Physiotherapy Indications for Elderly Bedridden Patients After Intracranial Hemorrhage Stroke
All elderly bedridden patients with intracranial hemorrhage (ICH) should receive early multidisciplinary rehabilitation including physiotherapy, which should begin as soon as the patient is medically stable and continue through community-based programs to maximize functional recovery and quality of life. 1
Specific Indications for Physiotherapy
Immediate Post-ICH Phase (Acute Care)
- Medically stable patients should be admitted to a stroke unit or neuro-intensive care unit and undergo interprofessional stroke team assessment to determine rehabilitation needs 1
- Early mobilization should begin once the patient is clinically stable 1
- Physiotherapy should be initiated within the first week after ICH onset 2
- Goals in this phase include:
- Prevention of complications of immobility (contractures, pressure sores, pneumonia)
- Maintenance of joint range of motion
- Proper positioning to prevent spasticity
- Gradual progression to sitting and standing as tolerated
Early Rehabilitation Phase
- Physiotherapy should focus on:
- Motor function recovery using task-specific exercises
- Balance training using standardized protocols
- Gait training when appropriate
- Transfer training (bed mobility, sit-to-stand)
- Activities of daily living (ADL) retraining
Long-term Rehabilitation Phase
- Physiotherapy should continue beyond the acute phase as recovery after ICH takes longer than ischemic stroke 1
- Rehabilitation should be continued in the community setting as part of a well-coordinated program 1
- Focus on:
- Progressive strengthening exercises
- Advanced balance and coordination training
- Functional mobility in home environment
- Community reintegration activities
Evidence-Based Protocols
The American Heart Association/American Stroke Association guidelines recommend:
- All ICH patients should have access to multidisciplinary rehabilitation (Class I, Level of Evidence A) 1
- Rehabilitation should begin as early as possible and continue in the community (Class IIa, Level of Evidence B) 1
- Physiotherapy interventions should be structured and task-specific 3
- Treatment frequency of at least twice weekly for a minimum of 10 consecutive weeks has shown benefit 3
Special Considerations for Elderly Bedridden Patients
- Cognitive assessment is crucial as cognitive deficits may affect rehabilitation potential 1
- Individualized intensity based on tolerance and medical stability
- Caregiver training is essential for continued care and exercises between therapy sessions 1
- Location flexibility - evidence shows similar outcomes whether physiotherapy is provided at a primary health center or at the patient's home 3
Long-term Benefits
Research has demonstrated that physiotherapy interventions are effective even when applied late after stroke 4. A meta-analysis showed significant improvements in:
- Short and long-distance walking speed
- Activities of daily living
- Overall functional outcomes
Clinical Pitfalls to Avoid
- Delaying rehabilitation - The notion of a "plateau" in recovery is challenged by evidence showing benefits of physiotherapy even in chronic phases 4
- Inadequate intensity - Insufficient therapy dosage may limit recovery potential
- Neglecting cognitive aspects - Cognitive impairment can affect motor learning and recovery
- Failing to address secondary complications - Spasticity, contractures, and pain must be managed concurrently
- Discontinuing therapy too early - Recovery after ICH continues beyond traditional rehabilitation timeframes
Monitoring Progress
Standardized assessments should be used to track progress:
- Modified Motor Assessment Scale (MMAS)
- Short-form Postural Assessment Scale for Stroke (SF-PASS)
- Barthel Index for ADLs
- Walking speed measurements
- Balance assessments (Berg Balance Scale)
Physiotherapy for elderly bedridden ICH patients should be part of a comprehensive rehabilitation approach that addresses physical, cognitive, and psychosocial needs to optimize recovery and quality of life.