Physiotherapy Rehabilitation: Cerebellar Stroke + Right Below-Knee Amputation | Age 74 | Minimal Command-Following

1. Cerebellar stroke deficits (ataxia, dysmetria, balance impairment, possible dysphagia/dysarthria)
2. Right transtibial (below-knee) amputation
3. Severely impaired communication and cognition (no speech, intermittent command-following)

Baseline Assessment (Priority Before Any Intervention)

Cognitive / Communication

• Consistent eye blink, hand squeeze, or eye gaze for yes/no
• All therapy must be gesture-led, demonstration-based, and tactile-cued

Motor / Neurological

• Tone assessment bilaterally (hypotonia is typical in acute cerebellar stroke)
• Truncal stability — sitting balance (static → dynamic)
• SARA (Scale for the Assessment and Rating of Ataxia) — modified for non-verbal use
• Berg Balance Scale — abbreviated/modified
• Assess residual limb: skin integrity, volume, wound healing (if recent amputation)

Rehabilitation Goals (Realistic for This Patient)

Note: Given age 74, cerebellar stroke + unilateral amputation + poor cognition, independent ambulation with prosthesis is unlikely in early phases. A realistic goal is assisted mobility and prevention of secondary complications.

Physiotherapy Intervention Framework

Phase 1 — Acute/Bed Phase (Days 0–14 post-stroke)

• Side-lying with pillow support; avoid prolonged supine (aspiration + pressure injury risk)
• Residual limb: elevate for edema control; DO NOT flex hip/knee >90° during this phase

• All four limbs: prevent contractures (particularly hip flexion, plantarflexion contracture on intact left leg)
• Residual right limb: gentle ROM to hip and knee; avoid end-range hip flexion initially
• Emphasis on trunk elongation and scapular mobilisation

• Cerebellar stroke → often reduced cough efficacy + aspiration risk
• Positioning for secretion drainage; assisted coughing techniques; encourage deep breathing

• Tactile stimulation (brushing, tapping) to facilitate arousal and motor responses
• Weight-bearing through hands in sitting to stimulate proprioception
• Mirror therapy on intact left limb to modulate cortical activation

Phase 2 — Sitting Balance & Trunk Control (Week 2–4)

• Grade I: fully supported by therapist/two-person assist
• Grade II: hand support on plinth, therapist at side
• Grade III: unsupported sitting with reaching tasks (when achievable)

• Rhythmic stabilisation techniques (PNF) applied to trunk/shoulders
• Weight shifts side-to-side and anterior-posterior in sitting
• Use of weighted vest or cuff weights to dampen ataxic movements (proprioceptive loading)

• Begin stump shaping with compressive bandaging (figure-of-8 technique) or shrinker sock — critical to prepare for eventual prosthetic fitting
• Check skin daily; pressure areas are high risk in neurologically impaired patients
• Maintain full knee and hip extension ROM

• All instructions delivered via demonstration + physical guidance
• Limit verbal instruction to single, short words ("UP," "HOLD," "PUSH")
• Consistent routine reduces cognitive demand — same sequence every session
• Use errorless learning techniques

Phase 3 — Standing & Transfer Training (Week 3–6 depending on progress)

• Begin with tilt table if sitting balance is not yet safe (graded orthostatic challenge)
• Progress to standing frame: modified for unilateral BKA — pad the right residual limb against the frame support
• Duration: start 5–10 min, progress to 20–30 min

• Initially: 2-person assisted pivot transfer to intact left leg
• Hoist if unsafe or if >2 persons needed
• Consistent transfer direction: always pivot over left (intact) leg
• Use transfer board when appropriate

• Frenkel's exercises (modified for upper limbs and trunk if lower limb unavailable): slow, rhythmic, precise movements to restore coordination
• Gait re-education on left leg only at this stage (no prosthetic fitting yet in acute phase)
• Wide base of support always; do not try to narrow BOS prematurely with cerebellar ataxia

Phase 4 — Prosthetic Preparation & Early Mobility (Week 4–8+)

• Stable residual limb volume (stump shaped and consistent)
• Intact skin and wound healing
• Ability to tolerate standing ≥10 minutes
• Cognitive ability to follow basic 2-step commands at minimum
• Adequate contralateral limb strength

• Propulsion with left leg (hemiplegic-style wheeling if upper limb affected)
• Pressure mapping cushion
• Footrest adjusted for residual limb position

Multidisciplinary Team (MDT) Integration

Key Safety Precautions

• Fall risk: VERY HIGH — cerebellar ataxia + single-limb status + impaired cognition
• Always use 2-person assist for any standing/transfer until balance improves significantly
• Dysphagia precautions: nil by mouth until formal SALT assessment; NG feeding may be required
• Skin integrity: daily inspection of residual limb and all bony prominences
• Orthostatic hypotension: common after stroke in elderly — monitor BP on standing (tilt table first)
• Avoid overloading cognitive-communication demands — patient will fatigue rapidly

Outcome Measures (Adapted for Non-Verbal Patient)

Recent Evidence (PubMed, 2024–2025)

• Bogaert et al. (2024, Disabil Rehabil, PMID 37639546) — Systematic review of tailored physical rehabilitation for cerebellar impairment targeting mobility and walking: emphasises individualised approaches targeting gait and balance specific to cerebellar features.
• Jiang et al. (2025, Eur J Phys Rehabil Med, PMID 40047654) — Meta-analysis of cerebellar non-invasive brain stimulation for balance/gait in stroke patients: supports adjunctive use of cerebellar rTMS/tDCS for balance improvement, though feasibility in non-verbal cognitively impaired patients requires caution.
• Wang et al. (2024, BMC Neurol, PMID 38879485) — Cerebellar TMS for balance and ADL in stroke: significant improvements in Berg Balance Scale and Barthel Index.

Summary Priorities at a Glance

1. Establish non-verbal communication → yes/no system
2. Dysphagia screen → SALT urgent referral
3. Positioning + pressure care + ROM → prevent secondary complications
4. Sitting balance → trunk control → standing frame (this sequence is non-negotiable)
5. Residual limb shaping → prosthetic readiness (parallel track)
6. Transfer training over intact leg (left)
7. MDT coordination for complex needs
8. Reassess cognition regularly → adjust goals as awareness improves