Effect of an integrated exercise programme and use of electromyography to track chronic functional recovery after hemorrhagic stroke: A case report

Case description and management: A 56-year-old women with left-sided hemiplegia following a hemorrhagic stroke in 2015 presented with significant motor deficits and reduced functional independence despite prior conventional rehabilitation. Ten years post-stroke (March 2025), she continued to experience spasticity, impaired mobility, and difficulty performing activities of daily living. Baseline assessment revealed low Functional Independence Measure (FIM) scores, increased muscle tone on the Modified Ashworth Scale (MAS), and reduced neuromuscular activation on electromyograph. The patient underwent a structured 15-week integrated physiotherapy programme, consisting of high-intensity sessions conducted six days per week. The intervention included task-specific functional training, strengthening, balance and gait training, spasticity management techniques, and oromotor and facial muscle stimulation. Electromyography was used to objectively monitor changes in muscle activation and motor unit recruitment throughout the rehabilitation period. Following the intervention, the patient demonstrated meaningful improvements in functional independence, reduced spasticity, and enhanced neuromuscular activation, as reflected by improved FIM, MAS, and electromyographic outcomes.

Conclusion: This case highlights that significant functional recovery and neuromuscular adaptation remain achievable even in the chronic phase of hemorrhagic stroke through an intensive, integrated rehabilitation approach supported by objective assessment tools.

This case study was carried out in the rehabilitation department to examine the effectiveness of an integrated physiotherapy programme in enhancing functional recovery in a patient with chronic hemorrhagic stroke.

After receiving standard physiotherapy treatment during the acute phase, she continued to face functional limitations even after ten years. In March 2025, she began regular physiotherapy sessions at a rehabilitation center, Bhubaneswar, Odisha, India. Before initiating the intervention, informed consent was obtained, and pre-treatment assessments were conducted to evaluate her neuromuscular function and overall physical condition.

This patient with left sided hemiplegia following a stroke and continued to experience mobility challenges despite undergoing prior rehabilitation. A detailed medical examination was conducted, including sociodemographic data, clinical history, neurological assessments, and electromyographic analysis to assess neuromuscular activation. Neuromuscular activation was assessed using a Clarity Octopus surface EMG system. Bipolar electrodes were placed on the biceps brachii and rectus femoris following surface electromyography for the non-invasive assessment of muscles guidelines. Data were sampled at 1000 Hz, and the Root Mean Square (RMS) amplitude was calculated during Maximal Voluntary Isometric Contractions to quantify motor unit recruitment. Functional impairments were evaluated using range of motion assessments, muscle tone grading, and functional independence scoring. A 15-week rehabilitation programme was implemented, consisting of six sessions per week, each lasting an hour and 15 mins [2, 6, 7]. For details please see Table 1.

Post-treatment evaluations revealed significant improvements in functional mobility, neuromuscular activation, and muscle tone. Outcome measures confirmed the physiotherapy regimen's effectiveness. The FIM score rose from 32 to 55, reflecting greater autonomy in self-care, mobility, and daily tasks. The MAS showed reduced muscle stiffness, with upper limb scores decreasing from 3 to 2, enhancing movement control. Lower limb scores declined from 2 to 1, indicating less spasticity and better voluntary movement. EMG assessments demonstrated improved neuromuscular activation, increased motor unit recruitment, and enhanced muscle coordination, underscoring neuromuscular adaptation and recovery.

Table 1 Fifteen weeks integrated exercise protocol a

This case report suggests that a 15-week integrated physiotherapy protocol may contribute to functional recovery in a patient with chronic hemorrhagic stroke. While recovery often slows in the chronic phase, the improvements observed in this instance point toward the potential utility of task-specific training. By focusing on functional mobility and Activities of Daily Living (ADLs), the protocol aimed to facilitate motor relearning, a process which—in this specific case—aligned with the improvements in coordination noted by Richardson et al., [8].

The transition from gravity-eliminated movements to resisted training (60–70% of 1-Rep Max) was associated with increased stance stability in the patient. Consistent with the framework described by Li X et al., combining resistance training with moderate-intensity gait tasks may have addressed some of the muscular atrophy common in chronic stroke. Furthermore, the use of spasticity management (icing and stretching) seemed to provide a temporary window of reduced excitability, potentially allowing for higher-quality repetitions during functional training [10].

As a case report, these findings are limited by the lack of a control group and cannot be generalized to the broader stroke population. The improvements noted in the FIM and EMG signals should be interpreted with caution, as they represent the response of a single individual. While the results are encouraging, they merely highlight the possibility that structured, late-stage intervention can be beneficial. Further large-scale, randomized controlled trials are necessary to determine if these outcomes are reproducible and to establish standardized protocols for the chronic stroke population.

Manuscript drafting and revising it critically: AP. Approval of the final version of the manuscript: AP, PS, LP, DP. Guarantor accuracy and integrity of the work: DP.