F33 PHYSICAL EFFECTS OF STROKE



Physical effects of stroke

Stroke can cause many different problems including difficulty with speech, concentration, memory or tiredness. But the most common effects of stroke are physical ones such as weakness, numbness and stiffness. This factsheet describes these effects and their treatments in more detail.

The brain controls everything we do, including the way we move. It is divided into two hemispheres, left and right. The left hand side of the brain is mainly concerned with language and movement on the right hand side of the body. The right hand side of the brain controls the left hand side of the body.

Nerve cells (sometimes called neurons) are stimulated by the brain and send electrical messages to our muscles to stimulate them to move. If the brain cells controlling those nerve cells are damaged by a stroke, the messages can’t be sent, and muscles can’t move.

What are the physical effects of stroke?

Weakness and paralysis

Weakness of an arm, leg or both is probably the most common and widely recognised effect caused by stroke, with 80 per cent of stroke survivors experiencing problems with movement. Weakness can vary in its severity. Some people have very mild weakness in one part of their body, for example their arm, leg or face. But for many people it affects one whole side of their body. This is called hemiparesis.

Paralysis differs slightly from weakness as it describes the loss of the ability to move a part of your body. The term hemiplegia is used to describe paralysis of one whole side of the body.

Having weak or paralysed muscles can affect your movement. For example, if you have weakness in your leg, you may find it difficult to get out of bed, to stand or to walk. Arm weakness can make it more difficult for you to do daily tasks such as washing and dressing.

Some people also have problems with balance after a stroke. For more information, see our factsheet F22, Balance problems after stroke.

Some people find the physical effects of a stroke painful. For further information on coping with pain, please see factsheet F30, Pain after stroke.

Spasticity

Spasticity is a condition that can develop if you have weakness or paralysis after your stroke. It is a form of muscle tightness - your muscles become tense and can contract abnormally.

Muscles need some sort of tightness (called muscle tone) as without this they would be floppy and not able to work. Following a stroke, a muscle may have very low tone when it is very weak, for example you may not be able to hold your arm up without support. If muscles recover, it is expected that the tone will increase to normal. However, some weak and damaged muscles develop high tone. The muscle feels stiff and tight, and can become painful. This is called spasticity. It can happen when you are resting, or might affect you when moving the muscle.

Getting moving early after a stroke is one of the cornerstones of good stroke rehabilitation on the stroke unit, and the therapists and nurses will work hard to keep your muscles moving as much as possible to avoid spasticity. However, it can develop later, for example after you are discharged from hospital.

If untreated, it can cause pain and discomfort, stiff muscles and joints, difficulty with walking and other movements. Rarely, it becomes permanent, in what is called “contracture”.

If you think your muscles are getting stiff and tight, even if you have been discharged from hospital, ask to see a physiotherapist who can assess you and discuss the best treatment plan for you.

Problems with positioning your feet

‘Drop foot’ describes the inability to lift the toes and feet properly when walking. As a result of this, your toes may catch on the ground as your foot is swinging forward. This can make walking more difficult and may increase the risk of a trip or a fall occurring.

Sometimes if your calf muscles are tight, poor foot position can cause the knee to be forced backwards when standing or walking, and can lead to balance problems and instability.

The increased effort that you may have to put in can result in your walking being slow and tiring, with the possibility of it being unsafe at times due to the increased risk of tripping or falling. It can also lead to a further increase in spasticity.

Changes in sensation

There are various ways that stroke can affect your senses.

• You may be less sensitive, for example to touch, so may not feel something you bump into. This is called hypoesthesia.

• You may have increased sensitivity. This can affect a range of senses such as taste, hearing, touch and muscular sensitivity to pain. This is called hyperesthesia.

• You may experience abnormal and unpleasant sensations such as the feeling of burning, cutting, tingling, stinging or numbness. This is called dysesthesia or paresthesia.

What are the treatments for physical effects of stroke?

How much recovery you will make after a stroke, and how long this takes is different for everyone. It depends partly on the amount of damage done by the stroke, and your general health before the stroke. Recovery tends to be fastest in the first few months after a stroke, but many people continue to notice changes and improvements over many months and even years.

The role of the stroke team

The earlier the rehabilitation process begins the more likely you are to regain lost skills and abilities. Recovery from a stroke depends on undamaged parts of the brain learning to take over the functions of the damaged parts.

Early treatment on a stroke unit makes a big difference to your recovery. Everyone admitted to a stroke unit will have an early assessment by the nursing and therapy teams. This will include an assessment by the physiotherapist and occupational therapist, as well as other members of the team as necessary (for example a speech and language therapist).

Weakness and paralysis

Stroke rehabilitation aims to help you to recover as much as possible and enable you to learn how to manage with any remaining difficulties, using exercises appropriate for you. Nurses, doctors and therapists work together on the stroke unit to assess the degree of muscle weakness you have, and how best to improve it.

Anyone with physical effects after a stroke should be assessed by a physiotherapist as soon as possible. Physiotherapy aims to help you to regain as much movement as possible and enable you to learn how to manage with any difficulties, using appropriate exercises.

Occupational therapy aims to help you to carry out daily activities and maintain your independence. Therapists may also be involved in providing you with specialist equipment when you go home.

Occupational therapists and physiotherapists will often assess you at the same time, to look at the amount of weakness and how it affects your daily activities, and to plan a programme of exercises.

The therapy team will work with the nursing staff to ensure that you can get out of bed as soon as it is safe to do so, and to start a programme of early mobilisation as soon as you are ready. They will also make sure that your weak limbs are in the best possible position to remain comfortable and to avoid problems, for example supporting a weak arm on a pillow to avoid shoulder pain.

The stroke team will talk to you about how best to keep your muscles supple, even when they are not working very well.

In the early stages of stroke, the team will often focus on helping you to sit up safely, and then move on to helping you to stand and then start to walk safely, perhaps with a walking aid. They may also look at other tasks such as dressing, eating, bathing and using the toilet.

You may also be given exercises to practise between therapy sessions, or your family can be given ideas as to how to keep your muscles supple. The occupational therapist will encourage you to carry out daily activities and maintain your independence. Initially they will do a detailed assessment of any problems you may have, assessing both movement problems and taking into account any additional problems that may affect your recovery, for example memory problems. The stroke team will help you to devise strategies to manage all the activities that you need to carry out after you leave hospital. They will work alongside you and your family to ensure you get the right equipment and support.

For further information please see our factsheets F16, Physiotherapy after stroke and F17, Occupational therapy after stroke.

Treatments for spasticity

There are several treatments for spasticity and early intervention by trained specialists can, in many cases, avoid spasticity developing.

If you think your muscles are getting stiff, talk to your physiotherapist (even if you have left hospital) about how to avoid spasticity. He or she may suggest how best to position your limb to reduce muscle tone, and may suggest some exercises. If more treatment is needed, sometimes an assessment from a specialist physiotherapist or a consultant in neurorehabilitation may be useful.

There are some drugs that can be useful to reduce muscle tone in spasticity, but these need to be prescribed by a specialist who understands all their effects and how they might help. These drugs include:

• Baclofen - this drug belongs to a group of medicines known as muscle relaxants. Baclofen also works on the central nervous system to relax the muscles.

• Gabapentin - an anti-convulsant drug which acts on the brain cells and dampens down electrical activity.

• Tizanidine - is used to decrease spasticity similarly by working on the central nervous system. It is suggested that these drugs cause less muscle weakness than Baclofen, which can be important for patients who are trying to regain physical strength.

Botulinum toxin (commonly known as ‘botox’) can help spasticity that affects only one or two joints (called focal spasticity). It works inside the nerve pathways by blocking the release of the chemical that stimulates muscle contraction. This can then help create temporary muscle weakness. In England, Northern Ireland and Wales this can be used as a treatment for spasticity. Botox is not currently recommended for use within the NHS Scotland for the treatment of spasticity.

The botox is injected directly into the specifically selected muscles and generates temporary relaxation and weakness of the muscles. You will gradually see effects from this treatment over the following 4-7 days, however in some cases this may be longer. The weakness in the muscles can last for about 3-4 months before the muscles recover their activity and the process will need to be repeated. It is suggested that the benefit from this type of treatment can continue for many months, particularly when it is accompanied by physiotherapy, however the effects then gradually wear off.

In severe cases of contractures, surgery to release tendons may be carried out, but this is rare.

Treatments for walking problems

An Ankle-Foot Orthosis (AFO) is a type of foot brace, usually made of plastic that can help with standing and walking. AFOs are designed to compensate for muscle weakness and spasticity and can improve the function and alignment of your whole leg, by controlling the position of your foot and ankle. They can improve your walking speed, stability and balance.

Some AFOs are ready made, but these are not suitable for more complex walking problems. In these cases an individually made AFO is necessary.

You may be referred to an orthotist who is a qualified rehabilitation professional, for advice on whether an AFO may be appropriate for you, and to provide you with the most suitable type. However this treatment is not suitable for everyone, so alternative solutions may need to be considered.

Functional Electrical Stimulation (FES) is another method of treating drop foot. FES uses small electrical signals to replace the nerve impulses that have been interrupted by damage to the brain. Electrical stimulation is applied either to the skin by surface electrodes or alternatively by implanted electrodes.

A specialist physiotherapist or consultant in neurorehabilitation will be able to refer you to an appropriate specialist in FES although it is not suitable for everyone. This will be determined by a physical examination that takes place in your initial assessment. If you are suitable for this treatment you will then be asked to attend again for two days to learn how to use the device. After this you will then be asked to return to the clinic for follow-up assessments, at regular intervals.

Treatment for changes in sensation

There is very little research into changes in sensation after a stroke. Unfortunately it is unlikely that any treatment will help to improve any changes in sensation, however often these sensations improve in time. This can take longer than recovery from other effects such as problems with movement. If you have any changes in sensation, but your movement is good, you should be taught how to take care of your limb to avoid any accidents or injury.

Useful organisations

All organisations are UK wide unless otherwise stated.

Stroke Association

Stroke Helpline: 0303 3033 100

Website: .uk

Email: info@.uk

Contact us for information about stroke, emotional support and details of local services and support groups.

The British Association and College of Occupational Therapists (BAOT or COT)

Tel: 020 7357 6480

Website: cot.co.uk

The professional body for occupational therapy.

The professional body for Prosthetists and Orthotists in the UK.

The British Association of Prosthetists and Orthotists

Tel: 0845 166 8490

Website:

Chartered Society of Physiotherapy

Tel: 020 7306 6666

Website: .uk

Has a register of therapists who are members of the Association of Chartered Physiotherapists interested in Neurology (ACPIN).

HemiHelp

Helpline: 0845 123 2372 (open from 10am to 1pm, Mon-Fri during term time)

Website: .uk

Supports children and young people with hemiplegia, and their families.

National Clinical Centre for FES

Website:

Offers more information about FES.

Physio First

Tel: 01604 684 960

Website: .uk

Offers details of private therapists specialising in neurology.

Disclaimer: The Stroke Association provides the details of other organisations for information only. Inclusion in this factsheet does not constitute a recommendation or endorsement.

Glossary of terms

AFO = Ankle-Foot Orthosis

Contracture = abnormal shortening of a muscle that results in deformity

Drop foot = the inability to lift the toes and feet properly when walking

Dysesthesia or paresthesia = abnormal and unpleasant sensations

FES = functional electrical stimulation

Hemiparesis = weakness of one part of the body

Hemiplegia = paralysis of one part of the body

Hyperesthesia = an increased sensitivity that can affect a range of senses

Hypoesthesia = a dulled sensitivity to touch

Spasticity = a form of muscle tightening

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|Produced by the Stroke Association’s Information Service. For sources |[pic] |

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|© Stroke Association | |

|Factsheet 33, version 05, published December 2010, updated April 2012 | |

|(next revision due March 2013). | |

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|Stroke Association is a Company Limited by Guarantee, registered in England and Wales (No 61274). Registered office: Stroke Association |

|House, 240 City Road, London EC1V 2PR. Registered as a Charity in England and Wales (No 211015) and in Scotland (SC037789). Also |

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