Physiotherapy Case Studies

Case 1: Acute Ischaemic Stroke

Age: 68 Gender: Female

Mrs. Patel presented with sudden right-sided weakness and slurred speech. CT confirmed an ischaemic infarct in the left MCA territory. She was thrombolysed 2 hours post-onset and is now on the acute stroke unit. Conscious, oriented, with right-sided hemiparesis. Nil by mouth pending SLT assessment.

1. What is the most common type of stroke?

Ischaemic strokes make up about 85% of all strokes and are caused by a blockage in a cerebral artery.

2. Which of the following is an early sign of stroke on assessment?

Facial droop is part of the FAST stroke recognition tool, indicating possible facial muscle weakness.

3. Which imaging modality is typically first used in suspected stroke?

A non-contrast CT scan is the first-line investigation to quickly differentiate between ischaemic and haemorrhagic stroke.

4. Which position should be encouraged to optimise cerebral perfusion in early stroke?

This position aids venous drainage and maintains cerebral perfusion pressure without increasing ICP.

5. What is a key physiotherapy goal in the first 48 hours post-stroke?

Early rehab focuses on preventing deconditioning, pressure ulcers, and respiratory issues.

6. Which member of the MDT would assist with dysphagia management?

SLTs are key in assessing and treating swallowing issues post-stroke.

7. Which term describes one-sided weakness following a stroke?

Hemiparesis is weakness on one side of the body, commonly seen after a stroke.

8. Which patient-centred approach is appropriate in early rehab?

Patient-led goals enhance engagement and relevance of therapy.

9. Which tool assesses stroke-related disability?

The mRS grades functional independence post-stroke and is commonly used in stroke units.

10. What role does early mobilisation have after stroke?

Early mobilisation supports both neurological recovery and general health maintenance.

Case 2: Traumatic Brain Injury (TBI)

Age: 32 Gender: Male

Mr. Smith sustained a moderate TBI following a motorbike collision. GCS on admission was 9. CT showed diffuse axonal injury without surgical lesion. He is now in the neuro ward, opens eyes spontaneously, follows simple commands, but has poor trunk control and agitation episodes. Full MDT involved, including neuropsychology and OT.

1. Which scale is commonly used to assess consciousness in TBI?

The GCS assesses eye, verbal, and motor responses to determine the level of consciousness in TBI patients.

2. What is a sign of increased intracranial pressure (ICP)?

This is Cushing’s triad, a classic sign of increased ICP indicating potential brain herniation.

3. What is a key early physiotherapy focus post-TBI?

Correct positioning reduces risk of joint deformities and supports long-term functional outcomes.

4. What type of brain injury is typically caused by rotational forces?

DAI occurs due to shearing of white matter tracts, often from high-speed trauma or whiplash.

5. Which intervention supports neuroplasticity in rehab?

Neuroplasticity is promoted through active, meaningful, and repetitive movement practice.

6. Which MDT member is critical in managing behavioural issues post-TBI?

TBI often leads to cognitive and behavioural issues requiring psychological strategies and support.

7. What is heterotopic ossification (HO)?

HO can limit joint movement post-TBI and must be monitored by physiotherapists during rehab.

8. Which goal reflects a realistic early rehab outcome in severe TBI?

Gradual tolerance to upright posture is a key early rehab milestone post severe TBI.

9. What role does family play in TBI rehab?

Family support is essential in emotional recovery, routine reinforcement, and long-term engagement.

10. Which assessment tool helps identify agitation in TBI?

ABS measures severity and presence of agitation, guiding behaviour management strategies.

Case 3: Multiple Sclerosis (RRMS)

Age: 29 Gender: Female

Miss Harding has a 3-year history of relapsing-remitting MS. She presents with worsening fatigue, mild right leg weakness, and occasional visual blurring. No relapse has occurred in 9 months. Currently mobilising independently indoors, she works part-time and uses pacing strategies. Cognition mildly affected. MDT includes neurologist, OT, and physiotherapist.

1. What is the most common type of Multiple Sclerosis?

RRMS is the most common type, characterised by episodes of new or worsening symptoms followed by recovery.

2. Which symptom is characteristic of MS?

Optic neuritis and fatigue are hallmark features of MS, caused by demyelination in the CNS.

3. Which of the following tests is used to confirm MS diagnosis?

MRI is the gold standard for identifying MS plaques and confirming demyelination.

4. What physiotherapy approach supports energy conservation in MS?

Fatigue management strategies help patients with MS optimise function and reduce overexertion.

5. Which MDT professional provides cognitive strategies in MS care?

OTs support executive function and task management when MS causes cognitive impairment.

6. What is Uhthoff’s phenomenon?

Uhthoff’s phenomenon is a temporary worsening of neurological symptoms due to increased temperature.

7. Which walking aid may be useful for MS-related ataxia?

A wheeled walker provides both support and the ability to manage poor coordination and balance.

8. What is the purpose of spasticity management in MS?

Spasticity limits range and increases discomfort — managing it supports mobility and ADLs.

9. Which goal is appropriate for a patient in an MS relapse?

Physiotherapy must balance rest and activity to prevent regression during acute MS flare-ups.

10. Which outcome measure evaluates MS walking ability?

The T25-FW test is used to assess speed and mobility in MS patients.

Case 4: Parkinson’s Disease

Age: 74 Gender: Male

Mr. Alan is a retired teacher with a 5-year history of Parkinson’s Disease. He presents with increased episodes of freezing when turning, shuffling gait, and bradykinesia. Currently on Levodopa with good response. Lives with wife, independently ambulates indoors but requires supervision outdoors. Reports occasional constipation and voice changes. SLT and physio involved.

1. Which of the following is a key pathophysiological feature of Parkinson’s Disease?

Parkinson’s involves the degeneration of dopaminergic neurons in the substantia nigra affecting motor control.

2. What is the cardinal triad of Parkinson’s motor symptoms?

These are hallmark signs of PD and help differentiate it from other movement disorders.

3. Which medication is most commonly used in Parkinson’s Disease?

Levodopa is the gold standard for treating motor symptoms by restoring dopamine levels.

4. What is an effective physiotherapy focus in Parkinson’s Disease?

Auditory or visual cues can help overcome freezing and initiate more normal walking patterns.

5. Which outcome measure assesses mobility in Parkinson’s?

TUG is sensitive to balance, gait, and fall risk in Parkinson’s patients.

6. What non-motor symptom is commonly reported in Parkinson’s?

Constipation is a frequent non-motor symptom due to autonomic dysfunction in PD.

7. Which strategy helps manage 'freezing' episodes?

External cues bypass the basal ganglia circuit and can help resume walking during freezing.

8. Which MDT professional may assist with communication in Parkinson’s?

SLTs help address hypophonia and communication difficulties due to bradykinesia in facial muscles.

9. What’s a realistic rehab goal in moderate PD?

The goal is to optimise independence and function despite progressive symptoms.

10. Which postural characteristic is often seen in Parkinson’s?

Flexed posture is typical and can affect balance and gait.

Case 5: Guillain–Barré Syndrome (GBS)

Age: 44 Gender: Male

Mr. Daniels developed progressive leg weakness and paraesthesia following a gastrointestinal infection. He is now diagnosed with Guillain–Barré Syndrome. He has reduced reflexes, bilateral foot drop, and moderate respiratory muscle weakness. IVIG therapy has begun. He is on the neuro-medical ward and requires assistance for bed mobility.

1. What typically triggers Guillain–Barré Syndrome?

GBS is often preceded by infections like Campylobacter jejuni or respiratory viruses.

2. What is the most common pattern of weakness in GBS?

GBS typically starts in the lower limbs and ascends symmetrically due to peripheral nerve involvement.

3. Which of the following is a red flag in GBS that requires urgent care?

Respiratory compromise is life-threatening in GBS and may require ventilatory support.

4. What is the typical nature of reflexes in GBS?

GBS affects lower motor neurons, leading to reduced or absent deep tendon reflexes.

5. Which treatment is commonly used in the acute phase of GBS?

IVIG and plasma exchange are mainstays of acute management in GBS.

6. What is an appropriate early physio goal in GBS?

Passive ROM and positioning are key to preventing secondary complications in early stages.

7. Which MDT professional may manage respiratory support in GBS?

They assist with oxygen delivery, ventilator use, and secretion management.

8. Which assessment tool can measure functional ability in GBS recovery?

The Barthel Index evaluates ADLs such as transfers, feeding, and toileting in rehab.

9. What kind of progression should be followed during physio rehab in GBS?

Overfatigue can hinder nerve recovery; rest and slow pacing are critical.

10. What patient-centred goal may be realistic post-acute phase?

Most patients improve function over weeks or months; mobility with aids is often an early goal.

Case 6: Motor Neurone Disease (MND / ALS)

Age: 59 Gender: Male

Mr. Lewis has a diagnosis of limb-onset MND. He presents with progressive weakness in both lower limbs, fasciculations in the arms, and recent swallowing difficulties. He uses a powered wheelchair for outdoor mobility and has home adaptations. FVC is declining. He is supported by neurology, respiratory team, SLT and physiotherapy for fatigue and positioning.

1. What is the hallmark feature of Motor Neurone Disease (MND)?

MND, also known as ALS, affects both UMN and LMN pathways, leading to mixed signs like spasticity and wasting.

2. Which symptom is common in MND but typically not present early in MS?

Twitching of small muscle groups (fasciculations) is characteristic of lower motor neuron involvement in MND.

3. What is the primary goal of physiotherapy in MND?

As MND is progressive and incurable, physiotherapy aims to maximise independence and comfort.

4. Which MDT member plays a key role in managing bulbar symptoms?

SLTs support patients with speech and swallowing difficulties common in bulbar-onset MND.

5. Which respiratory measure is important in MND monitoring?

FVC helps monitor respiratory muscle strength and need for ventilatory support.

6. What equipment can help MND patients conserve energy and prolong independence?

Mobility aids delay fatigue and support safe, efficient movement as muscle weakness progresses.

7. Which statement about exercise in MND is correct?

Light, tailored exercise can delay loss of function and reduce joint stiffness.

8. What is the role of a neurologist in MND management?

The neurologist oversees progression, treatment decisions, and MDT input in MND care.

9. Which emotional impact is common in MND and should be screened?

Emotional lability or depression is common and should be addressed through support or medication.

10. Which intervention supports respiratory function in late MND?

NIV improves quality of life and survival by aiding breathing in respiratory muscle failure.

Case 7: Spinal Cord Injury (T12 Complete)

Age: 36 Gender: Female

Ms. Edwards sustained a traumatic spinal cord injury following a cycling accident. MRI confirmed a complete lesion at T12. She is alert, oriented, with preserved upper limb strength and sensation. No movement or sensation below the umbilicus. Currently in the spinal rehab unit with MDT including physiotherapist, specialist nurse, psychologist, and OT. She uses a wheelchair and is learning transfer techniques.

1. Which spinal cord injury classification tool is widely used?

The ASIA scale classifies SCI severity from A (complete) to E (normal) based on motor and sensory assessment.

2. What is spinal shock?

Spinal shock is an acute physiological response that may mask the true extent of the injury initially.

3. What complication is associated with high-level SCI (above T6)?

This is a potentially life-threatening condition caused by over-activation of the autonomic system.

4. What intervention helps prevent respiratory complications in SCI?

Respiratory muscle weakness requires active management to avoid infections and atelectasis.

5. What is a realistic goal for early rehab in complete T12 SCI?

Paraplegia below T12 requires upper limb-based mobility and independence in transfers.

6. Which MDT member manages bowel care planning?

Neurogenic bowel requires careful planning and often nurse-led routines for patient health and dignity.

7. Which issue can occur with prolonged sitting in SCI patients?

Skin integrity is at risk due to decreased sensation and mobility — repositioning and cushions help prevent ulcers.

8. What equipment helps safe transfer training in paraplegia?

Sliding boards enable patients with limited lower body control to safely transfer between surfaces.

9. Which technique promotes independence in SCI rehab?

Repetition of meaningful tasks supports neuroplasticity and adaptive strategies for independence.

10. What emotional effect may SCI patients experience requiring support?

Sudden, life-changing injuries can provoke grief, requiring psychological support and peer input.

Case 8: Functional Neurological Disorder (FND)

Age: 30 Gender: Female

Miss Lister reports intermittent right leg weakness and sudden 'blackouts' with no clear trigger. MRI and EEG were normal. Neurologist diagnosed Functional Neurological Disorder. She is emotionally distressed, with recent bereavement and high work stress. Functional weakness improves with distraction. Referred to neurophysiotherapy, clinical psychology, and occupational therapy.

1. What characterises Functional Neurological Disorder (FND)?

FND presents with real neurological symptoms, but without identifiable structural cause on investigation.

2. Which sign supports a diagnosis of FND during examination?

Symptoms that change or improve with distraction are classic in FND and aid diagnosis.

3. What is a key principle in managing FND?

Building therapeutic alliance and validating the patient’s experience is central to effective FND care.

4. Which MDT member often leads therapy for FND?

Neurophysiotherapists deliver structured rehab to promote functional movement and confidence.

5. Which strategy is useful during physio sessions for FND?

Using distraction or automatic movements helps bypass maladaptive control and restores function.

6. Which mental health condition is commonly associated with FND?

Many FND patients experience concurrent psychological distress which may exacerbate symptoms.

7. What is the typical presentation of functional limb weakness?

Functional weakness may vary day to day and is not due to nerve damage or muscle atrophy.

8. Which phrase is helpful when discussing FND with a patient?

This phrase validates the patient's experience while instilling hope and supporting engagement.

9. Which outcome measure can assess functional improvement in FND?

The FIM assesses functional mobility and independence over time during rehabilitation.

10. What type of rehabilitation schedule is effective in FND?

Intensive, goal-oriented input with physiotherapy, psychology and OT is most effective in FND rehab.

Case 9: Brain Tumour – Post-Surgical Rehab

Age: 52 Gender: Female

Mrs. Collins underwent craniotomy for removal of a left parietal lobe tumour. Post-op symptoms include mild right-sided hemiparesis and intermittent ataxia. She is oriented, cognitively intact, and motivated. MDT includes neuro-oncology, physiotherapy, occupational therapy, and clinical psychology. Mobilising short distances with assistance.

1. Which symptom may result from a brain tumour depending on its location?

Brain tumours can compress or damage specific brain areas, leading to localised symptoms.

2. What is the primary goal of early post-op physiotherapy?

Early rehab aims to minimise deconditioning, prevent VTE, and encourage functional recovery.

3. Which condition may arise due to raised ICP from a brain tumour?

Raised intracranial pressure presents with classic symptoms including headache, nausea, and vomiting.

4. Which MDT member is responsible for adjusting steroid therapy post-op?

Steroids reduce inflammation post-surgery and are adjusted based on neurological symptoms by the medical team.

5. What physical therapy consideration is important after craniotomy?

Protecting the surgical area, especially in positioning and transfers, is critical for healing.

6. Which intervention helps with post-op cerebellar ataxia?

Cerebellar damage leads to coordination issues — rehab uses vision to aid balance strategies.

7. What emotional response is common after brain tumour surgery?

Patients often experience distress due to the diagnosis, surgery, and possible residual symptoms.

8. Which tool could assess function post-op?

The Barthel Index evaluates ADLs such as transfers, feeding, and toileting, supporting discharge planning.

9. What is a safe mobility progression for a hemiparetic patient post-tumour surgery?

Rehabilitation follows a staged approach based on safety, tolerance, and motor recovery.

10. What is the purpose of MDT meetings post-tumour surgery?

MDT meetings ensure all professionals contribute to a coherent, patient-centred rehabilitation plan.

Case 10: Cerebral Palsy – Young Adult

Age: 24 Gender: Male

Mr. Fraser has spastic diplegic cerebral palsy, GMFCS Level II. He walks independently with an AFO and uses a wheelchair for long distances. He lives at home, works part-time, and is interested in increasing his independence. He reports tight hamstrings, fatigue, and mild postural scoliosis. MDT includes physio, OT, orthotics, and social worker.

1. What type of movement disorder is most common in cerebral palsy?

Spastic cerebral palsy is the most prevalent type, characterised by increased muscle tone and stiffness.

2. Which tool is used to classify functional mobility in CP?

GMFCS categorises gross motor function into 5 levels based on age-related motor capabilities.

3. What is a key focus of physiotherapy in adults with CP?

Therapy supports joint mobility, posture, and participation in daily life as patients age.

4. Which MDT member may assist with vocational support in CP?

OTs help adults with CP engage in meaningful work and develop strategies for independence.

5. What condition may occur due to abnormal joint forces over time in CP?

Spasticity and asymmetrical forces may lead to joint instability, particularly at the hips.

6. Which assistive device may benefit an adult with hemiplegic CP for community mobility?

AFOs help stabilise gait and support dorsiflexion, especially with toe drag or instability.

7. What treatment may be used to manage focal spasticity?

Botox temporarily reduces muscle overactivity and facilitates stretching and functional training.

8. Which psychosocial factor can impact CP rehab outcomes?

A supportive environment enhances participation and goal achievement in therapy.

9. Which exercise principle is relevant for CP in adults?

Exercises should reflect the person's functional goals, motor ability, and fatigue tolerance.

10. What is an appropriate rehab goal for a young adult with CP Level II GMFCS?

Level II indicates independent walking with some limitations — rehab supports participation and stamina.

Case 11: Huntington’s Disease

Age: 41 Gender: Female

Mrs. Doyle has recently been diagnosed with Huntington’s disease. She presents with choreiform movements, mild gait imbalance, and new-onset difficulties in planning daily tasks. Her mother had Huntington’s. She lives with her partner and receives MDT support from neurology, physiotherapy, psychology, and dietetics. Rehab goals include fall prevention and functional task adaptation.

1. What is the pathophysiology of Huntington’s disease?

Huntington’s is caused by a CAG repeat expansion leading to toxic protein accumulation and cell death in the basal ganglia and cortex.

2. What motor feature is most characteristic of Huntington’s disease?

Chorea is the hallmark movement disorder in Huntington’s, often beginning subtly and progressing over time.

3. Which cognitive symptom is often seen early in Huntington’s disease?

Difficulties in planning, decision-making, and impulse control are common early cognitive changes in Huntington’s.

4. What is a key physiotherapy aim in mid-stage Huntington’s?

Physiotherapy focuses on gait stability and posture management to minimise injury and support function.

5. Which MDT member supports nutrition in Huntington’s disease?

Weight loss and high energy needs require dietary planning, especially with feeding difficulties from motor impairments.

6. Which intervention can help manage chorea during mobility tasks?

Adding weight or external feedback may stabilise involuntary movements and support balance.

7. Which technique supports independence in functional tasks despite cognitive decline?

Predictable routines and structured tasks help compensate for cognitive processing difficulties.

8. What is a realistic goal for late-stage Huntington’s rehab?

Later stages focus on palliative goals, such as contracture prevention and respiratory management.

9. Which tool can assess functional stage of Huntington’s disease?

The UHDRS evaluates motor, cognitive, behavioural and functional changes in Huntington’s disease.

10. Which psychosocial issue is commonly seen in Huntington’s patients and families?

Emotional distress is common due to the hereditary nature of Huntington’s and its progressive symptoms.

Neurology Case Studies

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Case 3

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Case 5

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Case 11

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