetry, arm swing

1. Start speed: 0.4-0.6 km/h with body weight support (20-30% if BWS available)
2. Therapist manually assists Rt leg swing phase if needed initially
3. Gradually reduce speed support and body weight support
4. Target: 0.8-1.0 km/h, 15-20 min by week 8-10

1. Walk corridor while counting backwards from 20
2. Walk while carrying an object in Lt hand
3. Walk while answering simple questions
4. This directly targets frontal lobe-driven executive function during motor activity

STEP 8 - UPPER LIMB REHABILITATION (Rt side)

1. Quadruped position (hands and knees on mat)
2. Weight through Rt wrist and hand
3. Hold 30 seconds → progress to rocking forward/backward
4. This activates shoulder and wrist stabilizers

1. Patient seated at table
2. Place cone 30cm in front - reach, pick up, place to Rt side
3. 15 reps, 3 sets
4. Progress: increase distance, change object size (small → large → irregular)

1. Place mirror vertically along midline of patient
2. Patient performs movements with Lt (unaffected) hand
3. Rt hand behind mirror (patient sees reflection as if Rt hand moving)
4. Movements: fist open-close, wrist extension, finger tapping
5. 15-20 min/session - strong neuroplasticity evidence

1. Both hands hold a cane/stick horizontally
2. Raise both arms overhead, lower, protract both shoulders, push forward
3. This uses Lt movement to facilitate Rt motor pattern
4. 15 reps, 3 sets

1. Week 4-6: Squeeze therapy putty - full hand grasp, 10 reps
2. Week 6-8: Pick up large objects (cups, blocks) - pinch and release
3. Week 8-10: Peg board, button a shirt, turn pages
4. Week 10+: Writing, drawing, folding paper

STEP 9 - COORDINATION TRAINING (Lt Cerebellar involvement)

1. Patient supine, eyes open initially
2. Exercise 1: Flex one hip and knee, slide heel up the bed, extend back
3. Exercise 2: Both heels together - abduct one leg, return
4. Exercise 3: Flex hip, place heel on opposite knee, slide down shin
5. 10 reps each, slow and controlled, progress to eyes closed

1. Exercise 4: Sitting - tap foot on marked spot on floor
2. Exercise 5: Sitting - slide foot forward to mark, return
3. 10 reps each foot

1. Exercise 6: Walking along a line on floor, placing feet on marked spots
2. Exercise 7: Walk in tandem (heel to toe)
3. Exercise 8: Step sideways over a line

1. Finger-nose test repetitions: 20 reps (smooth, controlled pace)
2. Alternating forearm pronation-supination: 20 reps each arm
3. Finger tapping in sequence: thumb to each finger in order
4. Ball catching with both hands (Lt and Rt)

STEP 10 - BALANCE TRAINING (Thalamic + Cerebellar)

1. Level 1: Stand with feet hip-width apart, eyes open, 30 sec
2. Level 2: Stand feet together, eyes open, 30 sec
3. Level 3: Stand on foam/folded blanket, eyes open, 30 sec
4. Level 4: Stand feet together, eyes closed (Romberg), 30 sec
5. Level 5: Tandem stance (one foot in front), eyes open
6. Progress level only when current level achieved for 3 consecutive sessions

1. Stepping over small obstacle (5cm height)
2. Step sideways over a line: 10 steps each direction
3. Walking with head turns (side to side) during gait
4. Reaching forward/sideways from standing for objects (Star Excursion modified)

PHASE 3 - FUNCTIONAL REINTEGRATION (Week 12+)

STEP 11 - STAIR TRAINING

1. Use one railing, therapist at Rt side with gait belt
2. Ascending: Lt (stronger) leg leads up first → "Good leg goes to heaven"
3. Descending: Rt (affected) leg leads down first → "Bad leg goes to hell"
4. Start: 3-5 steps → full flight of stairs
5. Progress: no railing, alternate feet on each step

STEP 12 - COMMUNITY MOBILITY PREPARATION

1. Walk on uneven grass/gravel surface (with therapist guarding)
2. Walk on incline/decline ramp
3. Outdoor walking: 50m → 100m → 200m
4. Crossing a simulated road (timed, with traffic awareness)
5. Carrying objects while walking (shopping bag in Lt hand, progress to Rt)

STEP 13 - AEROBIC CONDITIONING

1. Mode: Stationary cycle or treadmill walk
2. Intensity: 11-13 RPE (Rating of Perceived Exertion) - moderate
3. Duration: 15 min (Week 4-6) → 20 min (Week 6-8) → 30 min (Week 8+)
4. Frequency: 3x/week (alternate days)
5. Purpose: Reduces fatigue, improves mood, stimulates dopamine (directly counters frontal abulia/motivation loss)

COGNITIVE-MOTOR INTEGRATION STEPS (Every Session)

DAILY SESSION TEMPLATE

DISCHARGE CRITERIA / GOAL MILESTONES

KEY REMINDERS

• No spasticity = Do NOT stretch aggressively, do NOT use inhibitory positioning, DO facilitate and strengthen
• Myositis ossificans (Lt elbow) = Active ROM only, no passive force, no heat/ultrasound, no massage to that area
• Cerebellar (Lt) = Coordination before speed; slow precise movements first
• Frontal + Hippocampal = Errorless learning, repetition, same routine, short sessions
• SAH history = No breath-holding, no Valsalva, avoid head-down positions in early phase
• Re-assess every 2 weeks with BBS, FIM motor score, 10MWT, and Fugl-Meyer (Rt limb)