Hemiplegia Rehab: Early Stage Bed Exercises, Positioning & Safety Guide

The early phase of stroke recovery (often called the acute or flaccid stage) is critical. While the patient may not yet have voluntary movement, correct bed exercises and positioning are vital to prevent permanent complications like frozen shoulder, foot drop, and pressure sores. This guide covers the essential physiotherapy protocols for early hemiplegia management, complete with safety tips, MCQs, and student notes.

1. Goals of Early Bed Rehabilitation

• Maintain Joint Integrity: Prevent contractures (permanent shortening of muscles).
• Shoulder Protection: Prevent subluxation (partial dislocation) of the flaccid shoulder.
• Sensory Input: Provide tactile and proprioceptive stimulation to the affected side.
• Edema Control: Prevent swelling in the hand and foot.
• Skin Care: Prevent decubitus ulcers (bed sores) through regular turning.

Golden Rule: In the early flaccid stage, movements are primarily Passive Range of Motion (PROM) performed by the therapist or caregiver, progressing to Active-Assisted (AAROM) as tone improves.

2. Bed Positioning (Crucial for Recovery)

Proper positioning inhibits abnormal tone patterns and provides comfort. Positions should be changed every 2 hours.

A. Lying on the Unaffected Side (Good)

• Head: Supported on a pillow.
• Affected Arm: Proctracted (shoulder blade forward) and supported on a pillow in front of the chest. Elbow extended.
• Affected Leg: Hip and knee flexed, supported on a pillow.

B. Lying on the Affected Side (Excellent for Proprioception)

• Shoulder: MUST be protracted (blade pulled forward) to avoid crushing the joint. Arm straight, palm up.
• Leg: Hip extended, knee slightly flexed.
• Note: This side provides weight-bearing input but must be done carefully to avoid shoulder pain.

3. Early Stage Exercises (Passive & Self-Assisted)

Exercise / Joint	Technique & Instruction	Why is it important?
Shoulder Mobilization	Caregiver supports the arm, gently moves shoulder blade (scapula) forward and backward.	Ensures scapulohumeral rhythm; prevents frozen shoulder.
Shoulder Flexion (Safe range)	Lift arm forward/up. STOP at 90° if scapula is not moving. Never pull the arm.	Maintains range for future reaching activities.
Self-Assisted Clasped Hands	Patient interlocks fingers (affected thumb over unaffected). Lifts both arms up towards ceiling.	Protects the weak wrist; allows patient to control the movement.
Elbow & Wrist	Slow flexion and extension of elbow. Full extension of wrist and fingers.	Prevents flexor synergy contractures (curled arm).
Hip & Knee Flexion (Heel Slides)	Slide the heel up towards the buttocks and back down. Can be assisted by therapist.	Prepares for walking gait; maintains hip mobility.
Ankle Dorsiflexion	Gently push the foot up towards the shin (stretching the calf).	Prevents Foot Drop and tight Achilles tendon.
Hip Abduction	Slide leg out to the side and back. Keep toes pointing to ceiling (prevent external rotation).	Maintains adductor length for hygiene and gait.

4. Safety & "Red Flags"

⚠️ The "NO PULL" Rule:
NEVER pull a hemiplegic patient by their affected arm to help them sit up or move. The muscles are flaccid and cannot hold the humerus in the socket, leading to supraspinatus tear or subluxation.

• Avoid Overhead Pulleys: In the early stage, overhead pulleys can cause shoulder impingement because the scapula doesn't rotate properly.
• Watch for DVT: Redness, heat, or swelling in the calf (Deep Vein Thrombosis). Do not exercise if suspected.
• Avoid Pain: PROM should never be painful. If it hurts, check the joint alignment.

5. One-Page Student Notes (Revision)

Stage: Flaccid (Hypotonia).
Priority: Protection & Prevention.
Shoulder: Most vulnerable joint. Keep protracted. Don't go >90° flexion without scapular glide.
Ankle: Keep at 90° (neutral) to stop foot drop.
Positioning: Change q2h (every 2 hours). Lying on affected side is good for sensory input if shoulder is safe.
Bridge: "Bridging" (lifting hips in supine) is a key early active exercise for bed mobility.

6. FAQs (Patient & Viva Questions)

Q1. How many times should exercises be done?

Ideally, passive movements should be done every 4 hours. A formal session of 10-15 repetitions per joint should occur at least 2-3 times a day.

Q2. Why is the hand swelling?

Paralysis means the "muscle pump" isn't working to push fluid back to the heart. Also, if the hand hangs down (gravity), fluid accumulates. Solution: Elevate the hand on a pillow above heart level.

Q3. Should we use a stress ball for squeezing?

Generally NO in the early stage. Squeezing stimulates the "flexor synergy" (grasp reflex), which can lead to a tight, curled hand later. Focus on opening (extending) the fingers instead.

Q4. What is "Bridging" and why do we do it?

Bridging involves bending knees and lifting hips off the bed. It helps in: 1) Bed pan use, 2) Putting on pants, 3) Strengthening glutes for standing later, 4) Relieving buttock pressure.

7. 10 Practice MCQs (Test Your Knowledge)

Q1. The primary goal of passive ankle dorsiflexion in bed is to prevent:

Answer: B) Foot drop is a common complication where the calf tightens, making walking difficult.

Q2. When positioning a patient on their affected (hemiplegic) side, the shoulder must be:

Answer: B) Protraction prevents the body weight from crushing the glenohumeral joint.

Q3. Why are overhead pulleys often contraindicated in early stroke rehab?

Answer: A) Without proper scapular rhythm, pulleys force the humerus into the acromion, causing pain.

Q4. "Clasped hand" exercises (self-assisted) are beneficial because:

Answer: B) By supporting the weak hand with the strong one, the wrist is protected from dangling.

Q5. To prevent hand edema (swelling), the hand should be placed:

Answer: C) Elevation assists venous and lymphatic drainage.

Q6. Passive Range of Motion (PROM) exercises should be performed:

Answer: C) Frequent movement is needed to maintain tissue length and joint lubrication.

Q7. Which bed mobility exercise helps most with future sit-to-stand transfers?

Answer: B) Bridging strengthens the glutes and extensors needed for standing.

Q8. During the flaccid stage, pulling the patient by the arm can cause:

Answer: A) The lack of muscle tone means the joint capsule is the only thing holding the arm; pulling stretches/tears it.

Q9. While lying on the back (supine), the affected hip tends to roll into:

Answer: B) Gravity pulls the weak leg outward. A towel roll (trochanter roll) is often used to keep it neutral.

Q10. "Heel slides" mainly maintain Range of Motion for which joints?

Answer: C) Sliding the heel up flexes both the hip and knee.

References & Further Reading

• O’Sullivan, S. B., & Schmitz, T. J. (2019). Physical Rehabilitation. F.A. Davis.
• Carr, J., & Shepherd, R. (2010). Neurological Rehabilitation: Optimizing Motor Performance. Elsevier.
• Stroke Foundation. (2023). Clinical Guidelines for Stroke Management.
• Kisner, C., & Colby, L. A. (2017). Therapeutic Exercise: Foundations and Techniques. F.A. Davis.