Ask the Experts

These articles first appeared in Different Strokes.
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October 2009

My husband had a massive stroke two years ago and we have worked very hard with his rehabilitation. He is walking with a stick etc., positive and motivated. However his arm and all surrounding muscles are fine but....his arm is being pulled in by a muscle which causes a spasm which seems to come from his chest if he sneezes or coughs. I have asked all the physios for exercises etc., which we have done every day yet nothing seems to work very well because the spasms although not too bad now seem to undo all the hard work, we do not want baclofen or similar drugs but we want to get his arm moving more than it is.

A common problem after stroke is that people experience strong spasms following coughs, sneezes or even fits of laughter. At other times, the effort of rising from a chair or walking can also cause them.

These spasms most commonly occur in the arm. They can just affect the muscles that close the hand causing the hand to clench into a first, or they can affect the whole arm causing it to clamp tightly against the person's body. In the affected leg, these spasms can cause the foot to turn in or the whole leg to shoot out straight.

When these spasms occur frequently, the muscles that go into spasm can become tighter overtime - even at rest. Stretching the muscles regularly will prevent this complication. I would strongly advise that appropriate stretches are taught by a specialist Neurological Physiotherapist following a thorough assessment to avoid injury and ensure success. By improving the way the person rises from sitting, or their walking technique, these spasms can be reduced in intensity or even prevented.

October 2009

I suffered a stroke earlier this year and I am up using a stick but my arm is still very weak using Saeboflex. I have been told me that it takes the brain a year to start to heal and that they felt better after a year is this fact or fiction?

Historically, it was believed that once the brain was damaged, it could not be healed. Research over the last 25 years has shown that the undamaged parts of the brain can learn how to do the functions that the damaged part can no longer perform.

Immediately following a stroke the whole brain can be in shock, so even the affected side can appear weak. There is also swelling around the damaged area. This swelling interferes with the functioning of the neighbouring brain centres and exaggerates the initial effects of the stroke.

Much of the early recovery following a stroke is the brain coming out of shock (few days), and the swelling reducing (few days to a few months). Thereafter, recovery involves the undamaged part of the brain in the learning how to perform the tasks that the damaged area used to do. This learning process can go on for many years after the stroke.

Depending on the severity of the stroke, many people "feel better" after a year, for others it may be quicker, but for some much longer. I have seen progress in stroke survivors 5 or 10 years after their stroke. Exercising, whether as part of a Different Strokes exercise class, or using a device such as the Saeboflex has a vital part to play in recovery.

July 2009

My recent stroke has caused my face to drop on one side. As a result I have trouble eating and am dribbling. My face feels like it has been numbed by the Dentist. Are there any exercises or massage that would help speed recovery?

Jenny Carkeet of Physiofunction: It is common following a stroke for your face to drop on one side causing facial asymmetry, difficulty in forming words and dribbling when eating and drinking.

In the initial few weeks it is important to: massage the face with strokes towards the ear, support the cheek on the affected side with your hand whilst talking, ensure that the affected side of the mouth is clean as food can become lodged between the gums and cheek, use a straw to aid drinking but ensure it is placed in the centre of your mouth and complete the lip seal with finger pressure and not to over emphasise the movements of the unaffected side.

If spontaneous recovery does not occur within the first few months and muscle wasting has occurred you may need to use Trophic Electrical Stimulation (TES) to improve the health of the muscle and to remind your brain that you have two sides to your face. A small and portable machine will deliver pulses to your face by means of small electrodes and is used between 1 to 3 hours daily.

You will need a facial assessment by either a physiotherapist or speech therapist to decide which parts of your face need treatment and agreed progression points.

December 2008

I am suffering from a loss of tone in my fingers, so much so that they are starting to stiffen and stick up (a form of Dystonia I think). Are there any exercises that would help?

One of the immediate effects of a stroke is a lowering of muscle tone. This makes it very difficult to take up the slack in the muscles and the person struggles to perform the desired movement.

As the brain starts to recover the muscle tone increases – in many cases to the point that normal use returns. Other times, the tone can come back partially giving rise to uncontrolled movements – this frustrating condition is referred to as dystonia. However, more commonly, either: the tone can increase dramatically with effort, coughing and sneezing and then become floppy again; or the tone remains very much increased and the muscle remains in its shortened/ activated state.

If you indeed have dystonia, then gentle stretching of your fingers to bend them into a “fist” might help. I would recommend asking your GP to refer you to an Occupational Therapist who specialises in hand therapy who could show you some more specific exercises and maybe prescribe a lycra glove which will help control the dystonia. You do not mention whether your hand is painful, or whether you also have a problem with your shoulder. Sometimes, stroke survivors with very stiff shoulders can develop a problem with the joints and circulation in their hand. If this is the case, I would recommend a thorough review by your GP.

August 2008

My stroke has been the cause of severe pain, which has recently been diagnosed as central nervous pain. Would physiotherapy help?

Pain can be a very common occurrence following stroke. The most frequent area where stroke survivors experience pain is in the shoulder on the affected (weak) side, but hips and knees can also become painful.

There are a number of potential causes. Sometimes old injuries or joint complaints become troublesome again. This is because the muscles around the joint may not be providing adequate support which in turn puts strains on some of the ligaments or increases the pressure across tender parts of the joint.

New injuries can occur as the affected muscles may struggle to protect vulnerable joints against over stretching either by the person themselves, care staff or therapists.

The sensation of pain can be exaggerated following a stroke either in overall intensity or in terms of the total area over which pain is felt. A rarer source of pain is Central Stroke Pain, which occurs when a particular part of the brain called the Thalamus is affected by the stroke. This area is a relay station passing on information to the rest of the brain about temperature, touch, joint position and pain.

When this area is damaged, the stroke survivor can experience severe and unrelenting pain affecting their whole arm, leg or side of the trunk. A thorough examination by a Physiotherapist can rule out whether the pain is from a joint, ligament or muscle. Physiotherapy and perhaps injection therapy can most often resolve these; unfortunately, physiotherapy can do little to help Central Stroke Pain and it normally requires medical or surgical intervention.

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.

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.

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.

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

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.