Regaining Function After A Stroke: Is It Possible?

A stroke is a brain injury that occurs when the blood supply to the brain stops, and it is the leading cause of disability in the US. The effects of a stroke vary from person to person, but can include physical symptoms such as weakness, paralysis, and difficulty with balance or coordination, as well as emotional symptoms like depression and impulsivity. The faster you receive treatment for a stroke, the better your outcome is likely to be. But can you regain function after a stroke?

Rehabilitation exercises for the hand and arm

Overview

Stroke rehabilitation for the hand and arm involves passive movements done with the help of a therapist and more active exercises done with little or no assistance. The two main goals are to enhance muscle control and reduce spasticity—the constant contraction of muscles that can lead to pain and other problems.

Passive Movements

Passive movements are performed with the help of a therapist and are important for preventing muscle shortening and joint stiffness. They include:

• Range-of-motion stretches: Using the unaffected arm to produce the forces needed to move the disabled arm.
• Thumb and finger stretches: Using the unaffected hand to stretch the thumb and all the fingers on the affected hand.

Active Exercises

Active exercises are performed with little or no assistance and are important for improving muscle control and reducing spasticity. They include:

• Strengthening exercises: Using squeeze balls, wrist weights, or hand weights to tone and build muscle.
• Electrical stimulation therapy: Using electrical currents to stimulate the nerves that make muscles contract, helping to regain control over the limb, improve muscle tone, and reduce pain and spasticity.
• Constraint-induced movement therapy: Wearing a restraining device on the functioning arm and using the affected hand and arm as much as possible to perform repetitive tasks, which may increase brain plasticity and help regain function in the affected hand.
• Fine motor skills practice: Performing small, precise movements with the hand and fingers, such as tracing a design with a pen, shuffling cards, using a pegboard, or picking up small beans and putting them in a cup.

Other Techniques

In addition to the above, other techniques that may aid in hand and arm rehabilitation after a stroke include:

• Active-passive bilateral therapy: Performing tasks using both the affected and unaffected hands together, which may help restore balance between the two sides of the brain and improve hand function.
• Robotic devices: Assisting movement and providing more consistent, measurable repetition than conventional therapy.
• Functional electrical stimulation: Generating an electrical current to stimulate nerve activity in affected limbs, strengthening weak or spastic muscles.
• Brain stimulation: Using magnetic or direct current stimulation on the healthy hemisphere of the brain to reduce the activity of overactive neurons and restore balance.
• Biofeedback: Providing a sound or light signal that indicates if muscles are active, which may help create greater awareness of muscle contractions, making it easier to relax muscles and coordinate hand movements.

At-Home Exercises

• Shoulder shrugs: Sitting with feet flat on the floor, shrug shoulders up to ears and count to two, then release. Repeat 10 times.
• Shoulder blade squeeze: Sitting tall, squeeze shoulder blades back and together, hold for two seconds, then relax. Repeat 10 times.
• Table and towel reach: Seated and facing a table, place a washcloth or folded towel on the table directly in front of you. Push down slightly and reach forward, letting the towel slide forward as you reach with a straightened elbow and lean forward. Repeat 10 times.
• Cane or dowel exercises: Using a cane, mop handle, or other dowel-like item, perform various exercises such as pushing and pulling, or bending and straightening the elbows.
• Washcloth squeeze and scrunch: Place your hand palm down on an open washcloth and use your fingers to scrunch it up, then push it open while focusing on extending your fingers. Repeat 10 times.
• Washcloth roll and squeeze: Fold a washcloth in half, roll it up, and squeeze it firmly using all your fingers and thumb. Relax and repeat 10 times.
• Cup flipping: Line up five cups on a table, grasp the first cup, flip it over, and place it back on the table. Repeat with the remaining cups, then twist and turn each cup to grasp, lift, and replace.
• Card flipping: Hold a deck of cards in your good hand and use the fingers of your affected hand to pick up the top card, flip it over, and place it on the table. Repeat until all cards are face up.

Speech and language therapy

Speech and language therapists work with stroke survivors to address specific challenges, such as:

• Difficulty understanding speech (receptive aphasia): Stroke survivors may struggle to understand what is being said to them, requiring assessment and support from therapists to minimise the impact on their daily lives.
• Difficulty expressing themselves (expressive aphasia): Those who experience expressive aphasia have trouble expressing their thoughts and may need assistance from therapists to improve their ability to communicate effectively.
• Difficulty finding the right words (word-finding difficulties): Stroke survivors may know what they want to say but have difficulty retrieving the words from their memory, which can be frustrating and impact their ability to communicate.
• Reading and writing difficulties (dyslexia and dysgraphia): Reading comprehension and writing skills can be affected by a stroke, leading to challenges with literacy and potentially impacting daily tasks such as reading instructions or writing emails.
• Slurred speech or difficulty speaking clearly (dysarthria): Muscle weakness or impaired muscle control can result in dysarthria, causing speech to sound slurred or difficult to understand. Therapists can provide tongue and lip strengthening exercises to improve articulation and clarity of speech.
• Difficulty with the sequence of speech movements (dyspraxia): Dyspraxia refers to challenges with the coordination of muscle movements required for speech. Speech and language therapists can provide targeted exercises to improve muscle memory and help individuals regain control over their speech muscles.
• Swallowing difficulties (dysphagia): Up to 78% of stroke survivors initially experience dysphagia, which can lead to serious health complications if left untreated. Speech and language therapists assess and support these individuals to minimise the risk of aspiration and choking, helping them enjoy food and drink safely.

Physical therapy

Types of Therapy

• Stretching exercises: These promote blood flow and make it easier for the patient to move their arms. Therapists will gently stretch the hand, arm, and shoulder through a full range of motion. Patients can also be taught to use their unaffected hand to stretch the wrist, fingers, and thumb on their affected hand.
• Strengthening exercises: Strengthening the muscles in the hand and arm improves grip and the ability to use the limb. An early exercise involves holding the weak arm with the strong arm and rocking it back and forth. As strength and mobility improve, squeeze balls, wrist weights, or hand weights can be incorporated.
• Constraint-induced movement therapy: This involves wearing a restraining device on the functioning arm, forcing the use of the affected hand and arm to perform repetitive tasks. This therapy is believed to increase brain plasticity and aid in regaining function in the affected hand.
• Fine motor skills practice: Fine motor skills are small, precise movements made with the hand and fingers. These can be improved by performing tasks such as tracing a design, shuffling cards, using a pegboard, or picking up small objects.

Neuroplasticity and Repetition

The brain's ability to rewire neural pathways and connections is known as neuroplasticity, and it plays a key role in stroke recovery. High repetition of specific tasks and movements maximizes neuroplasticity, helping the brain to rewire itself and recover movement. Consistency in performing these exercises is crucial, with daily practice being ideal for optimal results.

Additional Techniques

In addition to traditional physical therapy exercises, there are other techniques that can be used to enhance recovery:

• Electrical stimulation: This technique uses electrical currents via electrodes placed on the skin to stimulate nerves and muscles. It can help enhance neuroplasticity and improve the rewiring of new motor pathways.
• Mirror therapy: This involves placing a mirror over the affected hand so the patient sees the reflection of their unaffected hand. Performing rehabilitation exercises with the unaffected hand while watching the mirror can trick the brain into thinking the affected hand is moving, stimulating neuroplasticity.
• Mental practice: Mental practice involves visualizing the performance of a specific movement or task. This technique can be especially useful for those with limited hand function, as it allows the brain to rehearse and rewire connections for that movement.

Timing of Therapy

The sooner rehabilitation begins after a stroke, the better. In some cases, rehabilitation can start as early as 24 to 48 hours after the stroke, once the patient's condition has stabilized. The first three months after a stroke are the most critical for recovery, with most individuals making the biggest gains during this period. However, it's important to note that improvements can continue for up to 18 months or more, depending on the rehab received.

Occupational therapy

Home Modifications

An occupational therapist can help stroke patients make adjustments to their home environment to ensure their safety and a smooth transition back home after discharge. This can include adding doorknob extenders, using non-slip bathmats, and removing rugs and clutter from the floor to lower the risk of falling.

Rehabilitation Exercise Programs

Occupational therapists can provide targeted rehabilitation exercise programs for patients to practice at home. These exercises are important for stimulating neuroplasticity, the brain's ability to rewire itself, by strengthening neural connections and creating new ones.

Task-Specific Training

Task-specific training involves improving a skill by practicing it directly. For example, an occupational therapist may work with a patient on tasks such as reaching into a cupboard, turning door knobs, or flipping light switches. This form of therapy helps improve functional independence by increasing the use of affected muscles.

Constraint-Induced Movement Therapy

Constraint-induced movement therapy (CIMT) involves restraining the non-affected limb to promote the use of the affected limb. This technique helps stimulate the brain and activate neuroplasticity, reducing the risk of learned non-use, which can lead to further complications such as muscle weakness and atrophy.

Electrical Stimulation

Electrical stimulation is a safe way to stimulate the nerves that make muscles contract, helping to improve mobility and reduce spasticity. It works by placing non-invasive electrodes on the skin and sending gentle electrical impulses to the affected muscles.

Mirror Therapy

Mirror therapy is particularly helpful for patients with hand paralysis or severe hand impairments. It involves placing a tabletop mirror in the middle of the body to reflect the non-affected side and hide the affected side. The patient then completes simple exercises with the non-affected side while focusing on the image in the mirror, stimulating the parts of the brain associated with movement.

Mental Practice

Mental practice involves mentally rehearsing a movement, which can spark changes in the brain similar to those produced by physically practicing movements. For example, a patient with limited mobility in their right arm can picture themselves moving their arm to grasp a cup of coffee. This mental exercise can help strengthen the neural connections for that movement and make it easier to physically execute.

Activities of Daily Living Training

Occupational therapists can help patients practice activities of daily living, such as eating, bathing, and getting dressed, and provide adaptive strategies and equipment recommendations to improve safety and independence.

Sensory Re-education

Sensory re-education is a common occupational therapy intervention for stroke survivors, as many experience sensation deficits such as numbness. Therapists may use activities to stimulate the sense of touch and discuss safety strategies, such as reducing the maximum hot water heater temperature.

Cognitive Training and Adaptation

Fine Motor Activities

Fine motor activities are a common part of occupational therapy for stroke survivors, as fine motor skills are often affected. Therapists may use a combination of fine motor coordination and strengthening activities, such as manipulating small objects or using a hand therapy ball.

Work Accommodations

Mental health support

A stroke can have a significant impact on mental health, and it is important to address these issues as part of the recovery process. Emotional symptoms such as depression and impulsivity are common after a stroke, and can have a significant impact on the person's life and their recovery.

Rehabilitation Psychologists and Neuropsychologists

These professionals can help screen for cognitive and emotional challenges and create a plan to improve cognitive function and build resilience in the face of what could be permanent lifestyle changes. They can also help with behavioural, emotional, and cognitive functioning, as well as community reintegration, which can aid in recovery.

Social Activity

Increasing social activity can be an important part of treating depression after a stroke. This can include more visits at home or going to an adult day care centre for activities. Socialising with other stroke survivors can also help improve mood.

Medication

Antidepressants can be prescribed to help with depression, and a doctor should be consulted if there are concerns about mental health.

Therapy and Counselling

A referral to a therapist or counsellor can be beneficial for treating depression, and can also help with the emotional and behavioural changes that can occur after a stroke.

Family Counselling

Family counselling can help family members and caregivers cope with the changes and challenges of caring for a stroke survivor, and can also help them learn how to best support their loved one's communication and recovery.

Support Groups

Support groups and community resources can provide practical, emotional, and financial support for stroke survivors and their caregivers. These groups can include community organisations, local colleges, churches, senior centres, hospitals, nursing homes, and adult daycare centres.

Preventing Setbacks

It is important to be aware of the risk of setbacks, such as pneumonia, a heart attack, or a second stroke, which can have significant physical, mental, and emotional effects. Working with a care team to adjust rehabilitation goals can help manage these challenges.

Progress and Hope

While recovery may slow down after six months, improvements are still possible, and small advances can continue to be made. It is important to focus on progress and hope, and to celebrate milestones, no matter how big or small.

Frequently asked questions