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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
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KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

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Dr. Anuradha
On Jan 2020

Important Notice

Case report
Year : 2023 | Month : June | Volume : 17 | Issue : 6 | Page : YD07 - YD09 Full Version

Approach-oriented Physiotherapeutic Management of a Patient with Right Thalamic Bleed: A Case Report

Published: June 1, 2023 | DOI:
Neha Rajesh Badwaik, Pallavi Harjpal, Ragini Dadgal

1. Ex-Postgraduate (Student), Department of Physiotherapy, Ravi Nair Physiotherapy College, Wardha, Maharashtra, India. 2. Assistant Professor, Department of Neurophysiotherapy, Ravi Nair Physiotherapy College, Wardha, Maharashtra, India. 3. Professor, Department of Neurophysiotherapy, Ravi Nair Physiotherapy College, Wardha, Maharashtra, India.

Correspondence Address :
Neha Rajesh Badwaik,
Madha Colony Zade Layout, Wardha-442001, Maharashtra, India.


Rehabilitation is essential for stroke recovery. Professionals with experience in stroke rehabilitation from the different fields should make up a basic multidisciplinary stroke rehabilitation team. A stroke is the sudden loss of blood supply to the brain followed by a neurological deficit for more than 24 hours. A 42-year-old male patient presented with chief complaints of sudden weakness over one side of the body, slurred speech and blurred vision. The patient showed typical features of stroke-like tonal abnormalities, altered sensorium, diminished reflexes, reduced range of motion and strength. Magnetic Resonance Imaging (MRI) showed bleeding in the right lenticular capsular, basal ganglia and intraparenchymal part of the thalamus. The physiotherapy treatment started from the Intensive Care Unit (ICU) itself for better results with the collaboration with neurosurgeons and nurses, after the surgery. The Proprioceptive Neuromuscular Facilitation (PNF) approach and Rood’s approach were used to generate neuroplasticity as early as possible. The motor relearning program helped to regain the movements. Various outcome measures like the National Institute of Health Stroke Scale (NIHSS), Brunstorm grading, and Barthel index showed many crucial changes in tone, strength, balance, and coordination that improved the patient’s Quality of Life (QoL). Also, speech therapists and neuro-optometrist play an important role during rehabilitation.


Brunstorm grading, Stroke, Tonal abnormalities

Case Report

A 42-year-old male patient, driver by profession, right-handed, presented with the complaints of weakness on the left-side of his body for the last two days. The patient experienced a sudden fall from the bed at night and was unable to move the left half of his body. He was unable to walk and severe headaches with vomiting were noted. The MRI showed a haemorrhage in the right lenticular capsular, basal ganglia and intraparenchymal thalamic area. Decompressive craniotomy and tracheostomy were done. He was unable to speak because of increased secretions. The patient’s bowel and bladder were affected, necessitating intermittent catheterisation. Manual muscle strength and deep tendon reflex findings were documented according to Modified Ashworth Scale (Table/Fig 1),(Table/Fig 2) (1). The postoperative thalamic bleed patient was referred for physiotherapy to normalise the muscle tone, increase strength and improve his functional independence.

Physiotherapeutic Intervention

The tailor-made physiotherapeutic protocol is discussed below in (Table/Fig 3),(Table/Fig 4).

The regimen primarily emphasises approaches like Rood’s method, PNF and strengthening combined with stretching. It was critical to maintain the joint integrity and mobility of the patient during the first week since he had no movement as a result of respiratory insufficiency. Therefore, the main objective was to prevent further complications from occurring during this phase.

In week 2, the patient became conscious and the respiratory issues were resolved, but the affected side’s muscles remained flaccid. So, the rood strategy was utilised. It causes the tone to increase. The patient was finally more stable in week 3, but it was a rise in tone that was causing the spasticity. To stop the synergistic movement, PNF was applied along with the rood’s inhibitory strategy. As the tone subsided, the concentration was on strengthening and stretching strategy.

Outcome Measures

National Institute of Health Stroke Scale (NIHSS): Pretreatment score was 37 (severe stroke) and the post-treatment score was 14 (moderate stroke) on day 24 (2). Brunstorm Stage of Recovery score for the upper limb on day 24 was 4 and for the lower limb was 6 (3). Montreal Cognitive Assessment Scale (MoCA) pretreatment score was 12 and postscore was 20 out of 30 total scores. The patient was followed-up to day 25 regularly, after that monthly for four months.

The dysarthria interventions provided by a speech therapist resulted in significant improvement in speech of the patient. Approximately, 20% of the visual field was affected, and proper glasses were prescribed by optometrist (4).


The present case report focuses on early physiotherapy rehabilitation for better results. According to Krutulyte G et al., found that task-oriented strategies, like motor relearning programs, are preferred over facilitation/inhibition strategies (e.g., Bobath program) for stroke patients’ rehabilitation. Additionally, she emphasised on the patient’s body being guided by the physical therapist at key moments, activating natural postural reactions, and training natural movement patterns (5).

Research by Shimura K and Kasai T concluded that the PNF position increases the joint’s mobility by altering the order in which the muscle groups contract (6). According to Bordoloi K and Deka RS, a home exercise program that incorporates conventional physical therapy with Rood’s method is more effective than conventional physical therapy alone at enhancing patients’ capacity for independent self-care following intracranial haemorrhage (7).

Rehabilitation is essential for stroke recovery. Stroke patients commonly have reduced mobility, which limits their ability to participate in social events and Activities of Daily Living (ADL) and lowers their likelihood of returning to their prior level of work (8). The motor function may contribute to the low overall QoL, together with other factors (such as social or personal issues) (9). A high-intensity, early physical therapy program improves poststroke motor performance and functional capacity for performing ADLs, according to research (10).

Rood’s method was used in this case report, practical including both caregivers and patients since it is reasonably simple to use and places no cognitive demands on the patient. The study by Chaturvedi P and Kalani A suggested that rolling and light joint compressions are used to suppress aberrant hypertonia while exteroception and proprioception are promoted to produce muscle tone (11). According to Ankar P et al., methods of the Brunnstrom approach, Rood’s approach and NDT will aid the patient’s recovery of their motor skills. Therefore, if the entire treatment protocol is adhered to correctly and regularly, the patient will demonstrate a good recovery (12).

According to Sheikh S et al., haemorrhagic stroke patients who receive early therapy have a better chance of recovering quickly after their stroke. Basic bed mobility exercises enhance joint integrity and mobility. Active assisted range of motion exercises, bilateral training, and the Rood’s method are examples of joint integrity and tone facilitation techniques which were also used in this case report (13).

According to Rodrigues A et al., respiratory complications like atelectasis, sputum retention, facilitation of ventilatory weaning, and/or prevention of reintubation were historically the mainstay of physiotherapy treatment. Active mobilisation and rehabilitation may enhance muscle strength, functional independence and decrease delirium, according to mounting evidence, especially if started within the first few days of an ICU admission. Regular physical treatment and PNF were more efficient in enhancing static and dynamic balance in poststroke patients (14).

Interdisciplinary strategy is a major factor in the quality of care provided by stroke services. Professionals with experience in stroke rehabilitation from the following fields should make up a basic multidisciplinary stroke rehabilitation team including consultant physicians, nurses, physiotherapists, occupational therapists, speech therapists, clinical psychologists, rehabilitation aides and social workers (15),(16).


The thoroughly monitored rehabilitation after decompressive craniotomy with tracheostomy reduces the symptoms and enhances the QoL of the patient. Early intervention in neurosurgery, physiotherapy, speech therapy and optometrist can improve the development of neuroplasticity and enable a person to resume most of the activities of a normal day. An ICU based physical therapy rehabilitation protocol was initiated in order to reduce the risk of complications and improve tone. In order to improve early independent movements, Rood’s approach may be used to facilitate and inhibit tonal input at appropriate times. PNF is used to break synergistic patterns to be more effective in daily activities. Professionals with experience in stroke rehabilitation from the different fields should make up a basic multidisciplinary stroke rehabilitation team. The consultant neurosurgeon, nurses, speech therapist and optometrist play an important role in neurorehabilitation.


Harb A, Kishner S. Modified Ashworth Scale. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.
Kwah LK, Diong J. National Institutes of Health Stroke Scale (NIHSS). J Physiother. 2014;60(1):61. Available from: retrieve/pii/S1836955314000137. [crossref][PubMed]
Huang CY, Lin GH, Huang YJ, Song CY, Lee YC, How MJ, et al. Improving the utility of the Brunnstrom recovery stages in patients with stroke. Medicine. 2016;95(31):e4508. Available from: PMC4979857/. [crossref][PubMed]
Vision loss after stroke: Why it happens and how it’s treated [Internet]. Healthline. 2022. Available from:
Krutulyte G, Kimtys A, Krisciu –nas A. The effectiveness of physical therapy methods (Bobath and motor relearning program) in rehabilitation of stroke patients. Med Kaunas Lith. 2003;39(9):889-95.
Shimura K, Kasai T. Effects of proprioceptive neuromuscular facilitation on the initiation of voluntary movement and motor evoked potentials in upper limb muscles. Hum Mov Sci. 2002;21(1):101-13. Available from: https://www. [crossref][PubMed]
Bordoloi K, Deka RS. Modified Rood’s approach and ability of independent selfcare in haemorrhagic stroke patients of Assam, India. International Journal of Research in Medical Sciences. 2020;8(3):1070-1075. Available from: http:// [crossref]
Marwaa MN, Kristensen HK, Guidetti S, Ytterberg C. Physiotherapists’ and occupational therapists’ perspectives on information and communication technology in stroke rehabilitation. PLOS ONE. 2020;15(8):e0236831. Available from: [crossref][PubMed]
Guiu-Tula FX, Cabanas-Valdés R, Sitjà-Rabert M, Urrútia G, Gómara-Toldrà N. The efficacy of the proprioceptive neuromuscular facilitation (PNF) approach in stroke rehabilitation to improve basic activities of daily living and quality of life: A systematic review and meta-analysis protocol. BMJ Open. 2017;7(12):e016739. Available from: [crossref][PubMed]
Pak A, Eisen DP, McBryde ES, Adegboye OA. Hospitalisation for lower respiratory tract infection is associated with an increased incidence of acute myocardial infarction and stroke in tropical Northern Australia. Sci Rep. 2021;11(1):6826. Available from: [crossref][PubMed]
Chaturvedi P, Kalani A. Motor rehabilitation of aphasic stroke patient: The possibility of Rood’s approach. Neural Regen Res. 2023;18(3):551. Available from: https:// stroke_patient_.27.aspx. [crossref][PubMed]
Ankar P, Samal S, Vikrant, Kovela RK, Dagal R, Thimoty R. Effect of physiotherapy on hand rehabilitation in acute ischemic stroke survivor: A case report. J Pharm Res Int. 2022;28-32. Available from: JPRI/article/view/35343. [crossref]
Sheikh S, Samal S, Kovela RK, Dagal R, Thimoty R, Harjpal P. Effect of early proprioceptive neuromuscular facilitation on a hemiplegic patient post-hemorrhagic stroke: A case report. J Pharm Res Int. 2021;2494-99. Available from: [crossref]
Rodrigues A, Castro GM, Jácome C, Langer D, Parry SM, Burtin C. Current developments and future directions in respiratory physiotherapy. Eur Respir Rev [Internet]. 2020;29(158). Available from: 29/158/200264. [crossref][PubMed]
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Dworzynski K, Ritchie G, Playford ED. Stroke rehabilitation: Long-term rehabilitation after stroke. Clinical Medicine. 2015;15(5):461. Available from:[crossref][PubMed]

DOI and Others

DOI: 10.7860/JCDR/2023/60780.18088

Date of Submission: Oct 19, 2022
Date of Peer Review: Dec 08, 2022
Date of Acceptance: Apr 07, 2023
Date of Publishing: Jun 01, 2023

• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

• Plagiarism X-checker: Oct 29, 2022
• Manual Googling: Mar 14, 2023
• iThenticate Software: Apr 03, 2023 (3%)

ETYMOLOGY: Author Origin


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