Gaining Strength After Stroke

by Jayesh Mehta
(Wellingborough in UK)

Question: I suffered a hemorrhagic stroke and subsequently got senses back in all of my body. As an effect of the stroke, my left side, even though movement feels OK, is a bit weak due to prolonged time in bed (8 months in hospital+rehab). My body has lost its strength and hence I can't get up from a sitting position. I have joined a gym to gain strength and am a full time worker post stroke. The reason for this note is to see what you can suggest to get some strength back - to be able to get up by myself and take a few steps, etc. (not looking for running down the street). Please share anything that you think might help.

Thanks
Jayesh

Answer: I like to use hi-lo mats to help patients improve their ability to stand from a sitting position. A hi-lo mat can be adjusted to a low or high position. I will have my patients sit on the mat and then raise the height. We will practice weight bearing through the legs with the mat elevated (with the buttocks still on the mat) and then will practice sit to stand from this position. I will block the knee on their weak side if necessary to prevent the leg from buckling. An air splint can also be used to help keep the leg from collapsing. Once a patient has gained confidence in standing then I work on the patient shifting weight side to side and learning to take more weight through the weak leg. I also vary the height of the hi-lo mat to work on sit to stand from different heights. As the legs and core get stronger, one will be able to get up from a lower height.

A physical therapist should be able to help you with the techniques described above. I don't know about equipment in the UK but hi-lo mats are standard equipment in a US therapy clinic.

One might could use a hospital bed or lift chair to achieve the same effect as a hi-lo mat, however, I haven't tried this out. You should always check with your medical provider before attempting any exercises and also have a therapist or trained caregiver with you when attempting such exercises as described above.

Below is an examples of a hi-lo mat. One can purchase these mats, however, they are expensive.

What is missing from my list of stroke exercises?

by KHZ

Question: Hi dear therapist, this is the list of exercises I use in my treatment plan, from first stage to end of treatment:

1- Roll over (to reduce spasticity)or trunk lateral rotation
2- four foot kneeling (on hands and knees)
3- active pelvic elevation
4- active shoulder elevation
5- sitting down to standing up
6- balance in standing
7- try walking with walker, with help of family.

What is missing?
Thank you very much

Answer: Your stroke treatment plan is good in my opinion. I don't know your limitations, but if you are able, I would add fine motor coordination activities for your hand. Some examples of fine motor activities can be found at www.stroke-rehab.com/hand-exercises.html. Also, if you are able, I would add some gross motor activities for your arms such as trying to hold, bounce, toss, or catch a medium to large size ball. If that is too difficult, just try holding a ball using both hands and moving it around (i.e. lifting it overhead, pushing it out in front of you, rolling it forwards and back). I also recommend stretching for any tight muscle groups.

If you have problems with sensation (numbness, tingling, difficulty feeling touch), then sensory re-education activities would be important. Sensory re-education activities can be found at www.stroke-rehab.com/sensory-re-education.html.

The above are all physical activities of course. If you have problems with speech, swallowing, or cognition then you will want to make sure you are addressing these areas as well. Thanks for your question!

Recovery from Stroke

by Lisa
(NSW)

Question: My mother is 78. She had a stroke 3 years ago. She cannot move her left arm and can lift her left leg only a little and shuffle it if she really tries. Other than that she is physically well but is always depressed and crying. Will my mum ever get better or ever smile again?

Answer: I suggest that you read the following page on stroke and personality changes: www.stroke-rehab.com/personality-changes.html. I encourage you to have your mom see a physician or neuropsychiatrist to see if they can help her with the depression symptoms. I also encourage you to get some support by reaching out to other caregivers who are going through the same thing as you. You can find a list of various online support groups at www.stroke-rehab.com/stroke-support-groups.html. You don't necessarily have to ask questions, but you can read through countless conversations and questions of others that you will find helpful.

As far as the physical aspect of her stroke, I cannot predict the outcome, but I will say that stroke rehabilitation requires much determination and effort to improve in most instances. If she is involved in an exercise or rehab program, she will have a much better chance of improving or sustaining her physical well being. From your submission, I really feel that both your mom and you need to address emotional well-being which in return will put your mom in a better state of mind for physical rehabilitation.

Weakness in Whole Body

by neelam malhotra
(India)

Question: I had a stroke a month back. I feel acute weakness and get tired easily. When will I get my strength back? I am 57 years old.

Answer: It is not possible to predict when or if a stroke patient will get their strength back. You are still in the early stages after stroke and may see dramatic changes over the next few months as your brain continues to heal and adapt. Often, there are many positive gains early in the stroke rehabilitation process, and it is important to keep working on your recovery each day.

Stroke Protocol

by Maryam
(KSA)

Question: Hi, thanks for providing this page to listen to us. I looked for a precise physical therapy protocol for a stroke patient as an outpatient. Unfortunately, I didn't find anything. Could you help me?

Thanks,
Maryam

Answer: Each stroke patient is different so it is hard to apply a protocol that applies to all stroke patients. Some stroke patients are severely paralyzed where others may have mild weakness or speech difficulties without extremity weakness. Here's a couple of resources that may be helpful:

www.stroke.org - A stroke recovery guide with exercises

Fame Group Exercise Program - See the pictures in the second half of the document.

Grasp - An arm and hand exercise program for stroke patients

www.stroke-rehab.com/stroke-rehab-exercises.html - Provides a list of the various types of exercises done after stroke with examples of some types of exercises or resources where to find them.

Goals and Intervention

by Brittany
(Jonesboro, Arkansas)

Question: Hi, I am a new occupational therapy student. I am learning about writing goals and have a case study on a stroke victim that has very unsafe modifications to be made to his home and bathing routine as well as a home exercise program I wanted to implement in his treatment. Could you give me good goal examples for him?

Answer: I will let you determine the goals, but I will give you an idea of some home modifications and safety issues that I would investigate for bathing safety:
1)Are the bathroom doors wide enough for a w/c or walker?
2)How does the patient get into the bathroom?
3)Is there a walk in shower or tub shower and which type of shower or tub seat would be appropriate?
4)Make sure the patient and caregiver are trained and safe with shower or tub transfers.
5)Make sure that the shower is adapted as necessary(e.g. hand held shower and grab bars)
6) Determine if the patient has adequate sitting balance to sit on a shower seat and to actively participate in bathing and address balance/safety as needed.
7)Determine if the patient needs any other adaptive equipment (e.g. a long handled sponge).
8)Determine if patient needs assistance and how much (consider physical, cognitive, sensory issues, etc.)

As far as a home exercise program goes, this could vary widely depending on the level of the patient. You just have to identify the deficits and make sure to tailor your home exercise programs to the deficits.

EXERCISE

by F.M
(CA)

Question: Hi, I'm a post stroke victim (stroke 2000). Since then, I have gone through a government clinical study for the upper extremity with a very positive outcome. DO you know of one for the lower extremity? I'm now going to the gym/exercise class three times a week. Any ideas on what exercise equipment I should work out on? Thank You, Frankie.

Answer: You can get information about clinical trials by visiting this page on my website: www.stroke-rehab.com/stroke-clinical-trials.html. Leg exercises you should do at the gym depend on what movement and what deficits you have as well as any precautions you might have. You could consult with an exercise physiologist or certified personal trainer that is experienced in working with stroke patients or injured individuals for ideas if you no longer see or have access to a physical therapist. Just make sure you have your MD clear you for your fitness program.

Stroke and exercise

by pamela
(Raleigh,NC,USA)

Question: My mom had a stroke about 3 months ago that affected her left side. With no posture/balance, its hard for her to keep good posture without slumping down. She went through PT,OT, and speech before coming home a week ago. I was exercising her affected leg while she was in the wheelchair and noticed that when she put her leg down to rest it just took off and started bouncing up and down. Is this a good sign or was I doing it incorrectly?

Answer: I have seen the response you describe many times when working with stroke patients. It could be that you just need to move the leg slower to prevent increased spasticity or it may just be a reflex when the foot touches the ground. Since I cannot see the movement, I cannot assume to know what is wrong so you could demonstrate it to her doctor or therapist for feedback. If it is the response that I have seen in many cases, I usually just push down with my hand putting weight through the leg which will stop the response. Once the response has stopped, I then carry on with exercise.

Stroke Rehab Facilities Criteria

by Anonymous

Question: Can you tell me what criteria a stroke victim must meet before entering a rehab facility.

Answer: There are several criteria for inpatient rehab facility admission, but two of the main aspects examined is whether or not the patient can tolerate 3 hours of therapy a day and if they need these services. For example, a patient who has had a major stroke and is barely responsive and not following directions may not be a candidate because of the inability to participate in 3 hours a day. In this case, the individual may be referred to a skilled nursing facility instead. Another example would be a person who had a mild stroke and may only have mild residual weakness or speech deficits that can be addressed by outpatient services and inpatient services are not needed. The criteria below was copied from the www.cms.gov website and is from the Medicare Benefit Policy Manual Chapter 1 - Inpatient Hospital Services Covered Under Part A (this is for US only):

1. The patient must require the active and ongoing therapeutic intervention of multiple
therapy disciplines (physical therapy, occupational therapy, speech-language
pathology, or prosthetics/orthotics), one of which must be physical or occupational
therapy.

2. The patient must generally require an intensive rehabilitation therapy program, as
defined in section 110.2.2. Under current industry standards, this intensive
rehabilitation therapy program generally consists of at least 3 hours of therapy per
day at least 5 days per week. In certain well-documented cases, this intensive
rehabilitation therapy program might instead consist of at least 15 hours of intensive
rehabilitation therapy within a 7 consecutive day period, beginning with the date of
admission to the IRF.

3. The patient must reasonably be expected to actively participate in, and benefit
significantly from, the intensive rehabilitation therapy program that is defined in
section 110.2.2 at the time of admission to the IRF. The patient can only be expected to benefit significantly from the intensive rehabilitation therapy program if the
patient’s condition and functional status are such that the patient can reasonably be
expected to make measurable improvement (that will be of practical value to improve
the patient’s functional capacity or adaptation to impairments) as a result of the
rehabilitation treatment, as defined in section 110.3, and if such improvement can be
expected to be made within a prescribed period of time.

4. The patient must require physician supervision by a rehabilitation physician, defined
as a licensed physician with specialized training and experience in inpatient
rehabilitation. The requirement for medical supervision means that the rehabilitation
physician must conduct face-to-face visits with the patient at least 3 days per week
throughout the patient’s stay in the IRF to assess the patient both medically and
functionally, as well as to modify the course of treatment as needed to maximize the
patient’s capacity to benefit from the rehabilitation process.

5. The patient must require an intensive and coordinated interdisciplinary approach to
providing rehabilitation, as defined in section 110.2.5.

Getting into Rehab

Question: My husband had mini strokes, and his right side is weak, who do I talk to or call so I can get him into therapy?

Answer: He would need to visit a physician who can write a prescription for therapy. Once you have a prescription, you can contact whatever facility you would like, and they can check to see if rehab is covered by your insurance. If you are unaware of facilities near you, ask the physician who writes the therapy prescription.

Long Term Care for Stroke Survivor

by Mary
(Montana)

Question: My brother is 53 years old and had a bi-lateral stroke. He is in a wheel chair and has only limited use of his right arm and requires complete care. He is verbal and intelligent, but has issues related to frontal lobe damage. What facilities are available for long-term care? Anywhere in the country west of Chicago
Thank you
Mary

Answer: You can go to www.medicare.gov/NHCompare and do a search by zip code or state to find various nursing facilities and their ratings. The website also provides information on health inspections and staffing. I would look for several nursing facilities with high ratings and then do more research on your own by visiting the facility and interviewing the facility staff. If you get a chance, ask residents or family of residents for their opinions. Also, investigate the facility online to see if you can find complaints. Good luck in your search.

Don't base your decision solely on what the staff says or a good ranking. Make sure you really look around the facility, talk to residents, check for cleanliness, watch attentiveness of staff, and ask for any reports they can give you such as satisfaction surveys. The website above also has a nursing home checklist which gives you a detailed list to use when considering a facility. I recommend using it!

Since your brother is only 53, you might go a little further in your search and see if you can find a facility that has some younger residents which may make yor brother feel more comfortable. You can also visit the government link here for information on alternatives to nursing home care. Good luck in your search.

Stroke Rehabilitation Help

Question: Hello, my gran had a stroke 2 weeks ago, and has been in the hospital ever since. She has been left in bed all day, and they have not even started physio yet. We are worried the longer they leave it the harder it will be for us to get her going again. Is there anything you can suggest we do with her please??

Answer: You could ask the doctor if it would be okay to do passive range of motion and range of motion exercises with her. Passive range of motion is done by the caregiver moving the affected extremities through gentle, pain-free movement. Active range of motion is done by the patient moving their own extremities. If the doctor says it's okay, you could have them ask the therapist to come in and show you how to perform these exercises on your loved one. Even if they aren't ready to order therapy, they could at least come in and do one training session with you. The following page describes some of the different types of exercises done with stroke patients: https://www.stroke-rehab.com/stroke-rehab-exercises.html.

Any Treatment if Stroke Happened Years Ago

by Christa
(Colorado)

Question: My father had a stroke several years ago. The stroke occurred during heart surgery. While we understand now that a stroke can occur after surgery we were unaware of that at the time.

Since we were unaware of the signs and symptoms of stroke we, (nor the doctors) gave him any treatment for the stroke. The realization that he had a stroke came after questioning the doctors why he would be so quiet since his surgery.

My dad spent several weeks not communicating after the surgery. Months later he mentioned that when ever he wanted to talk he couldn't figure out how to speak. The doctors said this was a side affect of the anesthesia from the heart surgery. We now know different.

Anyway my question is...
After such a long time (6 years) is there anything, exercises etc. that he could to to help him. He has loss of strength in his right hand. Occasionally stumbles due to loss of strength in his right foot. And has trouble remembering things.

I know that time is against him in the sense that the sooner you treat a patient that had a stroke the better. However are there things he can do to improve his strength and coordination now.

Thanks for the help.

Christa

(sbi forum www.thecookingblock.com)


ANSWER:Christa, your father could definitely benefit from therapy. I am wondering if he ever had any treatment for his stroke. If not, I would have the physician write a prescription for occupational and physical therapy (possibly speech therapy as well). We see stroke patients all the time that come back for therapy years after having their stroke due to decrease in function or ability to walk. If therapy isn't an option at this time, I would refer you to my page on fine motor exercises to help improve hand function. It can be found at www.stroke-rehab.com/hand-exercises.html

You mention that your father has trouble with stumbling. Does he have foot drop by chance? If he can't lift the front part of his foot completely due to muscle weakness, this could cause him to stumble or drag the foot. He may need to be evaluated for an ankle foot orthoses (AFO brace). This type of brace can help prevent from dragging the foot. They also have electrical stimulation devices such as Bioness and Walkaide to help with foot drop, but they are more expensive.

Last of all, cognitive function can be improved or maintained through playing games, doing memory exercises, working puzzles, playing online games specifically developed for improving memory,and reading. Studies have show that eating a diet with omega-3 fatty acids and staying physically active can help maintain/improve memory as well. Physical activity can be maintained through stationary bikes or pedal exercisers for the arms/legs if other means of physical exercise are too strenuous.

These are just a few ideas, but I believe your father would definitely benefit from doing some of the activities above. Some stroke patients feel like they don't have enough time to perform all the different exercises/activities in a day. My response to that is to incorporate two tasks together such as fine motor activities with cognitive games and so forth to more effectively manage time. Thanks for your question!

Exercises to Build Up Core Muscles to Enable Sitting Up

by Pat
(Batavia, Ohio)

Question:What exercises should one do for strengthening core muscles to enable a stroke patient to be able to sit up?

Answer: Initially a therapist will help a patient sit up on the side of a bed or mat and help support the patient while working on sitting balance. Sometimes it takes two individuals to help the patient safely maintain sitting depending on the size of the stroke patient and severity of stroke. The patient will work on maintaining sitting in neutral with support, shifting weight forward and back over the pelvis, shifting weight side to side and various other directions, as well as leaning forward and back up. As the patient gets stronger, less support will be provided from the therapist or therapists, and eventually the patient will be able to maintain their own sitting balance.

Some examples of balance exercises can be seen at www.stroke-rehab.com/balance-exercises.html. These exercises are shown without the assist of others, but the exercises can be adapted by having the therapist assist the patient in maintaining balance so they do not fall.

Physical Exercise and Fatigue After Stroke

by Emebet
(California)

Question:Is not daily physical exercise for stroke victim too much and is not a break needed every other day to let muscles rebuild? Also how much sleep is good for person with right hemisphere stroke?

Answer: Honestly, the amount of exercise that a stroke patient can tolerate depends on the type of exercise, severity of stroke, and the person's recovery from stroke. Some individuals experience stroke, recover quickly and then return to their normal activities including daily exercise. Others are affected more severely and may not be able to participate in even simple exercise programs. Most individuals who experience stroke fall somewhere in between these two extremes. After stroke, it is important to consult your physician prior to initiating an exercise routine especially to determine if there are any cardiac conditions to consider.

The AHA Scientific Statement regarding Physical Activity and Exercise Recommendations for Stroke Survivors states that 3-7 days of aerobic exercise per week for 20-60 minutes (or multiple 10 minute sessions), 2-3 days of strength training per week, 2-3 days of flexibility training per week, and 2-3 days of coordination and balance activites per week are recommended.

The type of exercise in which a stroke victim can participate of course will depend on the physical capabilities of the person. Examples of aerobic exercise might include walking, stationary bike, arm bike, chair aerobics, or pool exercise. The more severe the stroke, the harder it is to participate in such activites and this is when it may be necessary to divide exercise into 10 minute intervals as well as find the right activity that involves moving large muscle groups. Exercise will often have to be adapted for stroke victims.

When you ask if a day in between is needed to let muscles recover, it depends on what you are talking about. Traditional strength training involves giving muscles a day or two of rest between workouts. This isn't necessarily the type of workout that a stroke victim is getting during rehabilitation though. Often, the stroke victim is doing range of motion exercises or very light resistance which would not fall under the realm of strength training that requires time for muscles to recover. If the stroke victim is truly participating in strength training with significant weight then yes, it would be necessary to spread out workouts and allow time for muscle recovery.

I don't know of any specific sleep requirements for persons who have experienced stroke. Stroke victims do fatigue more easily so taking naps during the day can be helpful to overcome fatigue, but I would not recommend excessive sleeping throughout the day. It is not uncommon for stroke victims to sleep a lot in the immediate days or sometimes weeks after a stroke, but once the patient has stabilized and is able to participate in the rehab process, a more normal sleeping pattern should be resumed. The healthy adult need for sleep usually ranges from 7-10 hours/day. The stroke victim will sleep more than this in the beginning and will most likely continue to require nap breaks during the day to battle fatigue rather than trying to achieve all their sleep during the evening.

Loss of speech and body movement

by Jay
(USA)

My father (very healthy and clean habits person) had a minor Tumor surgery in his head,6 months ago. After surgery, he was in coma for a month and he lost his voice and body movement. Now he is able to move only his arms and legs,not the body. He still didn't get his voice back. We are so upset. Please suggest some exercise and home equipment to improve his health.

Thanks!!

Answer Hopefully, he has been receiving some therapy over the past 6 months. Usually one can begin to regain sitting balance with therapy. I think it's very important to have a therapist involved when the patient lacks trunk control because the patient is at a much higher risk of falling and needs a professional with experience. If your father was discharged from therapy but has started to make gains in movement (i.e. arms and legs) then ask the physician to write a new prescription for therapy to start again.

If therapy is not an option, I would work on sitting balance activities from the wheelchair. Sitting balance activities such as shifting weight side to side and forward/back, reaching for items, and trying to lean forward and back up. Examples of these activities can be viewed at www.stroke-rehab.com/balance-exercises.html. If there is no trunk control, then it is imperative to have a caregiver (maybe even two) present to prevent the patient from falling. You could even go in for a few therapy visits just to have the therapist instruct the caregivers on balance activities and exercises to do at home if the expense of multiple therapy visits is an issue.

For speech, you could attempt making or purchasing a communication board. A communication board has pictures of various activities that a patient may want to communicate such as wanting food, needing to use the bathroom, expressing pain, wanting to go to bed, etc. There is also a website, www.speech-therapy-on-video.com, that has dvds you can purchase to work on speech therapy activities at home.

I think my main advice to you would be to continue to seek therapy as you are able for your father. Sometimes therapy isn't as effective in the beginning for individuals with severe impairment because they need more time for their medical condition to stabilize and to build up their endurance from being hospitalized for so long. It's not usually the case, but therapy can be more beneficial later in the process for some individuals.

Trouble Putting Weight Through Weak Leg to Balance

by Danni

Question: Hi there, my mum had a sub arachnoid hemorrhage, and after 6 months of rehab regained the ability to stand and walk short distances with the use of a quadstick (one person to helped in case she lost her balance). She maintained severe left sided weakness. Periodically, since leaving rehab in March 2011, she had seizures which left her quite immobile and tired for a week or two after, but then she would regain her ability to walk and carry on. Her most recent seizure was the 7th of December 2011. Since then she has been unable to straighten her left leg and put her heel to the floor when standing. The left leg has pain in the groin area when standing (this has happened periodically since her stroke when she has long periods of inactivity). Her knee is in a constant bend, and she is unable to put her heel to the floor when standing. This makes balancing and holding her own weight impossible, and she ends up almost sitting on my hand as I hold her up at the back.. then, after a while, I give up trying and put her back down in her wheelchair. She only had botox in December (5th) for spasticity in her leg and this batch has been wasted; her leg is almost impossible to bend without injury when she's sitting and just as impossible to straighten when standing. I'm at a loss as to how to fix this. How can I get her to put weight through her left leg to straighten it enough to weight bear and balance?

Please help!

Answer: If she has not had therapy recently, get her back in therapy. Since she is having seizures that are making her worse, she should qualify for more therapy if she is not already getting it. I would probably look into a dynamic knee brace to increase the extension in her knee. If you are unable to straighten the knee, and she is unable to straighten it, then it may be contracted. If this is the case, she needs prolonged stretch which can be accomplished with bracing. If there is severe spasticity, then bracing may not be appropriate so you should check with your therapist and physician to see if she is a candidate. You have to treat the knee contracture or spasticity in order for her to balance. Most often this is treated with bracing. The earlier bracing is done, the more effective it will be so I would look into it now. There are also surgeries to correct knee contractures so this is something to ask your physician about as well if the condition persists.

Also, I'm sure it has been addressed, but there are medicines to help control seizures so if she is not currently taking meds for this, ask her physician if meds can be prescribed. You can also ask about oral meds to help control spasticity and tight muscles.

12 YR. POST STROKE BALANCE RECOVERY EXERCISESFOR SENIOR

Question HELLO, I HAD A MASSIVE STROKE 12 YRS. AGO AND I STILL CAN'T WALK I AM 70 YRS. OLD I GET AROUND THE HOUSE USING A QUAD CANE WHAT ARE THE BEST BALANCE EXERCISES FOR ME? THANK YOU.

Answer: You would need to consult with a physical therapist or other trained professional to assess your balance/deficits to determine the best exercise plan for you. I can list websites that have balance exercises, however, it is unknown if those exercises would be appropriate for you personally. Here are some websites with balance exercises:

https://www.saebo.com/blog/reclaim-your-stability-with-these-balance-exercises-for-stroke-recovery/

https://propelphysiotherapy.com/exercise/static-balance-vs-dynamic-balance-exercises/

https://www.beyondstroke.ca/file/SelfRehab_Booklet_crop_EN.pdf

https://www.stroke.org.uk/sites/default/files/workshop_2a_exercising_after_stroke.pdf

Exercises

by Barbara Baccus
(Dayton Ohio)

Question: I would like to do some exercise at home. What can I do to help the movement and strength my leg?

See page 2 of this e-zine for standing exercises

See page 2 of this e-zine for leg exercises lying down

See page 1 of this e-zine for balance exercises

All of these exercises are from my monthly newsleter e-zine called Stroke Recovery Tips. You can subscribe to it at the bottom of my home page.

gait pattern correction

by Raghu
(hyderabad, A.P , india)

Question: Hi, how do you improve the gait in a hemiplegic patient?

Answer: This is a very broad question that could have many answers. One stroke patient may have drop foot that is causing impairment whereas another may have weak quadriceps and yet another excessive extensor tone. This means you need to evaluate the patient's range of motion, strength, sensation, and gait pattern (assuming their able to walk) to get an idea of where to start to improve gait. Usually a combination of learning to weight bear on the weak leg, strengthening the weak leg, and practicing the actual activity of gait is used to improve gait. Outside assistive devices may be needed to help a stroke patient learn to walk such as e-stim, braces, or devices that help support the weight of a patient such as specialized treadmills and other walking devices. If high tone is an issue, the patient may need meds to help control tone.

My advice to individuals who have suffered stroke is to ask your therapist your weaknesses and then work on exercises and activities that will improve your deficits. Each stroke patient will have different areas that need to be addressed to help improve gait. If you want to know more about the technical aspect of what is involved in gait then I suggest doing an online search for the terms gait cycle and gait analysis.

Hemiplegic Walk

by Carolina
(colombia)

Question Hello. I want to know which brand of shoes are the best for hemiplegic people when they are in rehabilitation and start walking.

Answer: This is actually a great question. At first I was going to give you my standard answer to patients and families when they come into rehab which is usually to say an athletic shoe/sneaker and not sandals/dress shoes/heels/houseshoes. Once I thought about it though, I realized that there is more to it than this. When you first start rehab, a good fitting athletic shoe is fine, but it may be a good idea to see an orthopedic foot doctor or orthotist if foot problems are an issue. Some issues that can be addressed by orthotics are curling of the toes, spasticity in the foot, equinovarus, and drop foot. Some of the various orthotic devices available include heel modifications, metatarsal bars and pads, toe crests, ankle foot orthoses and more. Visit www.footvitals.com/health/orthotics/ for information on various orthotic devices.

Something else to consider is that the size of the affected foot may change over time so the stroke patient may even need two different sized shoes. This is especially true if any orthotics are used in the shoe.

Edema in affected ankle

by Bill
(Sagamore Beach, MA)

Question: Is ankle edema in itself an issue, or is it a possible indication of DVT?

Answer: Symptoms of a DVT can include swelling in the foot/ankle, pain in the leg/foot/ankle, warmth over the affected area, and skin color changes. DVTs can also be present without these symptoms. To be safe, it would be best to have it evaluated by a MD to rule out DVT. Edema, however, is not uncommon after stroke especially in the affected limbs. If DVT has been ruled out, then you can try elevating the lower extremity and wearing compression stockings to help alleviate the edema. Check with your MD to make sure compression stockings are appropriate in your case. Some health conditions may not be appropriate for wearing compression garments (e.g. conditions with excessive fluid around the heart/lungs, thrombophlebitis, wounds, skin problems, etc).

Left knee "locking back" when walking without a single tip cane.

by Donald Little
(Honey Grove, Tx. USA)

Question: My wife had a major stroke a year ago that paralyzed her entire left side. Therapists got her walking with a single tip cane pretty good. She can bend her left arm at the elbow and bring her arm "counter top high". Her fingers stay open and she can close them but cannot open them herself. We do about 22 different exercises everyday plus muscle stimulation on arm and hand.

The problem now is her left knee(the affected leg) "locks back" whenever she tries to walk without a cane. It is very painful and makes her have a serious limp. The knee goes backwards past center. The therapist told her to either take longer steps with that leg or walk with that knee slightly bent. She has a hard time doing either exercise. What do you suggest?

Answer: Knee hyperextension (genu recurvatum) can be caused by several factors or combination of factors some of which include knee extensor weakness or spasticity, weakness of the buttock muscles, weakness of the hamstring muscles, limited dorsal ankle flexion, avoidance of painful pressure on the ball of the foot and proprioceptive disorders. Determining the cause can help determine what action to take. Some things that could be tried to prevent knee hyperextension include:

1. An ankle foot orthoses may be beneficial - consult with an orthotist who specializes in working with neurological patients

2. Knee brace - consult with your PT or MD

3. Kinesiotaping to help prevent knee hyperextension - various taping techniques can be reviewed online or on youtube.com

4. Exercises to strengthen weak muscles. Some of these exercises may include:
a) squats
b) standing on the weaker leg and raising the strong leg up and down while trying to control the weaker knee and not let it hyperextend
c) while sitting, put feet on floor and lift toes/front of foot off the floor (heel stays on ground) improving strength of dorsiflexion
d) exercises to strengthen the quadriceps, hamstrings, and buttocks

If none of the solutions work for preventing knee hyperextension, then it would be best to use the cane if she doesn't hyperextend with it.

Aquatic exercise after stroke

Question: My brother-in-law had a stroke three weeks ago. He has regained some use of his right leg and can walk with assistance. His right hand/arm is showing some improvement, as he can move his fingers and flex his elbow. Swelling in his hand has also subsided. He is still unable to raise his arm unassisted. He is 56 years old, has melanoma, but it's otherwise physically strong. He is in a skilled nursing/rehab facility where he receives therapy, but he will likely be released in a couple of weeks. I am a Certified Personal Trainer and Corrective Exercise Specialist through the National Academy of Sports Medicine. I have worked with a few clients in the pool after strokes, mostly focusing on balance and range of motion training. However, they were at least a year into recovery. Is it too soon to start water walking? Perhaps, bicycling with flotation belt as tolerated? Leg swings holding onto side? Moving upper extremities through water resistance? Of course, we will get physician clearance before starting any program. Just curious about effectiveness of aqua exercise in this population, how soon it is usually started and any suggestions on specific exercises to improve balance, increase ROM and strength on right side and improve functionality to perform ADL. Thank you so much.

Answer: There have been several studies that have show aquatic therapy to be beneficial in stroke patients. One of the studies was performed on patients that were one to six months post stroke so I don't think it would be too soon as long as the MD gives clearance, the patient can safely get in and out of the water with assistance or mechanical aids, and there is trained personnel to work with him. The main factors I use for determining if patients are appropriate to get in the pool include are they continent, are they free of open wounds, can they safely be treated in the water, and do they have a MD's prescription/approval. Stroke patients can work on range of motion and walking in the pool. The buoyancy of the water can be quite beneficial. One thing to watch out for though is foot drop. You don't want the patient dragging and scraping his foot in the pool so this will need to be addressed if it is a problem. Some stroke patients will have poor sensation/proprioception issues and may not be aware of where the foot is or if it is being injured so it's important to know if the patients have these type of issues.

Equipment used to open fingers after a stroke

by Maurice Cox
(West Wickham, UK)

Question: My friend had a stroke which left the fingers of one hand clenched. She had treatment using a wooden ? piece of equipment which forced open the fingers a little bit more each week. It was then stopped but she wishes to obtain that equipment to carry on with self treatment. Do you know what it is called, please?

Answer: Unfortunately, I do not know what specific piece of equipment you are talking about. There are some wrist hand orthoses (splints) that provide rolls that can be increased in size to help open a contracted hand more over time. One such splint is the Rolyan Kwik-Form Progressive Hand Splint. The splint is not used to make the hand functional but rather to keep the hand from contracting too much and keeping the fingers out of the palm.

If someone else knows what equipment is being described, please provide your comments!

Walkaide and/or L300

by Thompson
(Carlsbad, Ca)

Questions:Can you use these devices if your have a pace maker?

Answer: From the Bioness website:
"Patients with a demand-type cardiac pacemaker, defibrillator, or any
electrical or metallic implant should not use the NESS L300"

From the Walkaide website:
"If you have history of seizure or have an implantable pacemaker, you should not use the WalkAide, unless directed otherwise by your Physician"

Therapy for Affected Leg

by Alice
(Mississippi, USA)

Question: Should a stoke survivor try to lead with the weak leg when walking? Will this help strengthen the weak leg?

Answer: During a normal walking pattern, a person steps through with each leg so there is not really a leading leg except on the first step. Often with a stroke, a patient will not perform full alternating strides, but instead will step with one leg and then bring the other leg forward and next to the lead leg. If the person is using a hemi-walker, they will be instructed to lead with the walker and weak leg. If the person is not using a walker, then it may vary which leg is used first. I think it is beneficial to learn to lead with both legs.

If a stroke patient has trouble moving the weaker leg, then it may be more beneficial to work on moving the weaker leg forward and back. On the other hand, if the patient has more trouble with the weaker leg's knee buckling, it will be more important to work on stepping forward and back with the strong leg because this makes the weaker leg take the person's full body weight. Taking the full body weight on one leg is usually much more difficult than swinging the leg forward. What this means for the stroke patient is that it is important to work both on stepping through with the weak leg and taking weight while the other leg steps forward.

Leg range of motion exercises

Question: My wife suffered a stroke when she was 13..now 42. She is losing more and more range every year. What exercises are best and where can I learn to help her with them? Thank you.

Answer: You can find some leg exercises on my website at https://www.stroke-rehab.com/Leg-Exercises.html. If you are looking for passive range of motion exercises that you can use to move her limbs then you could look at http://www.alsworldwide.org/pdfs/rom_exercises.pdf. The exercises at the above website are provided for patients that have ALS, but they have good pictures on how the caregiver can help someone do range of motion/stretching on the lower extremity.

stretching

by Jeremy Williams
(Delhi,India)

Question:My father is around 80 years old.He had a stroke last month and has developed right side paralysis. The physiotherapist we engaged does some stretching exercises for his legs ( where he bends the affected leg and spreads both legs in a half split while the patient is lying on bed). My father,though unable to speak,expresses extreme discomfort while doing the stretching.The physio says the stretching is necessary to avoid muscle tightening.Is it advisable to continue with the stretching ?

Answer: According to a sytematic review of research in the the Journal of the American Physical Therapy Association, "regular stretch does not produce clinically important changes in joint mobility, pain, spasticity, or activity limitation in people with neurological conditions." With that said, however, I as a therapist find that if people don't participate in stretch/range of motion exercises, they tend to get stiffer and have less tolerance for movement. You could probably just ask the therapist to be less aggressive with the stretching. Here is an article about the effect of stretching with stroke patients if you want to share it with your father's therapist:

http://ptjournal.apta.org/content/91/1/11.full

Hypotonicity of Lower Limbs after Stroke

by Colleen
(Vancouver, BC Canada)

Question: What type of manual therapy can increase tone in an individual with low muscle tone (lower limbs)several years after a brain-stem level stroke? The patient is able to run and and do lunges and squats, but she feels colder in her lower half and the muscle tone is completely different (with minimal weakness) than in her upper body . Mentally, she also feels disconnected from her lower half. Thanks.

Answer: I don't know of specific research dealing with this problem especially in a patient population that only has mild hypotonia. I can only give you an opinion of what I might try. It appears there are somatosensory changes, and I think therapy should be targeted at changing the brain's interpretation of signals from the lower extremity. I would try doing some mental imagery, biofeedback, and would consider using a virtual reality program with biofeedback. The goal would be to "trick" the brain into thinking that there is normal function and sensory feedback coming from the lower extremities. I know these technologies are not available everywhere, but I would try to find out if there are any near the patient or look for research trials the patient could enroll in that may employ these techniques.

Limp wrist after stroke

Question: Is there anything I can do with my husband's limp wrist - post stroke? ( July 2011) He was down on the right. The leg is coming back. Right shoulder was subluxed but that seems to be improving slowly and he can move his upper arm slightly ( i.e. can move the arm slightly forward and in small circle). However, the wrist has been limp. The OT never addressed it. In fact, the home health said they couldn't do anything for him other than show me passive range of motion exercises. I just find that hard to believe. My concern: Should this limp wrist be splinted in some way? His fingers are swollen but do move with passive exercise. The thumb is very swollen and does not move very much. Of course, we elevate the hand and some days there is little swellling of the hand. The wrist does not appear swollen at all.

Answer:

1. Make sure the hand is elevated when sleeping or sitting. You especially want to make sure that the wrist is in neutral or slight extension and not flexed (or bent down) when sleeping. This can help with swelling.

2. Splinting may be an option, but you would need to consult with an OT or hand therapist so that they could evaluate your husband's hand. You can ask for a prescription for OT from your husband's physician specifically asking for a splinting evaluation. Make sure you go to someone that has experience with splinting and working with stroke patients.

3. Definitely continue passive range of motion to maintain range.

4. Exercises that I like to use for the wrist include:

* Tapping the back of the forearm while asking the patient to try and lift their hand extending the wrist back. This often work best when the patient is lying on their back with arm pointed up toward ceiling and supported by me.

* Electrical stimulation for wrist extensors (as long as the patient doesn't have any contraindications). A prescription would have to be issued by a physician for this.

* Placing the hand on a soccer ball with fingers spread out and have the patient try to roll the ball slightly side to side and forward/back without the hand falling off. You can kind of get an idea from viewing this video on Youtube:
https://www.youtube.com/watch?v=7l3bYncNWL0.

* Placing the hand on a soccer ball with fingers stretched out and then I apply pressure against the ball to stretch the patient's wrist back.

* Placing both hands on side of soccer ball with fingers spread out and just trying to keep weak hand/wrist on the ball without falling off. If patient is able to do this then I have them try to rotate the ball side to side using the wrists/hands.

Exercises to Improve Typing After Stroke

by Peggy
(Wichita, KS)

Question: My daughter use to be a 90wpm typist. She had a stroke, and now the connection between her brain and her hand is horrible. She just failed a test at 25wpm with 13 mistakes. Her stroke was 7 years ago. Is there anything she can do to help with her typing at this point?
Thank you
Peggy

Answer Many times when therapists or stroke patients work on hand function, they focus on gross grasp or pinch activities with the index finger. These activities are good for learning to pick up objects or hold something like a pencil but aren't the most effective for learning to improve an activity like typing. During typing, the fingers have to be able to work independently of each other. This is often difficult for the stroke patient due to tone or possibly stiffness from disuse.

Exercises I would recommend to improve typing:
1)Place the hand flat on a table and try to lift each finger independently while keeping the other fingers on the table.
2) Drum fingers on table
3) Practice touching each finger to the thumb
4) Pick up small object like peg or screw with the thumb and index finger, then thumb and middle finger, then thumb and ring finger, and lastly the thumb and little finger.
5) Push each finger individually into theraputty.
6) Use Digiflex to exercise each finger individually (see below for product).
7) Pick up marble and transfer to inside of hand (same hand as picking it up). Then while keeping marble inside hand, pick up another marble. Keep doing this until you can't pick up anymore then put each marble back down one at a time.
8) Use Chinese balls or take two golf balls and rotate them in the hand.
9) Play the piano or just hit keys individually with each finger.
10) Place a piece of paper on a table. Use the weak hand to crumple the paper into a ball then try to uncrumple the ball with on the table with the same hand.
11) Use online typing games to practice. There are many online typing games that teach kids to type that would be great for stroke patients wanting to practice typing.

Those are just a few ideas for you. The main thing is to practice individual finger movements and activities that require in hand manipulation (such as the marble activity or Chinese Balls).


For more hand exercises, visit www.stroke-rehab.com/hand-exercises.html

hemiparesis arm exercises

Question: I love the pictures of upper extremity exercises on this website. Are there any other public resources on the web that you know of with pictures of bilateral upper extremity exercises? I'm looking for ones where the unaffected side assists the affected side such as clasping hands over head and stretching arms up or out in front especially. I generally work in pediatrics and often infants, and thus don't have a variety of home program sheets for this group. And hate to "reinvent the wheel" if there are great pictures - even stick figure drawings - of upper extremity exercises out there. Any place you can recommend?

Katie Horn, MS, OTR/L

Answer: Hi Katie. You might try http://www.sld.cu/galerias/pdf/sitios/rehabilitacion/self-range_of_motion.pdf. The pictures are of adults but do show self passive range of motion. When I am looking for specific exercises, I do a Google search and a Google images search. I just now tried the search term "passive range of motion infants", and it pulled up several options so you might try that. When searching images, I click on one that I like and then it will give the name of the website which I then click on if it is relevant. I have found an abundance of material using the images search. I made the pics for my website because it is often expensive to use other's pics and/or I didn't want to violate any copyright infringements. It also allowed me to make the pics that I wanted rather than trying to find that "perfect" pic to use.

Strength in arm

by Jill
(Birmingham, Al)

Question: My husband is recovering from stroke 7 months ago. His right side was affected, but he has gotten a pretty good range of motion in his arm. But, he complains that no matter what he does, his arm does not get stronger and it feels so heavy. He does regular exercise, therapy and uses it as much as he can. Is exercise going to make his arm stronger, or is only time going to make it stronger? We don't understand why he hasn't gained a little muscle at least.

Answer: Strength training can improve strength after stroke especially when range of motion is intact. I cannot tell you, however, how much strength can be gained or how long it will take. I definitely would encourage him to continue what he is doing, and I do believe there will be more gains.

Muscle grade 2 triceps: strengthening exercises

by Brandee
(Wisconsin )

Question What types of stretching/strengthening exercises for poor triceps strength?

Answer: Some exercises that could be tried - sliding washcloth forward on table (progress by sliding up inclined surface or adding wrist weight on towel), placing cane on floor and pushing cane forward and back (add theraband resistance if too easy), lying on your back and try to extend elbow against gravity (someone may need to support upper arm if patient is too weak to hold shoulder at 90 degrees).

ARM passive treatment

Question: Hi,this is Khabat from Iran.
My father 12 months ago had a big stroke in his left brain. He had some progress but he is still not able to walk alone. He can with the help of some of us.

Unfortunately, his arm hasn't had any progress. He can't move his fingers and arm at all, and while we work with it, he signs a lot of pain, and he shrieks.

Is it possible for you to guide us about effective exercises to perform and how much time we must work with it during a day?

Thank you for your kindness.

Answer: I recommend that you do move his arm 2-3x/day, but be very gentle and slow working each joint including the shoulder, elbow, wrist, and hand. You can view how to do passive range of motion exercises to the upper extremity by watching the video on this page: www.stroke-rehab.com/stroke-rehab-exercises.html. Please note the person they are moving did not have a stroke so when working with your father, you will move him much more slowly and only to the point that he can tolerate it. You may want to try some relaxation techniques prior to doing range of motion such as gentle massage and warming or cooling the tissue (be careful with using heat or cold though because many stroke patients don't have good sensation and may not be able to tell you if something is too hot or too cold against their skin). You can also try a quiet environment with soothing sounds to help reduce tension. Do not force movement or cause excessive pain as this will cause your father to tense up more. You can also show him how to move his own arm (see the passive range of motion exercise page on this website) which is even better and gets him more involved.

surgery to regain use of hand

by David Tullock
(United Kingdom)

Question: I had my stroke 4 years ago and lost the use of my left leg, arm and hand although I am now able to walk a little with the aid of a stick. My left hand and arm are still pretty much useless; I have restricted movement in my arm but it is very weak. I will admit that I do think this could be partly down to myself, as my left hand is constantly curled and I cannot use it. Therefore my arm is getting no use either. I received almost no physio for my hand and arm and suggested to my stroke doctor that if the hand would work, by using it, it would overcome the problem with my arm naturally. He then referred me to a plastic surgeon who carried out an operation on my arm to reduce the length of muscles and tendons for my fingers in order to make them straighter, although he did advise it may take another operation or two for it to fully work. Unfortunately, it has not worked, and he is now considering a second op.

As I understand it, the reason my fingers do not work is because of damage in my brain (I had a blood clot), therefore no amount of surgery on my hand will resolve this problem. Am I correct in this because I do not want to undergo further surgery if it stands no chance of working.

I have no movement in either my fingers, thumb and no wrist rotation. I look forward to your advice and thank you in anticipation

Mr D Tullock

Answer: I apologize for the late response to your question. Surgery will not cause your arm to move again. Surgery can help with contractures (e.g. it can help straighten bent fingers), but if you have no muscle movement, then surgery would merely be cosmetic to improve the appearance of the hands or for some it would help reduce pain.

Sometimes people have high spasticity and will have botox injections to reduce the spasticity to help make moving easier, and I guess the same applies to this type of surgery, however, if the movement isn't there, then the only effect of these treatments is a more relaxed hand not a functional hand that moves. I would discuss it with your doctor, and specifically ask him, "If I haven't had any movement since my stroke, why would this surgery help my hand?" Let him know that you are not merely looking to relax the hand or cosmetically change the appearance but rather that you want the hand to move, and see what he says. I would consider getting a second opinion from another doctor as well.

Therapy is not helping my mom , Why?

by Donna
(Fort Worth, TX)

Question: My mom had a stroke on her left side and she is always very uncomfotrable. Therapy is not working, why?

Answer: Unfortunately, I can't really answer your question because I don't know what type of treament your mom is receiving or anything about her stroke or level of impairment. Here are some reasons though that therapy might not be benefitting a patient:

1) Severe impairment from stroke - e.g. patient's level of brain damage and physical impairment is so severe that they are unable to participate in therapy

2) Post stroke pain that interferes with patient's ability to participate or tolerate therapy

3) Inexperienced therapist

4) Lack of quality of care outside of therapy (e.g. patient is laying in bed all day except when having therapy)

You mention that your mom is uncomfortable. I would check with the physician for pain management, and I would check with your therapist to make sure your mom is positioned properly when in a chair or in the bed. Improper positioning can cause her to be uncomfortable, and if she lacks movement, she may not be able to reposition herself. Someone should be repositioning your mom every couple of hours if she is unable to do so herself.

Also, make sure your mom is receiving quality care. Is she having appropriate one on one therapy that is addressing her weaknesses? If not, find another facility or therapist.

Stroke 3 months ago, exercise program and nutrition

by Steph
(Vic Melbourne Australia)

Question: I had a stroke 3 months ago. I can exercise now. I have lost 15% of motor skills in my left side, and I would like to re-educate my limbs especially my pelvis. What strengthening, propioceptive tasks, and cardio should I do?
40 y/o male.

Answer: As long as your doctor has given you the okay, you can participate in any cardio task that you are able. Walking is good. A stationary recumbent bike, upper extremity bike, or aquatic exercise may be more appropriate if you cannot walk well enough to get your heart rate up.

For pelvis strengthening, I recommend sitting on a large therapy ball and working on moving the pelvis forward and back, side to side, and in circles. Check with your therapist before trying these exercises to make sure you have enough balance to do it safely on your own. You can also do bridging where you lie down on your back, knees bent and feet on the floor and then lift the pelvis toward the ceiling. Another good exercise from this same position is to take your knees side to side keeping your hip close to the floor which helps separate lower body movement from the upper torso (do not do this one if you have a history of back problems or if it causes back pain). Trying to stand up straight on one leg is good for strengthening lateral hip muscles. These muscles may be weak if you notice that the hip of the leg you are standing on drops out to the side.

For proprioception, I would recommend trying something like tai chi, adapted yoga, or even some of the video game dance programs (e.g. Xbox Kinect). If some of the moves are too difficult, then you can always adapt them.

Make sure you check with your doctor and/or therapist for clearance before trying any of the above mentioned exercises.

Aggressive Therapy

Question: My mother is in a rehab center for stroke recovery. The therapists do not seem agressive enough...can I request extra therapy or possibly hire in extra therapists on the weekend when she's sitting in the room doing nothing? My mother wants to walk again and is willing to do whatever it takes...I am so frustrated with this entire facility! I would greatly appreciate your input!

Answer: I'm so sorry for your frustration. This honestly is not an uncommon complaint. Some facilities are ran better than others, and you really have to go observe therapy sessions and check facilities out ahead of time (and not just for a few minutes) to really know if a facility is adequate. I would discuss your concerns with the director of the rehab. I would find out which therapists working there have the most experience and are the most aggressive in working with stroke patients and request that your mother be assigned to those therapists. I don't know if you can bring outside therapists into a facility for private therapy on the weekends. That would be a question for the facility, and they may have some type of restriction against that due to liability issues, but it wouldn't hurt to ask. Private therapists would still require a physician's order for treatment, and finding one might be somewhat difficult. You could ask for family training from the therapists at the facility, however, and then family members (or paid caregivers) could come in on the weekends and work with her.

If you don't get an adequate response from the rehab facility after expressing your concerns, then you may consider changing facilities, but you need to act quickly as rehab stays are rather short nowadays. If looking at another facility, check out their equipment, therapists, and reviews ahead of time and actually go observe therapy sessions. One thing that you want to look into now is where she will have therapy after she leaves the rehab facility. If she has home health, then you should look into the therapists that they have. Outpatient is usually a better choice as they have more equipment and often spend more time with patients, so if outpatient is going to be an option, start checking into the facilities and therapists now.

The most important advice I can give you is to have family and caregivers work with your mother daily outside of therapy. Therapy alone is not enough. Recovery requires working hard throughout the day and doing exercises on one's own (or with family help if needed). This can make the biggest difference in one's recovery.

Exercise Equipment for Complete Paralysis

by Ann jeremy
(Malaysia)

Question: For the 100% paralyzed body, is there any device or machine in market that can help the patient to exercise without assist by other people?

Answer: I assume you are talking about complete paralysis on one side of the body or hemiplegia. If that is the case, the other arm can be used to help move the paralyzed arm. This is called self passive range of motion. There are robotic devices and passive range of motion machines that can move a patient's limbs. There are also electrical stimulation devices that may cause muscles to contract. There are standing frames that help hold a patient up to get weight bearing through the legs. Most of the these devices would have to be applied by a helper so even though another person doesn't help the patient move, a helper would have to be present to set up and apply the devices. Also, most of the robotic devices may only be found in select clinics/hospitals or only be available at a very expensive price. You can do a internet search on robotic devices for stroke or passive range of motion machines for stroke to find out more information. You could also check out www.abledata.com for information on various assistive technology.

Flaccidity

by Sakshi
(Chandigarh)

Question: My grandmother have stroke in August 2019 from that she doesn't doing any physiotherapy.. In December she starts her physiotherapy... Her thigh muscle is flaccid.. Ans in her hand there is no movement at all... She is bedridden from very long time.. What can we do to regain her movement?

Answer: You can get some ideas by visiting https://www.stroke-rehab.com/flaccid-paralysis-treatment.html

Left Side Paralysis

by Lindsey
(Columbus, OH)

Question:Hi there:

My father had a stroke that left his entire left side paralyzed about 10 months ago. Since that time we've been to 7 or 8 different facilities for inpatient rehab due to insurance reasons. Now we're being told he is improving somewhat, just not to the point that he can come home and safely move about the house on his own. He can move his left hand from the elbow and shoulder (no use of his hand) and his left hip and knee are still very weak. We're left with no other choice but to put him in a nursing home of sorts.

This is such a disappointment to me as I never thought we'd be in this position. I'd like to think this isn't a hopeless situation, but after ten months and no ability to walk on his own or use his wrist/hands and fingers, I'm starting to believe it is. Are there any studies or facts or resources or treatments I can look to to discover that stroke victims can in fact recover somewhat (enough to come home in our situation) or things we can discover that may help at this point in our journey?

Thank you so much,
Lindsey

Answer: Unfortunately, each stroke is different. There are patients that have fairly severe paralysis that can learn to walk or at least transfer themselves and others who require maximal assist despite long term therapy. Cognitive and visual issues as well as the size of an individual also play into a person's ability to recover. I'm not sure of your situation, but many families can learn to manage a stroke patient at home or can sometimes hire caregivers to help out. I've seen many families take home individuals who could not walk and manage well at home, however, it can be a huge responsibility and time commitment. This may not be an option for some families who have to work, have their own health issues, and/or do not have funds to hire caregivers to help when needed.

The best advice I can give you is that if your father hasn't used all of his insurance benefits then try to find him a therapist who is extremely skilled in working with stroke patients. You also want a facility that allows for the same therapist to work with your father repeatedly. I've seen many times where patients are shuffled from therapist to therapist. This can make it hard to make progress especially with a stroke because the next therapist has to learn what the patient can or can't do. One therapist may have a different approach than another therapist. In essence, it's like starting over each time a different therapist works with a patient unless the therapists are closely working together and have similar treatment styles.

When looking for a therapist, interview them first. Ask about their experience, how long they've been working, their approach to working with stroke patients, and their outcomes with other patients. You could go even further and ask if they've published research or instructed other therapists in stroke treatment though these therapists will be harder to find. Lastly, you need someone that will extensively work with your family and show you how to do therapy exercises, transfers, and care for your loved one.

You can find some various caregiver resources and recovery information that may be helpful to you on this page at the National Stroke Association website.

How do I get the arm functioning again, gravity is a problem

by john
(browning)

Question: How do I get the arm functioning again? Gravity is a problem.

Answer: There are various devices you can use to help support the weight of the arm including tables, pulleys, Swedish slings (at a therapy center), bands, balls, etc. With the weight of the arm supported then you can try moving it. You could try exercises in a gravity eliminated plane. This may involve lying on your side with the arm supported on a hard surface. You can also do active assisted exercises such as using a cane and the other arm to assist. This video has a few ideas:

https://www.youtube.com/watch?v=DoR9H9zuJPY

Stroke shoulder and toes.

Question: I had a stroke in 2011 I'm almost back to 100 percent it's just my shoulder and my toes all on the stroke side. My shoulder feels lose and it feels like its about to pop out of place and my toes are cramping up and they hurt when I walk. Can you please tell me what's wrong with them and what to do to rehab the problem?

Answer: It's hard to say without being able to actually examine your shoulder or foot. If you have a subluxed shoulder that is painful, you might try kinesiotaping or a shoulder sling. Quite a few patients I have worked with report that kinesiotape helps with making the shoulder feel more supported and less painful. I have never been crazy about slings, but a gentlemen recently sent me a sling he now makes and sells ever since his girlfriend had a stroke. I tried it with a patient of mine, and she had tremendous pain relief. You can read about that sling as well as other treatment strategies for shoulder subluxation at www.stroke-rehab.com/shoulder-subluxation.html..

You sat that your toes are cramping so I'm wondering if they have spasticity. If your toes do have increased tone or are curling under, you can purchase a toe crest that will help support the toes and prevent them from curling. You can buy toe crests online or you could talk to a podiatrist or orthotist and ask for suggestions for orthotics to make your foot more comfortable when walking.

Left hand and arm paralysis and drop foot.

by Gayle
(Elyria, Ohio)

Question: I had a CVA with paralysis on the left side. I am walking with a cane. The hand will not open voluntarily. Is there hope for the hand?

Answer: Some options to consider for the hand include botox injections (ask your MD if you are a candidate), electrical stimulation along with exercise (again, you will need to ask your MD or therapist if you are a candidate), splinting to prevent finger contractures, facilitation of extensor muscles by tapping the back of the forearm to help open the hand, inhibiting spasticity through weight bearing, and there are various devices that can be tried. Some of these devices include the Saebo Flex, Bioness, and the Hand Mentor. I cannot tell you if your hand will get better or not, but I definitely think you should try various options. Hands can definitely be stubborn and require lots of patience. One tip I give patients is to use less force when closing the hand so that spasticity does not take over. When trying to learn to pinch and release, only barely grasp an object so that it will be easier to let go. If you exert too much effort and force, the hand will most definitely become fisted and too difficult to open.

Strength Training

by Dominic
(Kumasi,Ghana)

QuestionIs strength training ideal for stroke patients? I understand that strength training helps to reduce spasticity. Being a Fitness Professional and with the research that I have done,I know that stroke tends to weaken the muscles of the affected side and strength training strengthens muscles. So in this case, is strength training ideal?

Answer: Strength training is appropriate for most stroke patients unless otherwise instructed by their physician. Stroke patients should have physician's approval or prescription for therapy before beginning strength training. One precaution to take with strength training is to make sure the patient is not holding their breath and straining during resistance training. This can lead to an increase in blood pressure which can be dangerous especially in those that already have blood pressure issues. Isometric exercises can raise blood pressure as well. Blood pressure should be under control before any strength training is initiated.

Scapular Mobilization

Question: Hi there! I am an occupational therapist (recently graduated) currently working in an inpatient hospital. I have a stroke patient who is experiencing severe shoulder pain with motion over 90 degrees (she has voluntary movement). I believe she lacks the scapular control and I think I am just adding to the problem by having her perform activities over this range, which is just crushing and pinching soft tissue and muscle. What are some good scapular mobilization exercises I could perform or assist her in strengthening these muscles?

Answer: An activity that I like to do with stroke patients (as long as they don't have back problems) is as follows:

1. Have the patient lie on their back with knees bent and both arms out to the side at approximately 45 degrees of abduction. Instruct the patient to to roll his or her knees side to side.

2. As the patient becomes comfortable with the above movement, move their arms further into abduction to approximately 90 degrees (arms straight out to sides) if tolerated without pain.

3. After rocking the knees side to side, ask the patient to roll onto their affected side with the affected arm out in front of them. Have them gently rock back and forth mobilizing the affected scapula. Return to supine and repeat three to five times.

4. Next, ask the patient to lie on their back and perform serratus anterior strengthening by doing scapula (or straight arm) punches. This is done by keeping the shoulder flexed to 90 degrees and lifting the shoulder blade off the mat and back down 10 times while keeping the elbow straight.

5. Finally, have the patient do self passive range of motion into shoulder flexion up to 90 degrees, then into full range of motion as able, and then into external rotation by placing both hands behind the head and relaxing in that position for 15-20 seconds. Have patient do range of motion in pain free range only.

If the above activity hasn't alleviated the pain, then I roll the patient onto their non-affected side (or have them sit up) and mobilize the scapula myself via NDT techniques. Youtube is actually a useful source for finding videos regarding mobilization techniques. Some of the therapy schools have videos of their instructors demonstrating techniques to students. Hope that helps.

Left and Right Hand Recognition

by Serban Remus
(Sibiu, Romania)

Question: After a stroke, what kind of exercises must be done to recognize which is the left and the right hand.
Thank you.
Your sincerelly,
Remus Serban

Answer: Not being able to recognize the left versus the right hand could be due to several factors including decreased cognition, receptive aphasia, visual deficits, lack of midline awareness, and/or neglect of one side. If the patient has neglect and is completely unaware of one side, then you must educate the patient and do activities that engage the person to this side. Let the patient know which side they are neglecting and help them become more aware of that side by participating in activities such as:

1. Have them stroke or rub the affected side with the non affected hand.
2. Have them participate in dressing or caring for the affected side (e.g. threading the affected arm through a sleeve, washing the affected arm with the non-affected arm, or putting lotion on the affected arm)
3. Scanning the room and turning their head to the affected side (you can place a marker for them to find so that they know when they have turned their head or scanned all the way to one side).

If the patient is confused, you could try labeling the right or left hand for their convenience or wear a ring on one hand indicating that it is the left or right (jewelry would preferably be on the non-affected side since it will not be swollen or have decreased sensation).

If the patient has decreased peripheral (or side) vision, then their sense of midline will be off. I recommend all stroke patients have their vision tested after stroke. Special glasses can be made for decreased peripheral vision by neuro-optometrists if the patient has access to such medical care.

You can also have the patient participate in activities used to teach children left from right. I suggest searching online for "teaching right and left" which will lead you to many different websites with ideas. These websites will be geared for activities for children but they can be used for adults as well.

Another option is using a phone app specifically designed to work on recognizing left and right parts of the body. It is called Orientate.

sensory re-education timing

by Janice
(Canada)

Question:Hello!

I was wondering about the timing for sensory re-education. My client has a lot of flexor tone in his right arm with contractures. Passively, we can bring his wrist to neutral which forces all fingers to further flex. We can extend fingers with wrist in approx. 90 degrees of flexion.

He lacks sensation along his radial and median nerve. As it isn't possible to grasp objects (many of the treatment options listed on this website), would it be more beneficial to wait to complete sensory re-education until he has more active ROM?

Thank you!

Answer: You do not have to wait for more AROM to due sensory re-education. In fact, sensory input to the arm can help improve a patient's awareness of the arm as well.

Shoulder Subluxation and Toileting Control

by Suman Ghosh

QuestionHi! My Father is a hemiplegia patient (left side) after stroke. He can not move his hand at all. Some time he asks, "Who's hand is this?". After 7 weeks he had a fall on his shoulder and complained of extreme pain on the affected upper arm. We have used shoulder immobilizer, but it developed spasticity. Please suggest.

Another problem is he does not have control over passing motion or urine. It's now 8 weeks after the stroke. Is there any exercise to help him over getting control over toileting.

Thank You
Suman Ghosh

Answer: Regarding your question on toileting, you can visit my webpage, www.stroke-rehab.com/bowel-and-bladder-incontinence.html.

As far as shoulder pain, did you make sure that your father's shoulder wasn't injured during the fall? Were x-rays done or the shoulder examined by a physician after the fall. If the shoulder was examined after the fall and nothing was damaged from the fall, then I recommend range of motion as tolerated and mobilizing the scapula (shoulder blade). For more information about how to mobilize the shoulder blade or deal with the spastic arm, you can read www.stroke-rehab.com/scapular-mobilization.html and www.stroke-rehab.com/treatment-of-flaccidity-and-spasticity-after-stroke.html

Questions about after care: stroke

by AMELIA
(Polokwane, Limpopo, South Africa)

Question : My name is Amelia, I am 44 years old. I had a stroke in October 2011. After the stroke my right arm and leg were paralyzed. My right eardrum also burst. I just want to know if I can fly again, if I can use alcohol again and my last question, if I can use laser on the right side of my face during a facial?

Thank you

AMELIA

Answer: These questions need to be directed to your physician, but these are my general responses:

1) Stroke patients can normally fly again without problem once released by their physician. Preventative measures can be taken by not sitting still too long, wearing support stockings, and drinking plenty of water when flying.

2) Drinking too much alcohol is actually a risk factor for having a stroke. Per the National Stroke Association, drinking more than 2 drinks per day may increase one's stroke risk by 50%. Most recommendations are to limit alcohol intake to no more than 1 or 2 drinks in a day. It is important to ask your physician if alcohol will interact with any medications you are taking. If your physician is okay with you drinking alcohol, then do so only in moderation.

3)Ask your doctor as well as the professional performing the facial laser treatment if there are any reasons why you couldn't have it done. Decreased sensation such as not recognizing heat, touch, or pain on the right side of th face could be a potential problem that would need to be considered.

Home therapy issues

by nancy
(PA)

Question: My husband had a stroke 3 years ago. He had therapy for 3 years but will not let me help with therapy at home. What should I do?

Answer: This is a tough question as many caregivers of stroke patients have reported this same problem to me. I would try to figure out an incentive to get him to work with you. If you can figure out something that will motivate him, then use it to your advantage. Maybe it's cooking a favorite meal for him, going somewhere, or giving him free reign to sit around and do nothing without being disturbed for an entire day.

Another option would be to incorporate therapy into his daily routine without him knowing it. I don't know the level of his disability so some of these ideas may not apply but will at least get you thinking. Some ideas may include having grandkids come over and play games with him, walking the dog, card or game night with friends, participating in a favorite hobby, helping you in the kitchen or around the house, or you just not being available sometimes causing him to be more independent (e.g. when dressing or needing something from the kitchen). Of course, you will want to make sure you choose something that is safe for him and not beyond his capability.

The last piece of advice I have would be to talk to other caregivers and visit caregiver websites for other ideas. People that are in your same situation will often have solutions and ideas that may work for you.

Movement Problem

by Nikita Modh
(India)

Question: Hi....I want to know why when a stroke patient tries to do movement on his affected arm, there is simultaneous movement on his non-affected arm.....and this make his movement on affected arm easier....what is this reaction is called?

Answer: I believe you are probably talking about associated reactions. Associated reactions occur when movement of one limb produces movement of the opposite limb. An example is having the patient try to bend his arm against resistance and the other arm bends as well. Another example is trying to close the weak hand and the strong hand is closing as well (or asking the patient to close the strong hand to improve closing of the weak hand).

I sometimes use associated reactions in the early stages of stroke to try and elicit movement. I might apply resistance to the strong side during a movement and have the patient try to produce the same movement with the weak side at the same time. Resistance is not necessary to produce the movement on the opposite side, but I sometimes use resistance to enhance the result.

Feeling but No Movement

Question: I had a stroke over 6 months ago and my arm can't move. Why can I feel it but can't move it?

Answer: We have sensory and motor pathways. If information to the motor pathway from the brain is impaired but the sensory pathway intact this can result in being able to feel but not move.

OA Knee with hemiparesis

by SATHEESH DURAIRAJ
(NEW DELHI)

Question:: Unfortunately, one of my patients suffered left hemiparesis along with severe bilateral OA in the knee.

When we do rehab, because of severe pain in his knee, he is afraid to weight bear on the sound leg.

Is there is any change or modification we can make to our treatment?

Answer: I have several thoughts. One is to make sure he is seeing a doctor to help manage OA pain. There are meds and sometimes injections that can help with this so that is something that needs to be addressed with a physician if it hasn't already. If the doctor says its okay, the patient could take meds to help control the pain right before treatment to help minimize it. As far as treatment itself, if you have access to a high lo table or mat, you could have the patient sit on the edge and raise the mat so that the patient is in a half stand/half sit so that he could work on weight bearing through the leg, but it would only be partial weight bearing so it would be as painful.

I see that you are in another country so you may not have access to something like this, but there are several devices that help take the weight of an individual as they walk such as a Lite Gait. It would be idea if you could come up with a way to bear partial weight at first and then ease into more weight bearing. You might also try some type of support/wraps or kinesiotape to see if that helps alleviate some of the pain or provide extra support.

I think your best line of approach though is to have the patient consult a doctor for pain control so that the patient can better participate in rehab.

Knee weakness after a stroke

by Patricia
(Virginia)

Question: I had a stroke eight year ago, was paralyzed on my right side which resolved after the better part of a year. I was left with this residual problem: I can move my knee normally, however, when I walk the knee " jerks" back as though it is going to hyperextended. I can't control this no matter how slowly I go. Now for eight years I have worn a brace that goes under my foot nearly to my knee - it was for foot drop initially but now it's worn because it seems to provide some knee support- my knee doesn't jerk. The physical therapist just brush it aside and does not really answer me. I don't think I need the brace for my foot any longer. Is there a brace for my knee that would help me. The foot brace makes for a miserable time and I would love to be rid of it. I know this is long but I would appreciate some sort of an answer, Thank you very much!

Answer: There are knee braces for hyperextension. Some are hard and bulkier, but they also have softer braces too. I would do a search for knee hyperextension braces online. You could try and see if a soft brace provides enough support to prevent hyperextension. You can also do taping that helps prevent knee hyperextension Taping and soft braces may or may not provide enough support to prevent hyperextension, and you will only find out by trying them. If they do not provide enough support, then you would probably need to look at a more supportive (stiffer) knee brace. You would then have to decide if the AFO or the stiffer knee brace was more comfortable. Hopefully, a softer brace or taping will help. You can also continue to work on exercises to strengthen the knee muscles in hopes of controlling the hyperextension.

Headaches and Numb Feet after Stroke

by carol gray
(monmouthshire)

I recently had a brain hemorrhage (july last year) since then I have had really bad headaches and tingling in my face. Also my feet are numb. Have you any ideas?

Answer: Headaches can be a problem after a hemorrhagic stroke. They will often lessen over time but can take a long time to resolve in some people. Consult your physician to see if anything can be done about the headaches and to make sure there isn't another underlying problem. If your MD confirms that the headaches are a residual effect from your stroke, I recommend visiting some of the various stroke forums to see what other people have found helpful to alleviate the pain. Always consult your MD before trying any medications or alternative remedies though. A list of stroke forums can be found at www.stroke-rehab.com/stroke-support-groups.html.

Unfortunately, numbness in the face and feet can be a side effect from stroke as well. You might look into finding a therapist who has experience with facial rehabilitation and sensory re-education since this is a more specialized area and many therapists are inexperienced in this area. Sensory re-education techniques are often used for the hand but some can be applied to the face and feet as well. For some sensory re-education ideas, you can visit www.stroke-rehab.com/sensory-re-education.html.

Right hemiplegia

by LoveMySister

Question: Hello, my sister(32) had a stroke 6 months ago (brain hemorrhage, 5.5 cm, left side). She had right hemiplegia and her speech was affected too. She couldn't speak at all.

One month after the stroke, she started to walk again by herself, but her arm was flaccid.

Now after 6 months, she is speaking much better, her leg is better she can make squats, and she can even run with support from the therapist. Her arm is not flaccid anymore, she can move it, but she can not move her fingers independently.

She started rehabilitation on day 3 of the stroke.
She went to robotic rehab for one and a half months. Now she is doing rehabilitation with professional therapists twice a day, 6 days a week.

Is it possible that she could fully recover? Is there a possibility of fully recovering from right hemiplegia? Do you have experience with something similar?

Thank you.

Answer:: The most improvement post-stroke usually occurs in the first 6 months. After this, improvements tend to be slower but still can continue. Some go on to full recovery and others have lifelong deficits.

My experience is if the hemiplegia is severe in the arm, and movement doesn't improve greatly in the first 6 months, then most will tend to have continued deficits in the arm. I have definitely seen someone have a complete loss of use of their arm and then it fully recovers, but this type of spontaneous recovery usually happens fairly quickly after the stroke within the first few weeks/months.

It sounds like your sister has had some amazing recovery already and is getting excellent care/rehab services. If she has movement in the hemiplegic arm, it is most beneficial to use it as much as possible. Many patients will experience learned non-use of the affected side which effects brain connections to the arm. In order to improve connections and use of the arm, it is important to do as much activity with it as possible rather than relying on the non-affected arm. If your sister can move her fingers and only lacks individual finger movement, there are definitely fine motor exercises that can help. Simple grasp/release requires the fingers to work together, but individual finger movement requires different types of exercises which the therapist should be doing with her.

Stroke Affecting Right Foot and Left Hand?

by Ju
(USVI)

Question:Can you have a stroke in your right hand and left foot at the same time?

Answer: Typically a stroke affects one side of the brain which in turn affects the opposite side of the body. For example if a person has a stroke in the right side of the brain, this could cause the left arm and leg to be weak. There can be exceptions such as a brainstem stroke which can affect both sides of the body, but these types of strokes are often quite devastating and would be more likely to affect the entire body. One can also have more than one stroke, and if the strokes are in opposite sides of the brain, both sides of the body could be affected. The typical presentation of a stroke, however, is one side demonstrates weakness rather than both.

Hemiplegic ,seeking advice

by Rameshwar Prasad Khoker
(kharagpur,west bengal,india)

Question Hello, I'm Rameshwar Prasad Khoker. I'm 20 years old and am a hemiplegic patient for the past 5 months. Now I can walk,(not properly)and the hand is not functioning so Please suggest to me some valuable advice so that I can recover from this life(like hell). It will be my great pleasure if you consider my mail seriously.....I'm waiting for your reply. One more problem..does this disease recover automatically with time?

Answer Hi Rameshwar. Throughout my website, I offer exercises and advice on how to recover from stroke and what exercises can be done. One does not recover automatically with time from stroke. Some people will recover quickly after having a stroke (within a few weeks), and their prognosis is better than someone who continues to have weakness or paralysis months or years later. Someone who continues to have weakness/paralysis months after a stroke will have to work harder at recovery and may or may not get return depending on the amount of damage to the brain. Some pages on my website that might be helpful to you in your recovery process are:

https://www.stroke-rehab.com/flaccid-paralysis-treatment.html

https://www.stroke-rehab.com/stroke-hand-rehab.html

https://www.stroke-rehab.com/hypotonia.html

www.stroke-rehab.com/hemiplegia.html

www.stroke-rehab.com/hemiplegic-hand.html

www.stroke-rehab.com/stroke-recovery2.html#how to improve stroke

www.stroke-rehab.com/shoulder-subluxation.html.

www.stroke-rehab.com/spasticity-and-stroke.html

www.stroke-rehab.com/spasticity.html

https://www.stroke-rehab.com/balance-exercises.html

https://www.stroke-rehab.com/passive-range-of-motion.html

Pad placement for an electric muscle stimulator

by Donald Little
(Honey Grove, Tx USA)

Question: My wife had a major stroke a year ago. We bought an electric muscle stimulator. Where can we find a chart which shows where to place the electronic pads to stimulate the muscle and nerve? She was paralyzed on the left side and we plan to use the stimulator plus exercises to get her left arm/hand/fingers re wired to her brain n hopefully functioning again. It is quad, 4 leads, and 3 modes stimulator. Thank you.

Answer: Make sure you have cleared it with her MD before using electric stimulation as some patients have contraindications for use of e-stim. Here is a link to a website that shows electrode placement and videos for various movements:
www.palsclinicalsupport.com/videoElements/videoPage.php.

Hyperbaric oxygen

by Anonymous

Question:Good Evening, Is oxygen treatment effective in stroke rehab? Does Medicare ever pay for this or acupuncture? Thank you.

Answer: I personally do not have experience with hyperbaric oxygen treatment (HBOT). Medicare pays for HBOT for some conditions, however, stroke is currently not one of them as HBOT is still considered an experimental treatment for stroke. Medicare does not pay for acupuncture either. I have read testimonials in favor of HBOT, however, at this time, there is a lack of conclusive research to prove or disprove its effectiveness in stroke treatment.

Chinese Herbal Remedies for Stroke

Question:I see a lot about Chinese Herbal use for strokes. Is there any factual info available? Thank you for a Great Website.

Answer: Two reviews in Stroke magazine from 2007 and 2009 concluded that there is not enough evidence to support or refute the effectiveness of traditional Chinese patent medicine (includes chinese herbal remedies). I do not personally have experience with such remedies so do not have an opinion.

The problem with proving efficacy appears to be related to the lack of rigorous research studies that meet international standards. From what I've read, post-stroke use of herbal remedies for stroke in China is standard care in hospitals. If there are any individuals who have experience with Chinese herbal remedies, please feel free to comment on your experience with them.

My advice to stroke patients is to carefully review any over the counter herbs or medicines with one's physician prior to taking to ensure safety and to identify any contraindications or possible interactions with other meds that are being administered.

Balance Therapy Success Rates

by Chris
(Uk york)

Question: I had a stroke 4 years ago leaving me with parasthesia down my whole left side. I've had no respite from the sensation since then and have been told that balance therapy could address the parasthesia/lack of feeling. I would welcome your comments and idea of the success I could expect and over what time period.

Regards
Chris

Answer: Chris, when you say balance therapy, I'm not exactly sure what you are describing. Since you are talking about parasthesia and lack of sensation, I think maybe you are talking about Muscle Balance Therapy. If this is what you are describing, Muscle Balance Therapy is a technique designed to address muscle imbalance. It may involve decreasing tightness in certain muscle groups and strengthening other muscle groups in order to get better muscle balance and joint alignment. While this technique may be successful in conditions such as back pain or repetitive stress syndromes, it becomes more complicated when dealing with stroke.

After having a stroke, muscle imbalance can occur because of spasticity of certain muscles and/or weakness of certain muscles. A typical muscle that is tight may have developed a trigger point, been overworked, or doesn't get stretched. A spastic muscle that occurs from stroke, however, is different. Spasticity is caused from neurological injury. You may stretch and relax a spastic muscle, and it will again become spastic within seconds, minutes, or hours. Obviously this is different than a tight muscle unrelated to stroke that relaxes in response to massage and continues to stay relaxed for a much longer period of time.

I am not saying that Muscle Balance Therapy isn't beneficial. It's very important to try to achieve muscle balance, and it may help with your parasthesia. I honestly believe it depends on the amount of spasticity and weakness that occurred from the stroke. There is no magic cure to permanently decrease spasticity and strengthen paralyzed muscles. Achieving muscle balance after moderate to severe stroke is close to impossible, but I do believe techniques to decrease spasticity and strengthen weak muscles could help with pain and parasthesia. Just don't let anyone fool you into believing that there is a cure all for your symptoms. My thoughts are to try different treatments (as long as they are safe and approved by your physician) and see what works best for you.

Cervical Spine Stroke?

by Lisa
(VA)

Question: Six months ago I had all signs of a stroke. I still have left side weakness, dysarthia and go to therapy for speech and memory. An MRI of my brain was done that showed no stroke, but an MRI was not done of my neck. I have disk disease in my c-spine C1 - C7, I found out two days ago I now have possible partial paralysis of my bowels due to a stroke my Neuro says "I did not have".

Would a c-spine stroke show on a brain MRI?
What tests should I ask for or should I just get a new Neuro? I am 44 Years old. Thank you.

Answer: Typically one thinks of the brain when someone mentions stroke, however, you can also have a stroke that effects the spinal cord. This rare condition occurs when their is an interruption of blood flow to the spinal cord. It would not be detected by a brain MRI. If you suspect that you have had a spinal stroke then you would need a special MRI of the spine. I am not that familiar with spinal stroke, but I don't believe it would cause you to have problems with your memory as this would be a brain function. Sometimes when you have a "brain stroke", it does not show up on initial imaging studies but could show up later. I would defintely talk to your neurologist about the possibility of a spinal stroke versus missing a brain stroke on the initial MRI and let him/her know that you would like to have further tests done. If your neurologist is not accomodating or you don't feel satisfied that you are getting an accurate diagnosis then I would definitely seek a second opinion. I'm not sure it will have any effect on your treatment in therapy, but it could be important to have an official diagnosis for insurance reimbursement purposes.

MCA stroke

Question: What is a middle cerebral artery stroke? what is the difference between MCA and other strokes?

Answer: Strokes are either ischemic (lack of blood supply) or hemorrhagic (bleeding) in nature. All other terms used with strokes are usually meant to identify where a stroke occurred. A MCA stroke is an infarct in the area of the brain supplied by the middle cerebral artery. Strokes can occur in various parts of the brain so deficits depend on what area of the brain is affected. Some of the effects you may see from a MCA stroke are facial, arm and leg weakness; aphasia; perceptual problems; loss of peripheral vision; and ataxia.

Preparing Meals and Concerns for Safety

by Kim
(Missouri)

Question: My grandpa had a stoke, and we are trying to work with him on getting his strength back as he is wanting to go back to being independent. He is fully motivated to participate. However, we have a few questions. How can he be prepared to participate in the activities such as meal prep, cleanup and safety procedures and emergency responses? As well, what would an OT practitioner be able to do for these concerns? Our concerns are dropping dishes or food, not having the strength to carry dishes to where they need to be placed (cleaned, put away etc) and as far as safety what if he had an emergency but couldn't get the help he needed as quick as he could pre-stroke. Thanks for all your help.

Answer: I think a consult with an occupational therapist could be very helpful in addressing some of your concerns. The OT could evaluate your grandfather and determine what his exact needs are and how to address them. Here are some adaptive techniques that could be helpful with your concerns:

1. Use lightweight, non-breakable dishes.
2. Use a rolling cart to push items around in the kitchen if grip strength or holding items is a problem. If the patient uses a walker then a walker tray or walker with a seat might be used for transporting items.
3. Slide items along countertops as needed if it is too difficult to pick them up.
4. Organize pots/pans/dishes where they are easily reached to prevent falls or straining.
5. If there are problems opening containers or cutting up food due to hand weakness, there are multiple products that are made to help meal preparation easier. Some of these products are described at http://extension.missouri.edu/p/GH7015#handle or do an internet search for adaptive equipment for meal preparation
6. It sounds like your grandfather is probably walking, but if he is in a wheelchair then you would need to look into making the kitchen wheelchair accessible.
7. For emergency situations, you could look into getting a medical alert system for your grandfather.

These are just a few tips. I will try to add more to the list and send to you.

Post stroke care - at home. Mainly exercises.

by Maria Tereza de Brito e Mendes.
(Caranzalem, Goa. India.)

Question: My 46yr daughter was born with Rubella since birth, has cataracts in both eyes, retarded, could never masticate her food (only swallow her food), does not understand the spoken word, and does respond to instructions, etc. She had a stroke two months back, and the whole right side of her body is paralyzed. She has forgotton how to swallow and is fed through a tube directly to her stomach. How and what can I do to improve her condition - at home?

Answer: This particular case sounds quite complicated so I would definitely recommend that you have your daughter evaluated by a speech, physical, and occupational therapist to best determine her needs and teach you any exercises or techniques that may be helpful or recommend equipment that may make it easier for you to take care of your daughter. Based on what you tell me, I would try to make your daughter as comfortable as possible and perform daily range of motion with her to prevent any contractures from forming. Muscle contractures can make it difficult to bathe and dress and can be painful so they need to be avoided. You can view a video on passive range of motion exercises at www.stroke-rehab.com/stroke-rehab-exercises.html. If you are looking for assistance with improving your daughter's swallowing, then I would definitely talk to a speech therapist.

Long term effects of stroke

by Howard Allum
(Brittany, France)

Question: I am 68 years old and I suffered a minor stroke about seven years ago. My balance was initially affected but quickly improved until the loss of balance was almost unnoticeable. However, over the years it has slowly worsened. It seems to fluctuate - sometimes I feel almost normal, others I feel very insecure particularly outside at night or if there is any indication that it might be slippery underfoot, wet leaves, muddy paths etc. In the last few weeks it has started to get quite bad.

I am also experiencing more difficulty with coughing and spluttering while eating or drinking. I seem to be having increasing incidents of tea or even water 'going down the wrong way' causing the spluttering.

I take a variety of medication - coumadine, statins, ramipril, etc.

My question is: Is the worsening of these symptoms as I get older normally to be expected and are the drugs I take likely to have any effect that might make the symptoms worse? Is there anything I could be doing to mitigate the worsening effect?

Answer: It is not abnormal for someone to have more trouble with balance as they get older, however, it is usually gradual and depends a lot on the person. Just from my own personal observation, I would say that people do begin to have more trouble with balance in their 70s. I would not expect someone, however, to have swallowing problems at your age. I would recommend that you visit a doctor or neurologist to determine why you are having these issues. The medicines you mentioned should not cause you to have balance and swallowing problems.

TIA

by RAY ALLEN
(Crossville,tn)

Question: I had 2 strokes 3 years ago coming this April . I had recovered really well except sometimes when talking to someone my speech would stop, and I could not finish what I was talking about . I also never recovered from being so tired and of course depression . Now 4 weeks ago I had a TIA, went to the hospital and recovered., I still feel tired all the time if not more so. Depression and worry have really got me scared . Am I to expect more of these ? I still have sharp pains in my head and after this last TIA my vision is not what it was.

AnswerHi Ray, I'm sorry to hear that you are having these issues. First and foremost, I would make sure that you are seeing a neurologist or other qualified MD and are addressing the possible cause of your strokes/TIAs as well as the effects. You want to make sure your cholesterol and blood pressure are under control and that your bloodwork is okay.

Exercise is a good way to combat depression as well as keep yourself healthy so if given the okay by your MD, I would encourage you to participate in a regular exercise program whether it be walking, aquatic or water exercises, swimming, stationary biking, tai chi, or whatever you are able to do. The hardest part is getting started, but exercise can really help with depression.

You may also want to examine all the medications you are taking to make sure they are not impacting you negatively. It's possible that you may need new medications to help you. This is where I think it's very important to have your doctors working together. If you have several different doctors prescribing you medicine, you want to make sure they are collaborating with one another and not overprescribing or mixing drugs that should not be mixed.

I also encourage you to surround yourself with family and friends so that you have a social outlet. Stroke support groups can be a good source of support as well. You are at greater risk of having a stroke if you already had a TIA/stroke so you do need to take care of yourself as much as possible and do all that is necessary to try and prevent future strokes.

You also mentioned your vision not being the same, so I recommend seeing a neuro-optometrist or neuro-opthamologist to examine how the stroke/TIA has effected your vision. There are various adaptations that can be made to glasses nowadays to help with vision even when visual field cuts have been caused by stroke.

What can I do to help my friends rehabilitation from a stroke?

Question: My friend is 51 male and had a stroke a few weeks ago and is now in a skilled nursing facility. He is paralyzed on his right side and cannot speak. I am pretty certain he understands what he is being told. He is experiencing depression also. I have no medical degree, but think I am intelligent enough to assist in his recovery.

Answer: If he has a spouse or primary caregiver that will be living with him, then I would help that person during this time with looking into disability benefits, arranging the home, running errands, and finding appropriate rehab services.

I would make sure that the facility where your friend is staying is giving him adequate therapy and not letting him stay in bed most of the day. If the therapy appears appropriate, then I would recommend that he stay as long as he can and receive as much therapy as possible. If he can then get strong enough to tolerate 3 hours of therapy, he could move to an inpatient rehab hospital (where more intense therapy occurs).

Talk to your friend. If he can't talk but understands you, he may be able to use some type of communication board with pictures or yes/no answers on it. You can look online for ideas for communication boards after stroke. Someone should be doing range of motion with him (moving his arms and legs) to prevent contractures. The therapists at the facility most definitely should be getting him out of bed and working on sitting balance. You can regain sitting balance even when totally paralyzed on one side.

On my website, I recommend reading the following webpages (pass them on to your friend's family as well):

www.stroke-rehab.com/caregivers.html

wwww.stroke-rehab.com/rehab-facilities.html

www.stroke-rehab.com/stroke-rehab-exercises.html

Left side neglect

by Edwina Smith
(Australia )

Question: Hi, I'm interested to know what are the main interventions an occupational therapist would use with left side neglect?

Answer: The interventions I would use:

1. Remind family and caregivers to approach the stroke patient from the left side and talk to the person from the left side. This is to make the person turn to the left and increase awareness of the left.

2. Have the patient take their right arm and stroke the left arm, perform passive ROM, and stretch the left arm. This also helps increase awareness of the left side. If someone has severe left neglect, the therapist or caregiver may have to give constant reminders to complete exercises.

3. Keep the action toward the left side of the patient (e.g. television, radio, people moving around). I do not encourage putting a call light on the left, however, because the patient may not be able to find it and this could jeopardize their safety in my opinion.

4. Provide markers for patients with decreased left peripheral vision. Putting a marker at the beginning of a reading passage or at some point in the room and instructing the patient to find the marker when reading or scanning the room can let them know how far to turn their head to compensate for the visual deficit.

5. Educate the patient and caregivers about the deficit.

6. Physically guide the patient's left hand through movements/activities.

Stroke Risk

by Cindy Rose
(Brantford Ontario Canada)

Question : I had a stroke 6 years ago and just found out last week that it did some damage to the brain in the left frontal lobe region. Since the stroke, I have lost 100 lbs, lowered my blood pressure, and started exercising. Will this help decrease my risk of having another stroke? I also had other tests that came back including a good echo doppler.

Answer: Congratulations on your weight loss and improving your health! Although no one can predict if someone will have another stroke or not, you definitely have decreased your risk by losing weight and starting an exercise program. My advice to you would be to continue regular physician visits, monitor your blood pressure, and continue with your new, healthier lifestyle. You can also visit another webpage I have at www.stroke-rehab.com/how-to-prevent-stroke.html which outlines various ways to help prevent stroke.

Associations for Stroke Therapists

by A.P.
(ASIA)

Question: Hi. I am a physiotherapist. Is there any association (in web) for therapist who deal with stroke, that they can be a member of it and be more trained and aware of new treatment techniques?

Answer: A great way to learn about the latest stroke rehab news is to have search engine results e-mailed to you with a tool such as Google alerts. Go to www.google.com/alerts and enter a search term such as "physiotherapy and stroke rehab" or just "stroke rehab" as well as your e-mail and alerts will be sent to you with the latest news. You can also use Google Scholar (http://scholar.google.com/) to get scholarly articles and research information.

These websites might help you locate what you are looking for as well:

www.nursingdegree.net/blog/31/100-essential-sites-and-resources-for-physical-therapists (This website lists 100 different sites that benefit PTs including various associations)

www.physiotherapy-treatment.com/index.html
(a website dedicated to physical therapy treatment)

Believe it or not, YouTube is also a great tool. Many therapists and/or schools post treatment videos which may give you some good stroke treatment ideas. Just enter the search term stroke rehab, and you'll get more than 2000 results.

Assessment scale

by Satheesh Durairaj
(Delhi)

Question I'm working in Stroke rehab set-up. We are ideally following the assessment like mRS, Karnofsky, Barthel index, MMT, if spasticity MAS

I would like to ask what scales are optimal for Acute stroke patients, Sub acute patients, only TIA, Recurrence of stroke, and Old stroke?
Please suggest to me.

Answer: Here are a couple of links that give information about assessment scales:

www.strokecenter.org

www.neuropt.org - This link goes to a chart that provides a number rating (4=highly rated and 1=not recommended)

Did I Have a Stroke?

by Bluesquid
(Canada)

Question: It coincided with dental work. All of a sudden I started to talk funny. It was so difficult to talk, food was falling out of my mouth, and I was aspirating and choking on food and liquids. I was still blaming it on the dentist because my mouth felt horrible and I talked slow. Inside of my head, my voice was normal, but when I tried to talk it just didn't work. I did everything in my power to get better at talking still thinking it was the crowns. Months passed and someone mention that I talked like someone coming out of a stroke.

Answer: There is no way for me to tell if you had a stroke. You need to visit a neurologist to find out why you are having these problems. There are various conditions that can cause facial weakness and paralysis such as Bell's Palsy, facial nerve damage, stroke, etc. A neurologist can perform tests to determine what has happened. If you experienced tongue and/or facial paralysis, you should ask your physician about having a swallow study. You need to make sure that you are not still aspirating food or drink because aspiration can lead to pneumonia and pose a potentially life threatening condition. One can aspirate without even knowing it so don't assume you are okay just because you aren't coughing when you swallow. It sounds like you could benefit from speech therapy as well.

Numbness or lack of facial movement does not usually last more than several hours (2-6 usually) after a dental procedure and definitely not for weeks. My advice to all is that if you continue to have numbness and paralysis the day after a dental procedure, contact your dentist or doctor immediately.

Stroke

by Samon Coward
(Louisville,KY)

Question: If I'm left handed, can I still have a stroke on my left side?

Answer: Yes, it doesn't matter if you are right or left handed, you can have a stroke that affects either side.

Stroke Victim Unable to Sit in Wheelchair

by shane
(TX)

Question My father had a devastating stroke (we were told it was both kinds) 3 years ago that left him paralyzed on the full left side. No improvement after 3 years of rehab etc. He essentially now lays in a bed 24 hours as sitting in a wheelchair becomes too painful for his buttocks. His left side, while paralyzed, still has acute pain and sensitivity when touched at all. Without him sitting in a chair daily, he will deteriorate very quickly. He has a 'regular' wheelchair. Is it possible that his buttocks also has the 'raw nerves' like the rest of his left side and what can be done to allow him to sit for 2-4 hours a day? He tried cushions, but if sensitivity is the issue, then they would just compound the issue. We asked about 'doughnuts' to prevent the seat from touching most of his buttocks but they are essentially banned due to restricting blood flow. What can we do to allow 2-4 hours of sitting a day (we have tried many positions etc) and what chair is best?

Answer: I won't be able to tell you what is best for your own father, but I can tell you some different seating solutions that are out there. It would be a good idea to have a physical therapist along with a rep from a wheelchair/seating company come in and do an evaluation to recommend the best wheelchair or home seating solutions for your father. An evaluation would be necessary to see what type of support he needs and how to best prevent skin breakdown. Here are some various seating solutions:

Electric recliner/lift chairs

Cardiac chairs (can use pressure cushions that line whole chair if needed)

Electric hospital beds that can be brought into a seated position (not just the head of the bed but the bottom folds down to make a chair)

Reclining wheelchairs

Specialized wheelchairs and cushions

Honestly, there are so many seating solutions out there that you should be able to find something that works for your father. I think the key is to find a specialist in seating to evaluate what your father needs (not just any therapist or medical equipment rep but someone who is highly qualified in seating intervention). Don't settle for something that doesn't work well.

Headaches after a stroke

Question: Is it normal to suffer headaches after a stroke?

Answer: It is not uncommon to suffer headaches after a stroke, but any severe or frequent occurrence of headaches should be discussed with one's doctor to determine the source and what treatments options are available.

Low blood pressure

by Gerald De Benetti
(Canada)

Question: My sister had a stroke two years ago. It has left her with some weakness and ongoing pain involving her left side,memory loss,and what is most significant and which seems to have just become apparent in the last year is that her blood pressure is very low (90 or less for her systolic). As a result she tires easily,has dizzy episodes and this has really impaired her ability to function. She sleeps a lot and says she is depressed.

From what I have read I feel this may relate to a posterior circulation dysfunction (one of her vertebral arteries had occluded or tore; she had whiplash in an accident in the time preceding the stroke)

There doesn't seem to be anything anyone can do about the LBP. Is this something that may improve over time? Can there be physical and/or mental tasks that could be done that would perhaps involve one part of her brain and at the same time indirectly result in improvements to part of the brain that is involved in autonomic functions?

Answer: I personally do not know of exercises that directly or indirectly improve persistent low blood pressure. Managing blood pressure issues would fall under the realm of the physician so that is who I would direct your questions to. If your sister has episodes where she passes out or has near falls because of the dizziness, I would advise that she take steps to protect herself from falls. Check with her MD to make sure these steps are right for her, but normally for someone with hypotensive episodes, I would advise the following:

1. After coming from a lying position to sitting, sit for a minute until dizziness resolves.
2. After coming from a sitting to a standing position, wait a moment before stepping/walking to make sure there is no dizziness or faint feelings.
3. If dizziness occurs when walking, sit to avoid falling.
4. If starting to faint or one becomes less responsive due to low blood pressure, have the person lie down and elevate the legs to increase blood pressure.

For information on hypotension treatment, you can visit http://www.mayoclinic.org/diseases-conditions/low-blood-pressure/basics/treatment/con-20032298. and have her discuss these options with her MD.

Regarding Early Mobilization

by Satheesh Durairaj
(New Delhi)

Question: Can anyone explain about
AVERT ()
AVERT- Phase1
AVERT- Phase II
AVERT- Phase III

What's the difference between these?

Answer: You can read about the AVERT trials at http://www.florey.edu.au/research/avert.

Is it safe for my husband to receive sports massage therapy?

by jane
(merseyside)

Question: My husband had a stroke over 2 years ago resulting in loss of speech and movement down his right side. He has a peg in his stomach. He can nod very slightly and I think he bites his lip when he's uncomfortable. He receives regular physiotherapy but is unable to walk unaided and is therefore in a wheel chair a lot. His legs are very stiff along with his neck, and I was wondering if it is safe for him to receive sports massage therapy and also if it will eventually allow him to walk as he understands movements and feels things as he wiggles his toes? Please can you help?

Answer: It shouldn't be a problem for him to have massage therapy, but I always advise people to ask their doctors since I do not know their medical condition nor precautions that may need to be taken with them. You don't have to take him into the doctor necessarily but could just call his doctor's office and speak to the nurse/leave a message to have them call you back regarding the question.

I would advise that you be with him during the first few massage sessions since he has lost his speech because you will have more insight into if he is comfortable or in pain and can help the massage therapist interpret his body language and facial expressions until the therapist becomes more comfortable with him.

Massage therapy will not necessarily help him be able to walk but may allow him to be more aware of sensation/touch and help with relaxing tight muscles. Honestly, you won't know the full impact of what massage therapy does for him until you try it out. If he has spasticity, you may see it improve during or right after the massage, but those effects will most likely be brief as spasticity is caused by the damage to the brain and not because of the muscles. I personally think massage therapy is a wonderful adjunct to physical therapy if done correctly.

Post Stroke Priority?

by Jill Bennett-Weaver
(United States)

Question: If one had a stroke one week ago and had previous heart conditions, is not able to swallow, is having heart edema, and is very weak, is it a priority to immediately focus on physical exercises, throwing balls, walking, leg exercises, etc., and can you trust their cognitive answers to questions at a week after a stroke? Especially if the patient is having other health issues, as a result of the stroke and has been diagnosed as seriously ill?

Answer: The physician makes the call as to whether a patient is ready for therapy. It would not be unusual for someone that has swallowing issues, severe weakness and cognitive issues to participate in therapy. When you say heart edema, I'm not exactly sure what you are describing, but I think you may be talking about congestive heart failure. There are many stroke patients I have seen that also have congestive heart failure. Again, the physician would have to make the decision as to if the patient could participate in therapy or not. I think that it is best to get a stroke patient in therapy as soon as they are medically cleared to do so. It would be important that the therapists are aware of any medical limitations and to design a program suitable for the patient. For example, if a patient had decreased cardiac function/output, therapy would be less rigorous and heart rate/breathing would need to be monitored. If you have concerns, I would talk to the physician about any precautions that should be followed and ask if the therapy being given is appropriate.

You also asked whether you can trust a stroke patient's cognition one week post stroke. This varies between patients. Some patients will only show physical deficits and cognition will be intact. Others may show ranges in cognition from mild deficits to severe deficits. A speech or cognitive therapist should be able to evaluate your loved one and give you an idea of his/her cognitive status. I encourage you to talk with the medical staff to help alleviate any concerns you have. If you see problems with your loved one, it is important to discuss these issues with the physician because you may have more insight into day to day or hour to hour changes with your loved one that others may miss.

Rehab Frequency

QuestionHow many times a week should you train and why?

Answer: The American Heart Association recommends:

3-7 days of aerobic exercise for 20-60 minutes (or multiple 10 minute sessions)

Strength training 1–3 sets of 10–15 repetitions of 8–10 exercises involving the major muscle groups 2-3 days per week

stretching/flexibility exercise 2-3x/week

coordination and balance exercises 2-3x/week

You can read about the research/reasoning behind their recommendations at http://stroke.ahajournals.org/content/45/8/2532.full

Stroke Support Group

by Virginia
(Houston, Tx)

Question: My husband had a stroke 3 yrs ago. He says his mind is making him angry, and he doesn't want to do anything, talks about ending life. He blames me for everything and nothing pleases him unless it is what he wants at that time. Is there anything I can do to make my life better other than leaving him to his own devices? I know he is not happy, but it is making me unhappy also.

Answer: You titled your entry Stroke Support Group so I am thinking you are interested in finding one for either you or your husband or both. I would encourage you to visit my stroke support group webpage at: https://www.stroke-rehab.com/stroke-support-groups.html. A stroke caregiver also recently replied to a question similar to this recommending their private Facebook group for support. Their are various private Facebook groups for caregivers that you can ask to join. You would want to search stroke support group on Facebook. Even though they are private, they are looking for other caregivers to join (unless otherwise noted). The private just means that only group members can post and see each other's responses. This allows caregivers to maintain privacy from the public. My experience is that caregivers and stroke patients really enjoy support groups (live ones are even better in my opinion) and have a lot to offer in helping people deal with stroke and caregiving.

The length of walking for a stroke patient

by Susan Greene
(New York new york)

Question: I am taking care of a lady who had a very massive stroke on her left side. This man who teaches, not a physical therapist, comes in to give her exercises, he want us to walk her in her home fifty times a day every day. Is that some thing that a patient should do?

Answer: I cannot comment on the particular patient you care for since I do not know her condition, but stroke patients should get up and move around as they are able. Fifty times sounds excessive in my opinion for a severely involved patient, but if you think about a person who is not disabled, they easily get up and down more than 50 times a day. What neuroplasticity research has shown is that repetition of movement/tasks is what helps "rewire" the brain so it is helpful to walk frequently if one is able (this includes with support from others).

As I said, I am not familiar with the particular patient you are caring for, but if you can safely help her get up and down and take steps (this includes without hurting yourself), then it is fine to let her walk as as she is able. You can always check with her physician if you have medical concerns about her doing this. I do want to clarify though that when you say "walk 50 times a day", I assume you are including walking to the bathroom, walking to the bedroom for sleeping, to the dining room for eating, or other rooms of the house as well as short walks/steps for exercise. Just walking back and forth to rooms to do daily activity could constitute 15-20 times a day. In my opinion, 50 times sounds like it is too much if she is severely involved as you describe, but I do not know her condition. If it is extremely difficult for her to get up and takes 15-20 minutes just to stand and take a few steps, then 50x a day would fatigue her too much and may not even be possible. Since you work with her on a daily basis, I would observe how she responds to walking and select a schedule that she can handle and that doesn't overly fatigue her. It is okay though to walk a stroke patient as much as they are able as long as they don't have any medical complications that would limit them from doing so.

Walking pace

Question: Hello, my brother-in-law aged 43 suffered a stroke 7 months ago. He has been walking with a single stick support, but his pace of walking has been slow. Do you think with more rehab and exercises he will be able to attain the capability to walk at a faster pace like us. How can we improve the walking pace ? Also, since he is young we are hoping that one day he will be able to walk without the stick.

Answer: In order to improve gait speed, it is good to perform exercises 4 to 5 times a week that involve a variety of movements (e.g. getting up and down, turning, side stepping, stair stepping, walking over uneven surfaces) combined with traditional exercise machines such as treadmills and bikes if the stroke patient is able. Of course, these type of exercises would not be appropriate for all stroke patients, and it is important to talk with one's MD or therapist to make sure what exercises can be done and if assistance from someone else is needed. There is a helpful exercise manual put out by the University of British Columbia called Fame. It can be found at http://neurorehab.med.ubc.ca/fame/. You have to first enter some info to access the manual, but it is just for their information on how the manual is being used and by whom. As stated before, stroke patients should check with the medical professional involved in their care to see if the exercises are appropriate.

LE weakness

Question I had a hemorrhagic stroke 5 years ago. I am 52. I have mostly recovered but my balance is not very good and I cannot flex my right hamstring. I just noticed this and want to try to rehabilitate it. I have found some home exercises but should I try PT or is it kind of late? Thanks.

Answer: It is never too late to try physical therapy. I would definitely recommend getting a physician's referral to a PT For treatment.

DIY Walking

by Cindy Power
(Nashville,TN)

Question: As I understand it, it's hemi walker, bad foot, good foot to walk straight. I've got that.if you need to go sideways to the right and the right is your good side, how is it done? What are the steps to the steps?!

Cindy

Answer: I have to say as an OT, I do not know if there is a specific training with the hemi walker for side stepping. I couldn't find anything on the internet either. I would check with your PT. I know there are sometimes where tight spaces would require you to side step. Most likely you will just have to move the hemi-walker, and if going right, step the right foot to the side and then the left foot. If you tried to step with your left foot first, the right foot would be in the way so that would not work. The main thing is to make sure you can maintain your balance when side stepping this way, and make sure you don't move the hemi-walker too far away from you. If you are simply just wanting to practice side stepping for strengthening and don't need to do it to get through a tight space, then it would be preferable to practice somewhere with something more stable to hold onto such as a counter or in the parallel bars and practice without the hemi-walker.

weight bearing

Question:How can I encourage weight bearing on the affected leg?

Answer:Weight bearing can be encouraged on the affected leg by shifting weight over to that side, one legged standing on the affected leg, and stepping the non-affected leg up and down on a bench which requires you to weight bear through the affected leg. Stepping forward and back with the non-affected leg will also encourage weight bearing on the affected leg. Please note that if the affected leg does not have enough strength and the knee buckles, it will be necessary to have a therapist or trained caregiver help support the leg while performing the exercises. It is most effective to do the exercises without holding on with the hands, but that may be too difficult for some so holding on to a steady surface may be necessary. All patients should consult with their therapist to see if the exercises are appropriate and should be trained by their therapist on how to appropriately do the exercises.

when should a stroke patient walk with a cane or without a cane

by Mai Mowrey
(Vietnam)

Question: My brother suffered from a hemorraghic stroke 3 months ago. He currently can walk with the walker, but we want to know when he can walk without the walker and move to a cane?

Also, he thinks his hip is not strong, how do we measure it? Also what exercises does he need to do to make his hip strong? Thank you.

Answer: A physical therapist should be working with your brother and can tell you when he is ready to move from a walker to a cane. If your brother has already been discharged from therapy, then I would recommend asking for more physical therapy to evaluate if he is ready to move to a cane. A physical therapist can also test the hip strength and design a home exercise program to strengthen the hip. I usually tell patients to strengthen all muscles/movements as able. Strengthening muscles is really no different for a stroke patient than for anyone else. It's just that the technique used may have to be adapted based on how much movement/strength the patient has. If therapy is not an option, your brother could also consult with a personal trainer that has experience or knowledge about working with stroke patient. Below is a link to a webpage that has a guide with some hip strengthening exercises. Always check with a therapist or doctor to make sure exercises are appropriate for the patient.

http://www.stroke.org/sites/default/files/resources/HOPE_Guide_2007_chap4.pdf

Also, here is a website with hip testing techniques:

http://at.uwa.edu/mmt/hip.htm

Stroke Deformities

by Ilma.izhar
(Dehradun)

Question: My patient is having external rotator deformity in the left leg. She had a stroke three years ago with upper limb spastic deformity. Please guide me on how to correct all deformities. Now she is having good balance for 20 min standing, and grade 2 and 3 hip movements

Answer: Many patients learn to walk and still maintain balance even with external rotation at the hip so I would not over focus or get too sidetracked with treating the deformity/spasticity. I would continue to work on gait and balance. You could also emphasize exercises that strengthen all the muscles around the hip and work on active internal rotation as well. You also want to work on standing on the affected leg with hip in neutral position while moving/doing exercises with the non affected leg so the patient can feel what it is like to have the hip in neutral while doing weight bearing on that leg. This will also help strengthen hip stabilizers on that side. I wouldn't worry though if the hip continues to externally rotate especially since it has been this way for some time. Many patients learn to work around this posturing and still be very functional.

As far as the arm, I would again emphasize trying to use the arm if the patient has any active movement. Strengthening and range of motion can be done with spastic muscles. Years ago, it was believed that strengthening may have a negative effect on spasticity, but it has been shown that strengthening does not have a negative effect on spasticity and is recommended if the patient is able to move the arm. If you want to know specifically about spasticity treatments, you can review what research says about spasticity treatment and stroke at:
http://www.ebrsr.com/sites/default/files/Appendix-spasticity.pdf.

Occupational And Physical Therapy

by Sol L. Gorrell
(Hammond, Indiana 46324 USA)

Question:Is it common practice for both Occupational Therapy and Physical Therapy to be performed simultaneously? (ie. two therapists working on the same patient at the same time?) Am I not understanding that the requisite is for the patient to have two hours of therapy not two hours of therapist time lumped together?

Answer: In the US, if two therapists are seeing a patient, then the time must be split between the two therapists for the purpose of billing insurance under Medicare B but not Medicare A. You would have to check with other insurance agencies on their requirement for billing. Under Medicare B, if a patient is seen for two hours, then the total time charged between OT and PT should be two hours not two hours for each discipline. Under Medicare A, each therapy can bill for the full time, but co-treatment must be shown to be necessary, and this should not be done for therapist convenience. Co-treatment is most often seen when a patient has more severe impairment.

Rebuilding left side motor skills?

by Tiffany
(Las Vegas, Nv)

Question: Hi, my dad had a stroke on 1/20/14. He is doing okay but the question is he has difficulty with his left side. He has strength, however, it seems that side is still "clumsy" as he puts it. What can I do to help rebuild the connection from hands to his brain? I am a licensed massage therapist.Any input would be greatly appreciated! Thank you for your time.

Answer: Some things I might try with my patients would include mental or graded motor imagery, mirror therapy, and repetitive use of the hand especially for in hand manipulation skills. Graded motor imagery can be done by having the patient imagine that the hand is working in a normal fashion doing different fine motor tasks. Recordings with vivid descriptions of using the hand can also be used while the person imagines using the hand. This technique would be used several times a day. You can find out more about graded motor imagery at www.gradedmotorimagery.com.

Mirror therapy would also be used for several sessions throughout the day. The patient would look at the reflection of the non-affected hand doing different motions and fine motor tasks. This has the effect of "tricking" the brain into thinking the affected hand is working as the brain will perceive the reflection in the mirror as the affected hand. The patient can still be trying to perform the same movements with the affected hand, but it will be occluded from the patient's vision. This technique is also described on the graded motor imagery website mentioned above. You can also view youtube videos on how to make a mirror box and use it at home.

In hand manipulation skills are the way that we handle small objects within our hand. Three important skills include translation, rotation, and shift. You can view a video of these movements at https://www.youtube.com/watch?v=wGdyXpqO7Jo. These in hand manipulation skills are movements that can be practiced to help improve fine motor function. You can also view a list of fine motor activities for practice at https://www.stroke-rehab.com/hand-exercises.html.

FOOT KEEPS GOING ON TO MY ANKLE

Question: I HAD A MASSIVE STROKE ON MY RIGHT SIDE AS A RESULT OF THAT I STILL CANNOT WALK AND WHEN I DO WALK MY FOOT KEEPS GOING TO MY ANKLE THANK YOU

Answer: I assume you must be talking about foot drop. To find out more about foot drop, you can visit https://www.stroke-rehab.com/foot-drop.html

Muscle contractions

by Wendy
(South Carolina, USA)

Question: I had a stroke 5 years ago at the age of 46 with weakness on the right side. My arm has some movement but I still can not pick up objects. But the real problem is my leg. My ankle tends to have muscle contractions which causes my ankle to roll making walking very scary. There are times that I feel like if I don't hold on to something I will fall even when sitting down. What can I do to help this?

Answer: You could try an ankle brace. They have various soft support braces that you could wear to support your ankle though I don't know if that would work. I would also check with your doctor to see if there is anything to help control the contractions or relax the ankle muscles. It would be better to treat the cause rather than the symptoms if possible.

Stroke

by Mary Munro
(Cheshire )

Question: My daughter who is 48 had a stroke 6 weeks ago. It has affected her speech only slightly, but now everything seems to be getting to her. She cannot stop crying. I don't know what else I can do to help her. She is going back to work tomorrow.

Answer: It is not uncommon to be emotionally labile after having a stroke. Since it is only six weeks after her stroke, it may just take time for her emotions to come under control. If, however, a part of her brain that controls emotions has been permanently damaged, and she continues to exhibit these symptoms over time, she could consult with a physician about meds to help with emotions. If it is interfering with her work, she could go ahead and talk to a physician and see if any meds might help temporarily.

what happens after the 100 days?

(Dallas, TX)

Question: My father, 84, had a left side stroke which left the right side of his entire body paralyzed to some degree. He has trouble swallowing, is incontinent, can't get himself to a sitting position, has trouble feeding himself due to his left hand also being weak...sadly, a turtle on its back - what happens when the days of covered care have been exhausted? He cannot come home, I am not qualified or equipped to offer the proper care.

Answer: If it is early on in his stroke recovery, he may change significantly over the 100 days. I've seen stroke patients present this way in the first couple of weeks of their stroke and then later go on to be independent or at least functioning at a much higher level. On the other hand, if he is nearing 100 days of care, and he has not improved to a level that you can care for him, you will need to talk to the social worker to determine what options you have for care in a facility. He may need to apply for government aid. I would definitely give yourself time to plan, so make sure you are communicating with the social worker early on.

Intracranial hemorrhage

by Somi
(Mumbai)

Question: My dad suffered from an intracranial hemorrhage 3 years ago...now his right back is paining and that pain goes to his feet his full right side is paining. He feels good when we massage his body with sesame oil...I want to ask is it ok to do massage without consulting any doctor or physiotherapist?

Answer: Massage should be fine in terms of his stroke being three years ago, however, if this pain is new, then I suggest you see a doctor to find out what is causing pain as there may be a new problem you don't know about. If you don't know what is causing the pain, then it's hard to say if massage is okay. For example, if he has a blood clot in his leg, then massage would not be okay. If he has chronic nerve pain from the stroke, then massage shouldn't be a problem. You need to know the cause of the pain to make the right decision.

PERMANENT DISABILITY

by ELIZABETH
(QUEENS, NY)

Question:MY BOYFRIEND, AT AGE 47 SUFFERED A HEMORRHAGIC STROKE A YEAR AGO. AFTER BEING STABILIZED HE WAS TRANSFERRED TO NYU LAGONE WHERE HE RECEIVED THERAPY BUT HE WAS STILL BED RIDDEN. AFTER A SHORT PERIOD THERE, HE WAS TRANSFERRED TO A NURSING HOME WHERE THE THERAPY WAS VERY BASIC. AFTER THREE MONTHS IN THE NURSING HOME, HE WAS ABLE TO GO HOME WITH A FULL TIME AID. HE CAN MOVE ENOUGH TO FEED HIMSELF BUT HE IS UNABLE TO SUPPORT HIMSELF - MEANING HE CANNOT SIT UP ON HIS OWN. HE NOW HAS BEEN GOING TO AN INTENSE THERAPY PROGRAM ABOUT THREE TIMES A WEEK FOR 1 1/2 HOURS. I M WONDERING HOW MUCH THERAPY SHOULD BE DONE TO ASSIST HIM IN RECOVERING. HE IS DETERMINED TO WALK AND WILLING TO W0RK HARD. I JUST FEEL WE HAVEN'T HAD THE CORRECT PEOPLE ASSISTING IN HIS RECOVERY AND ARE LOSING VALUABLE TIME. DO YOU THINK HE WOULD BENEFIT BY DOING PT EVERY DAY FOR A LONGER PERIOD OF TIME. ANY SUGGESTIONS WILL BE GREATLY APPRECIATED.

REGARDS,
ELIZABETH

Answer: If you can find a facility that offers more intense therapy daily with experienced therapists, then I do believe that would be helpful, but I do not know what type of facilities they have in your area. Typical outpatient clinics would usually only see patients three times a week. If you could afford to have a trained individual to work with him outside of therapy, that would be a good alternative as well. Recovery is done on a daily basis, not just in the short time period spent at therapy. Unfortunately, patients with more involved strokes will often not get the amount of therapy that they need, and it will be up to family members to help them find outside resources to help. I would ask the therapists working with him if they know of anyone that could help him outside of therapy days. If he has willing and able family members or if the aide was willing, they could attend therapy sessions and the therapists could show them activities to do at home.

Stroke Recovery

by Michael Busik
(Burbank, CA)

Question: My sister had a stroke 3 yrs ago. Her left side (arm and leg) are paralyzed. She was on the floor for 3 days before she was discovered. She has improved only in her speech. She has her mind back. What are her chances at this stage of her ever getting some use out of her left side? Doctors don't give her much hope but she thinks she will walk again. I don't want to tell her she will never walk again as it might break her spirit. Thank you..

Michael

Answer: I would allow her to continue to hope and keep trying. I have seen many severely affected stroke patients learn to walk so I would never discourage someone especially if they are determined. Even learning to take a few steps can be very meaningful to someone who has been severely affected by stroke.

Intensive Rehab

by Valerie-Rita's daughter
(Massillon Ohio )

Question: My mom had a massive hemorrhagic stroke 3 months ago and I need help to determine a care plan and course of action to rehabilitate her to the greatest capacity! I am not wishful in my thinking. I understand my mother as I knew her April 17 the night before her stroke is gone...but she has a lot of life left and has worked hard to overcome these obstacles in front of her...as have i and the rest of her family!
I and her therapists here in the skilled nursing facility have tried to provide the best chance into getting into a quality intensive rehab to help! I am not willing to stop seeking somewhere for her to be rehabbed because no one is willing to take her in an intensive rehab because she will not be HOME READY in under 16 days (that varies by facilities on amount of days but 16 was the top)! The rules within the medical and insurance companies truly are horrible! They want more 3 hr a day therapy to get them to take her, but insurance wont pay that in a skilled nursing facility and either way she will have to go home after her 100 days are up! She was bed bound in a reclining wheel chair tiring after a short time out of bed with a trach including oxygen and tube feed and now she is standing with assistance up all day board sliding eating drinking helping with self care standing/pivoting with help as examples! Accomplish the impossible to make it!
I want and need a second opinion and help to give my mom the best possible chance at some quality of life after this stroke! I'm not interested in what the insurance company will or will not pay as we can handle the cost either way I am interested in a doctor and therapy team willing to help my mom regain every single ability she can find the strength to achieve with treatment that is centered around her not the outcome being needed to keep their stats boosted! Please can anyone help me navigate this.
I sit with her 16 hrs a day giving her a repeat of her limited therapy moving her talking to her! She has only the nursing home doctor and the neurologist she saw in the hospital! Her OT therapist worked in an intensive stroke rehab and said she can handle intensive therapy and even broke the rules and had the whole therapy team create a 3 hr intensive day, but because of the guidelines now they still won't take her because she wouldn't be home ready in 2 weeks? Any input would appreciated. I just want my mom to have the best chance...she has already beat the odds. They said she would NEVER move her left side and she can left her knee off the wheel chair a half inch on command with a lot of focus and side to side 1/4 in and slightly kick her foot out as well as slide her left arm an up and down 1/4 inch cause I have been working with her so much! Any insight would be appreciated! Her stroke was right side in the thalamus hippocampus region if that matters!

Answer: You can contact the Patient Advocate Foundation. Their website is www.patientadvocate.org. They provides patients with arbitration, mediation and negotiation to settle issues with access to care among other things. You might look into hiring a private pay therapist to work with your mother in addition to the therapy she gets at the SNF if finances are not an issue. You would normally have to get the permission of the SNF to do this which might be a problem, but maybe they would work with you given the circumstances. Sometimes what facilities or well meaning employees tell you is a "rule" is really just their policy rather than an insurance requirement (usually based on how the facility can best make and not lose money). The Patient Advocate Foundation should be able to help you navigate the system and understand what the actual rules are or aren't.

Is there a doctor somewhere who can help?

by James Martin
(Eastpointe Michigan US)

Question: My wife suffered a stroke 3 years ago and lost the use of her right side but a lot has come back except for the movement below the right elbow and hand. With all this modern medicine, is there not one doctor who can help her gain the movement back in her right hand?

Answer: I understand your frustration. Unfortunately, the brain is very complex, and when a portion of the brain is damaged that controls movement, it may have lasting effects. The brain has been shown to have neuroplastic properties so sometimes new pathways are made and the brain can compensate for damaged areas, but the process is not well understood at this time and certain parts of the brain appear to be more adaptable than others. The only advice I can give you is to find the best neurologist that you can, keep up with latest research, and to tell your wife not to give up. One thing is for certain with the brain, if you do not use a body part, the learned pattern of movement with that body part deteriorates. You might investigate further into mirror therapy which is thought to "trick" the brain into thinking that the arm can move and possibly help with creating pathways in the motor cortex.

contraindications of using a one arm drive self propelling wheelchair

by Anna O'Loughlin
(Belfast Ireland)

Question: Are there any contraindications to using a self-propelling one arm drive wheelchair to mobilize after a stroke? Does it effect the affected side negatively?

Answer: Honestly, it should be fine. You do want to encourage a patient to use their affected hand as much as possible so they do not fall into the pattern of learned non-use. However, you do not want to stop a patient from doing a functional task altogether because they can't use their affected hand. Now if someone is trying to do a trial of constraint induced movement therapy for a couple of weeks and has been asked to not use the non-affected limb, that is different, but outside of a specific therapy protocol, I would not discourage a patient from doing a task independently. Remember to just encourage the use of the affected side as much as possible.

Returning to pre-stroke fitness level

by Krysta Owingd
(St. Louis, MO, US)

Question: I am a 25 year old stroke survivor at the one month anniversary of my stroke and AVM surgery. My recovery was a miracle and I regained function of my left arm and leg two weeks after my surgery. I no longer have to see my physical therapist, which has caused me to feel lost in my journey to regain the strength I had before my life changed. The problem I am running into is I feel like I have no help or guidance on how I should work out, what reps/equipment/movements I should be doing. Any ideas on personal workouts specifically targeting the younger survivors of stroke?

Answer: So, unfortunately, I am late in answering your question, and you probably have figured it out by now. However, in order to help others, I am going to go ahead and reply. If you have recovered full motion from your stroke and are pain free, then you can precede as you are able with strengthening and cardiovascular training as long as you have the okay from your physician. Now, obviously, you will have precautions in the weeks following a surgery, but once your precautions are lifted, you should be able to resume normal exercise as you are able.

You could hire the help of a personal trainer to help you with an exercise plan if you are struggling in this area. Even if your MD has certain precautions, you could still work with a personal trainer; they would just need to work within the parameters of any precautions laid out by your MD. It's important to monitor things like blood pressure and heart rate during exercise which a personal trainer should be doing anyway with someone that has had a stroke.

For those that do not have funds to higher a personal trainer, then you can read online about exercise recommendations for those who have expereinced stroke at http://stroke.ahajournals.org/content/45/8/2532/tab-figures-data. Specifically, you will follow the guidelines in the table that specify what is recommended for aerobic, strengthening, and flexibility exercises.

If you are physically capable, you can participate in whichever weightlifting and aerobic activities you like (always get clearance from MD first though). The main thing is to pay attention to how your body feels. For example, if you are trying to do 30 minutes of cardiovascular exercise, and you are too fatigued or out of breath, you may need to start with a lower goal like 10 minutes or with an activity that is less rigorous. You can work your way up to longer times and more rigorous activity as you progress.

stroke

QuestionHow do you deal with a 75 year old man who had a severe stroke, who is about 7 yrs old in his brain and he can barely move but runs off every chance he gets. He is mean and then he tells his wife so is so upset and scared when she can't find him, that he is teaching her a lesson.

Answer: I would visit with his MD for solutions and for referral to a neuropsychologist who may be able to help with solutions.

What to do?

by Gloria Kirk
(Martinsville Va.)

Question:My 87 year old Mother had a servere left brain stroke three months ago. She lost her ability to walk, talk, and eat. She was very active up until this point. She was dancing twice a week and always on the go. She went from 60 to 0. Mentally this has been very difficult for her. She is on continuous feeding from 8 in the morning until 8 at night. She is in the nursing home part of a health and rehab facility. I visit her everyday and try to take her outside awhile or take her to attend activities at the facility. Every time I get ready to leave her in the evening, she gets very agitated and doesn't want me to leave her. I think a lot of it has to do with her not being able to communicate and it just tears me up inside. Do you have any suggestions how I can ease her anxiety? Also I'm wondering that when the weather gets colder and I can't take her outside what we can do together to make the time go by. I don't want her just sitting in her wheelchair all day looking at 4 walls. Also I forgot to mention that she's being getting therapy at this Facility but because she's in the Nursing Home part and on Medicare Part B she's not getting as much therapy as she was. About a month ago we were trying to feed her and she got pneumonia so we're afraid to feed her again. I'm Taking her to a specialist this week to see if they think she can try eating again.

Answer: Gloria, I'm so sorry to hear about your mother. I'm not sure what you can do about her anxiety. Maybe you could put on some music or have staff come visit with her when it's time for you to leave. As far as indoor activities, again I would suggest music activities (if she likes music). Also, you could take photo albums or home movies to share with her. I don't know what her mental capacity is, but you could try jigsaw puzzles if she is able to put them together (there are larger, easier puzzles if the small ones are too hard). I would suggest to you to go onto an online caregiver forum to get more ideas from others in a similar situation as yours.

Doctors responsibility and care

Question: I am having difficulty obtaining the type of doctor I need to monitor my care and progress almost 3 years post stroke. What area of care handles years after a stroke? I have been discarded especially if I refuse Botox. Physiatrist, Neurologist, I don't know where else to look. Therapists such as Occupational, Physical, and a Nurse Practitioner, are mostly all I'm allowed to see. Can you help me? I have a few major problems that aren't being addressed. Thanks.

Answer: Typically, I would recommend these type of doctors for follow up, but once you are stabilized, they often will refer you to your primary care physician (PCP). The care you receive may depend more on the experience and personality of a physician rather than the type of physician they are.

A PCP may be your best bet because they can help manage all aspects of your care or refer you to other physicians if they feel there is something they cannot handle. The problem with a specialized physician is that sometimes they will only manage one aspect of care but not want to deal with other aspects. Sometimes physicians will push treatments or techniques that they are most familiar with and aren't really interested in a patient's opinion about the treatment (e.g. your experience with botox).

Family medicine doctors, internists, general practice doctors and geriatricians are all examples of primary care physicians. The best way to find out if someone would meet your needs may be to call their offices and question their office staff. If they truly listen to your concerns and give feedback as to the services they can offer you, then that is a good starting sign. If they dismiss you and can't answer questions over the phone or say they'll call you back and don't, then don't bother. Basically, you interview the doctor's office before even setting up an appointment. I would also look online for reviews which can be helpful in letting you know about a doctor's rapport with patients and the type of services they offer. You could also search online for doctors that deal with long term follow up after stroke and see what is offered in your area.

Hemiplegia on right side seeking one to one personal training

by Emma
(Northern Ireland)

Question:I am a Personal Trainer and have had a young woman approach me in gym asking if she could train one on one with me.

She has minimal grip on right side hand and she is at the gym approx 3 times per week with the staff helping her on some resistance machines but when they are not available she has no option but to walk on treadmill or stationery cycle.

I am wondering what is the correct advice for me to give her. Shall I simply suggest occupational/physical therapist?

Obviously I am not qualified in this field however I do not simply want to tell her I cant help her and leave it at that.

She primarily wants to do resistance training but I understand grip is primary.

Please could someone give me some advice as I don't want to let her down.

Thank you in advance.

Answer:: There are devices that can help wrap a hand to a device for grip, however, you would need to make sure that there is enough strength in the wrist and other arm muscles to use the equipment without getting injured. I've often thought that gyms or workout centers for individuals with handicaps are needed. These individuals can only be in therapy for a short period but have to live with their disability their entire life.

Here are some websites with grip assist devices:

http://gripeeze.com/

http://www.easierliving.com/holding-mitt.html

http://www.lwgripgloves.com/

http://www.activehands.com/

Stroke

by Candace
(Chicago)

Question:My father in law suffered stroke a week ago. Dr said full recovery, he was tranferred to rehab. Since then he is going downhill, cant use right arm, difficulty walking, swallowibg. Now he has pneumonia and they said he might need a feeding tube. Shouldn't he go back to hospital?

Answer: If it was my relative, I would request that he be transferred to a hospital to be examined further.

Post-rehab Exercise and Personal Training

by Michelle S.
(Wrightwood, CA)

Question: I am a personal trainer who has met with a woman who had a stroke seven years ago and has severely limited use of her left arm and leg. She's been cleared by her doctor and OT for all types of exercise that she wants/can do. I've read through your website -- very helpful and informative -- and would like to ask what advice you can offer as I work with this woman. She was extremely fit and active pre-stroke and has a strong desire to increase function and muscle mass. What precautions should I take, specific to her condition? I welcome any and all advice -- be it physical or psychological in nature -- on how best to help her improve her quality of life. Thank you for your time and input!

Answer: I would not be able to give you precautions specific to the individual because each person is different in how they are physically affected and what pre-existing conditions they have. In general when working with a stroke patient, I would recommend monitoring blood pressure and heart rate. I would be careful with the affected shoulder especially with activities above 90 degrees of shoulder flexion as the shoulder blade may not be rotating properly to allow shoulder flexion/abduction above this range (this will need to be evaluated). Obviously the range of motion of a stroke patient will often not be the same as a client that has not had a stroke so be aware of range of motion limitations and pain. With limited use of the arm and leg, there will be balance issues, and the individual will be a higher fall risk. Stroke patients often have poor endurance due to lack of cardiovascular conditioning, so it is important to include some type of cardiovascular work. You can view recommendations for exercise for stroke patients at https://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_463975.pdf

Sensory overload

Question: I've had 2 hemorrhagic basal ganglia strokes 7 weeks ago. I'm in OT and speech therapy and doing well but I can't handle too much stimulus! Busy places and bright light all gives me anxiety and wears me out! I have not gone back to work yet! Will this go away? It seems like I can only do one thing at a time. I go into overload when too many things happen around me! The anxiety can be debilitating ! Thanks

Answer: I wish I could give you a definitive answer, but only time will tell if it will go away. 7 weeks is still early on in the stroke recovery process, so I would give it time. You can always request less stimuli while doing therapy, and gradually increase the stimuli as time progresses. You might first start in a room by yourself and the therapist with dimmer lights, then move to brighter lights, then move to the door opened, then move to a secluded part of the therapy gym, and just keep progressing until you have the hang of it.

Why Can't I find Neuroplasticity Information in Israel?

Question: Hi, there is very interesting information here, but it is also sad because I cannot find anything in Hebrew. That means no one in Israel is using the neuroplasticity knowledge.

Currently, after reading some here, I'm looking for equipment to use for a hand that was badly effected. Maybe this will lead to introducing it to others in need over here.

Let me add that if you had some type of spell correcting tool for non natives, it would be helpful as many may feel unsure of typing in English. Thanks.

Answer: Hello, and thank you for your questions and comments. I check every submission before posting it on my website, and I correct grammatical and spelling errors. This means that people do not have to worry about misspelling or using the wrong words because I will ensure that it makes sense and has correct spelling/grammar.

As far as your question about a hand device, I am obviously not as familiar with rehabilitation in Israel, however, I am aware of a robotic hand device that a company and therapists use over there. In fact, I learned about it from a girl who was in the US. Her therapist was in Israel and helped her use the product communicating via online video. The website where the product can be located is:

http://www.meditouch.co.il/he

This link is the Israeli version, but they also have English interpretation if there are English speakers who want to read about it. Maybe you can contact this company and find out about therapists in Israel that use it. They may have info about therapists in Israel that are familiar with neuroplasticity research as well. I'm sure the information is there - it's just a matter of finding it.

If you find good information about stroke rehab in Israel that you would like to share with others on my website, please let me know.

Can I get another stroke on the same side?

by LC
(Los Angeles )

Question: Can I get a stroke on the same side again? My left side was affected, but I keep getting a tingling feeling on my face too, so I don't know if it's happening again or if this is normal.

Answer: You can experience a stroke on the same side. If this tingling feeling comes and goes, it may be a result of the initial stroke. If you just started this tingling feeling, and it is new (in the past few hours or days), then I would call your doctor or visit an ER to make sure that it's not an acute event. If it has been going on for a while (weeks to months), then it probably doesn't warrant an ER visit, and you can schedule a doctor's appointment to determine causes and possible treatment. The doctor's office can help you decide if you need to come in immediately or not.

STROKE REHAB STATUTE OF LIMITATIONS

by Rodolfo J. Valencia Sr.
(Fontana, Calif.U.S.A.)

Question: I suffered a stroke(cva) August 2004 at age 62. I have left side paralysis consisting of left arm & hand spasticity and left foot-drop.I had virtually no rehab as I was told initially there was virtually no hope of recovery other than a possible spontaneous recovery that would occur in the first few months after the CVA IF AT ALL. Because of this medical prognosis and my own feeling that I would probably not survive for long, I haven't looked for or expected any help with my condition. Well that's been 14 years of a very difficult life since. Since I'm not really on my deathbed yet, I've decided to look into whether the medical profession has made any progress along these lines in the last dozen years. What I'm looking for is information as to what medical specialty I should look into for any help.

Answer: You can absolutely ask a MD to write orders for physical and occupational therapy. It doesn't matter how long ago your stroke occurred. Once you have orders, you can contact a facility and they will let you know what insurance will or won't pay and what cost you might incur. Many stroke patients come back for repeated bouts of therapy as recovery can often be a long term process. Make sure you find a PT and OT experienced in working with stroke patients and someone that will push you. This is imperative so that you can get the best results.
I highly recommend doing research into a facility and its therapists before determining where you will go.

Massive Stroke

by Nancy Fenn
(Apple Valley, Ca)

Question: Hi I am asking if after 8 years from a Massive stroke leaving someone without the ability to Walk or Talk, is it possible for any kind of therapy to help re-connect the brain through electrical response to cure that original inability. I ask because I was approached by a friend to help financially for a person that my husband and I knew in High School and suffered a massive stroke and they claim that this Wellness Company has the ability to electrically stimulate and that his walking and talking can come back...Please advise...

Answer: I would be leery of such claims as there is no machine that can miraculously cure a stroke victim. There may be experimental devices that are being tried and there may be devices out there that could help patients make some improvement, but to claim that walking and talking can come back is not something that I think any reputable company would advertise.

Flushing and heat rash

by Cathy
(Reno, nevada)

Question My goddaughter, 25, is recovering from a right brain aneurysm and stroke. She is complaining of sudden warmth then a rash from the heat. Then symptoms disappear then return. Driving us nuts trying to figure this out. Any ideas?

Answer A stroke patient can be at risk for skin issues if they are not moving around or are staying in the same position for a while (e.g. sitting or lying down for a longer time). If there are bowel or bladder issues, this can cause skin issues as well. Lack of regular hygiene could also be a problem. If someone is taking new medications, there could be skin reactions related to this, so check with the MD or pharmacist to see if this might be the case. Though very rare, there have also been allergies to the metals used in surgery for aneurysm clips. Other things to consider is new clothing or new soaps/detergents used, and where clothing is hitting the skin (in this picture the rash looks close to the band of the pants).

Regardless of what the cause may be, follow up with her MD or a dermatologist. It would help to know exactly when the rashes started, any new meds with dates taken, when the allergy worsens, etc., so that you can narrow down a cause. Here is an article regarding skin care after stroke:

https://www.sralab.org/lifecenter/resources/skin-care-after-stroke

How to Make Neuroplasticity Repeatable On Demand

by Dean Reinke
(Michigan, USA)

Submission from reader: Neuroplasticity is widely touted as a way for stroke survivors to recover. To make it repeatable on demand, what exact signal is being sent from one neuron to a neighboring neuron, saying; 'Drop your job and help me with mine'. If we know what triggers that process, we can make it repeatable. Right now everything about neuroplasticity is just guesswork. We should be able to listen in on neuron signaling via this:

NeuroGrid:recording action potentials from the surface of the brain/

Or this: Use nanowires to listen in on single neurons

Or this: New brain implant device could record activity in thousands of neurons; Stanford University.

I'm just an 18 year stroke survivor writing Deans'Stroke Musings, you won't like me, but then you'll want to 100% recover when you are the 1 in 4 per WHO that has a stroke. 100% recovery is the only survivor goal in stroke.

Comment from Stroke-Rehab: It's estimated the brain has 80-100 billion neurons and each neuron can make connections with 1000s of other neurons. It's a vast network and very intricate. Technology still has a way to go when it comes to figuring out the mapping process and neurogenesis. AI should be able to help though. There will be a lot more learned in the upcoming years I'm sure, but unfortunately, that doesn't help current stroke survivors. You might find these articles interesting:
https://hms.harvard.edu/news/new-field-neuroscience-aims-map-connections-brain

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10473303/

www.ncbi.nlm.nih.gov

Range Of Motion for Rep for Exercise

Question:How much of the range of motion for the arm should be used for exercising? Or what do you recommend would count as a good "rep" to be used to count reps?

Answer: My response to that question would depend on the movement available to the patient. If I was working with a stroke patient that had regained movement and function and was simply needing a strength building routine then I would use exercise reps used in the general population for strengthening which is often 10-20 reps for several sets.

If, however, the patient has impaired movement/coordination, paralysis or only partial movement (which is the case with many stroke patients) then I would recommend hundreds of repetitions of functional movement each day since large amounts of repetition is needed for neuroplastic changes to take place in the brain. This would not be in the form of exercises like bicep curls but rather in repetition of functional activities that the patient wants to be able to do such as picking up objects, moving objects from one place to another, combing the hair, brushing the teeth, etc. Basically, there is no one size fits all answer to your question, but if you are looking to have a stroke patient regain movement and make neuroplastic changes in the brain, then there will be a lot of practice and repetition needed. Results will vary depending on the patient's existing movement, motivation, and the complexity of the task they are trying to complete.

How to Improve Stroke

by Sultan
(UK)

How do you improve patient's hand, fingers, and leg movement? Please tell me some exercises for my mother. Thanks.

Answer: If your mother already has some movement in her hand and fingers then I would recommend some of the exercises from this website's hand exercises page at www.stroke-rehab.com/hand-exercises.html.

If she does not have any movement or only little movement in her hand, then I recommend trying to put weight through the arm to facilitate sensory input. This can be done by placing the hand on a firm surface and helping to support her elbow while she leans into the hand. When there is little movement in the upper extremity, it's best to eliminate gravity as much as possible and provide assist as needed. I often place the hand on a ball and see if the patient can elicit movement. If approved by her MD, you could talk to a therapist about using electrical stimulation to facilitate movement.

Some simple hand and arm exercises I use after a stroke are as follows (stretch the hand prior to exercises):

1) Place patient's open hand on ball and have them work on just keeping the hand on the ball without assistance

2) Once they can keep the hand on the ball, try rolling the ball gently side to side and forward and back

3) Once they can roll the ball, place both hands on the sides of the ball (soccer ball works well) and try to lift the ball off their lap using both hands and without the weak hand falling off

4) As they are able to lift the ball, work on lifting the ball higher or moving it side to side

5) Work on taking weak hand off the ball slowly and with controlled movement

6) Once they can move hand off/on ball with some control, work on placing hand on smaller objects such as a plastic cup and letting go. Progress to trying to lift the cup.

Some other options to help facilitate return of the hemiplegic arm include using e-stim with a therapist or tapping the muscles you are trying to stimulate. If trying to close the hand, turn the palm up and tap the forearm muscles. If trying to open the hand, turn the palm down and tap the back of the forearm.

Weight bearing is also good for the leg. If your mother is able to stand, have a therapist show her how to shift weight onto the weak leg and work on weight bearing on the affected side. A physical therapist can also show you tapping techniques to help facilitate movement. For example, to elicit straightening the knee, you would tap the top of the thigh.

If you are looking for therapy ideas, I suggest looking on You Tube for stroke rehab exercises. Many therapists and patients have recorded their therapy sessions which might give you ideas on what would work for your mother. You should always consult a therapist or physician that has worked with your mom to make sure any exercises would be appropriate for her.