These articles first appeared in Different Strokes.
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March 2008

My physiotherapist has recommended Pilates to strengthen my core muscles but the thought of attending a class with able bodied people fills me with dread and embarrassment, and getting on and off the floor is very difficult. Do you have any advice?

Pilates has developed to assist in the rehabilitation of injured solders from WW1. It is focuses on improving posture, flexibility and breathing using gentle exercises and stretches.

It can be a particularly beneficial form of exercise for stroke survivors as it’s usually the postural muscles – back, tummy, bottom and hip – that are affected. Improvements in these muscles can lead to improvements in walking. The breathing exercises can assist with shoulder pain and help arm recovery. Some of the shoulder muscles are called upon to assist breathing, but over a longer period, this can cause pain and interfere with recovery.

The exercises are not always performed lying on the floor. Many exercises are done sitting and standing. There are even special Pilates exercise “benches” the user lies on. Pilates can be done as part of a group, or with one to one supervision. I would suggest visiting a couple of classes and meeting the people attending. You could find a group that is welcoming and supportive. Indeed you may even find a small group attended by fellow stroke survivors.

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December 2007

Eight months after my stroke I started to have severe pain in the affected foot when standing or walking due to my toes curling. The pain has spread to the ball of my foot and is excruciating - is there anything I can do to relieve it?

Toe curling is often due to the individual either ‘gripping’ with the toes to help with balance, or trying to lift the foot at the ankle using the ‘toe-lifting’ muscles rather than the ‘foot-lifters’. In both cases, the ball of the foot is pushed down against the sole of the shoe or floor and is painful.

Your Physiotherapist should be able to show you stretches that lengthen the muscles on the underside of your foot. They can refer you to a Podiatrist (foot specialist) who can provide you with an insole for your shoe with a soft pad (‘met-raise’) under the ball of your foot that lifts up this area and relieves the pain.

They can also make you a support from soft putty (like blue tack) that goes under and between your toes and blocks the curling.

Alternatively, Botulinum injections to the small muscles of the foot can be a very effective way to stop the muscles from clawing.

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July 2007

I get terrible clonus (involuntary muscular contractions) if I cannot get my heel down so anything I do barefoot, like a shower, is very tricky. I've heard that in America they cut the Achilles tendon, which seems rather extreme - is there anything else that might help?

You have clearly identified the cause of these involuntary muscular contractions which is the difficulty some stroke survivors have in getting the heel of their affected leg flat on the ground. This is most often due to shortening and/ or spasticity in the muscles of the calf. Barefoot standing puts additional stress on these muscles as the heel is not supported.

Clonus can occur in standing and also in sitting and can be troublesome for wheelchair users as their affected foot "bounces" off the foot plate.

Many people have found that by wearing plastic boating shoes in the shower, they have sufficient support for the heel and the clonus does not occur. I would recommend seeking a course of Physiotherapy to learn how to stretch these muscles so you can lower your heel to the floor.

With regards to surgery, a less extreme option would be having the affected muscles injected with Botulinum toxin, and wearing a series of splints that put increasing stretch on the calf muscle until the heel reaches the ground. This often takes between 3 and 6 months. This would require a referral to a Consultant Physician or Neurologist who specialises in such treatment.

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March 2007

I find that the toes of my affected foot catch on the ground and sometimes make me trip. I have been told that I have a ‘dropped foot’. What is this and can it be helped?

The muscles that help lift your foot at the ankle are often weakened following a stroke causing the foot to ‘drop’ (floppy foot).

In some individuals, the muscles in their calf can get very tight which forces the foot to point down (spastic foot/ ankle).

A plastic ankle splint (Ankle Foot Orthosis/AFO) can help keep your ankle at the correct angle so that the foot does not catch on the ground. The thickness and hence strength of the AFO depends on whether the foot is floppy or spastic.

Other special devices can help. The Foot- Up uses an ankle strap and a piece of strong elastic fixed under the shoe laces to lift the foot more naturally.www.technologyinmotion. com

The Odstock Drop- Foot Stimulator uses a discreet electrical muscle stimulator triggered by a small switch under the user’s heel to activate and potentially strengthen the weak foot-lifting muscles. www.odstockmedical. com

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December 2006

After seeing my physio today, I have a very stiff left shoulder, which has been trying to compensate for a weak hand; she has given me a rotator cuff strengthening band. Can you tell me how this works?

Muscles work often in pairs. For example, the muscle at the front of your upper arm brings bends your elbow. The muscle at the back of your arm straightens it. After a stroke some muscles become short and tight whilst the opposite muscle becomes longer and weaker. The strengthening band will enable you to strengthen the weaker muscles around your shoulder whilst stretching the tighter muscles.

You might want to ask your Physio about providing a shoulder pulley. This has two handles and a length of cord that runs through a pulley which can be hung over a door. It would enable your right hand to lift up and stretch your affected left shoulder. Another device would be the Saeboglide which is a plastic pole with a sliding sleeve that would also enable you to stretch your shoulder and strengthen your grip.