Recovering From Stroke: Reducing Strain And Regaining Strength

A stroke is a life-threatening condition that can lead to severe disability and pain. The effects of a stroke can manifest soon after the stroke or develop later. While treatment for a stroke depends on whether it is ischemic or hemorrhagic, it may include medicines or a procedure. To calculate the strain of a deformed rebar from stroke data, the following equation is used: strain = stroke/gauge length. However, this estimated strain calculation may not always be accurate. To convert a force vs. stroke curve into a stress-strain curve, a Shimazdu universal testing machine can be used to perform a 3-point bending test for flexural strength.

Shoulder pain and frozen shoulder

Causes of Shoulder Pain and Frozen Shoulder

One common cause of shoulder pain after a stroke is shoulder subluxation, which occurs when the rotator cuff muscles that support and stabilize the shoulder joint become weak and underactive due to muscle flaccidity. As a result, the ligaments and joint capsule of the shoulder are placed under increased stress as they try to hold the upper arm in place in the shoulder socket. The continual pull of gravity on the weight of the arm can cause subluxation, or partial dislocation, of the shoulder joint, leading to pain over time.

Another cause of shoulder pain is shoulder impingement, which occurs when the muscles of the back and shoulder do not work together in synchronicity due to muscle flaccidity. With overhead movements of the arm, the shoulder blades must rotate upward to allow space in the shoulder joint. However, when the muscles become weak and flaccid following a stroke, the shoulder blade cannot properly rotate upward, causing compression and pinching of the tendons in the shoulder. This can make movements of the arm painful and limit independence in performing everyday activities.

Frozen shoulder, also known as adhesive capsulitis, can occur when the tissue around the shoulder joint becomes inflamed and tightens, resulting in restricted and painful movement. This can happen when the arm is immobilized for a long period, such as in cases of hemiplegia or hemiparesis, which are common after a stroke. Frozen shoulder can also develop as a result of muscle spasticity, where increased muscle tone causes muscle contractures that stiffen and tighten the connective tissue in the shoulder joint.

Treatment for Shoulder Pain and Frozen Shoulder

Early treatment is crucial for optimal stroke rehabilitation and to prevent shoulder complications from worsening. If shoulder pain and difficulty with arm movements are present, stroke survivors should seek the care of a medical doctor and physical therapist as soon as possible. Treatment options may include:

• Physical therapy exercises: Gentle movement and passive range-of-motion exercises can help improve the shoulder joint's range of motion and stimulate the brain to rewire neural pathways.
• Occupational therapy: An occupational therapist can provide exercises for the shoulder, wrist, and hand to improve mobility and fine motor control, as well as help with activities of daily living.
• Electrical stimulation: Sending mild electrical impulses to the affected muscles can activate movement and improve muscle tone.
• Botox injections: Botox can help reduce pain and improve range of motion, as well as reduce fibrosis or adhesions in the shoulder joint.
• Shoulder taping or arm slings: While this does not treat the root cause, it can provide support for the shoulder joint and relieve painful symptoms.
• Medications: Anti-inflammatory medications, such as Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), can help relieve pain and inflammation, while oral medications like Baclofen or Botox can address spastic muscles or stiffness.
• Stretching and strengthening exercises: These exercises can help restore proper muscle activation, improve range of motion, and reduce pain and inflammation.
• Joint mobilization: This can help restore mobility and improve joint alignment.

Spasticity and contractures

Spasticity is a common post-stroke condition that causes stiff or rigid muscles. It occurs when a stroke damages the nerves controlling the muscles, leading to involuntary contractions and increased muscle tone. This results in very tight muscles, affecting movement and positioning. Spasticity commonly impacts the ability to move arms, hands, and legs, with around one in four stroke survivors experiencing it.

Spasticity can develop within a week of a stroke or later, and early treatment is crucial to prevent complications like contractures. Contractures are a possible outcome of untreated spasticity, causing a permanent shortening of the muscles. This restricts the full range of motion in joints, limiting the ability to bend or straighten them. Contractures in the arms or hands can cause difficulties in daily tasks such as dressing, while leg contractures can impair walking.

To prevent and manage spasticity and contractures, various treatments are available:

• Physical therapy and nursing teams employ stretches, exercises, and massage techniques to maintain muscle suppleness and prevent spasticity and contractures.
• Physiotherapy and occupational therapy focus on stretching and splinting to improve range of motion and avoid contractures.
• Botulinum toxin type A injections block the nerves' action on the muscles, reducing their ability to contract and helping to straighten limbs.
• Oral muscle relaxant medications help relax the nerves, preventing continuous contraction messages to the muscles.
• Functional Electrical Stimulation/Neuromuscular Electrical Stimulations (NMES) delivers shocks to activate nerves and increase movement, ranging from mild tingling to burning sensations.
• Intrathecal baclofen therapy (ITB) surgically implants a small pump to deliver medication directly to the spinal cord, reducing side effects.
• Braces, serial casting, and splinting help maintain normal muscle positions and prevent contractions.
• Surgical procedures may be considered for severe contractures and associated pain.

Central post-stroke pain (CPSP)

CPSP is associated with sensory abnormalities, particularly of thermal sensation, and a significant proportion of patients experience a latency period before the onset of symptoms. The exact pathogenesis of CPSP is unknown, but it is suggested that underlying causes include hyperexcitation in the damaged sensory pathways or damage to the central inhibitory pathways.

The primary symptoms of CPSP are pain and loss of sensation, usually in the face, arms, and/or legs. Pain or discomfort may be felt after being mildly touched or even in the absence of a stimulus. The pain may worsen with exposure to heat or cold and emotional distress. CPSP can significantly hinder a patient's ability to perform daily activities, interfere with sleep, and reduce their quality of life.

Pharmacologic and nonpharmacologic treatments for CPSP are available, but due to the limited published data from large clinical trials, the effectiveness of these treatments specifically for CPSP remains to be proven. Antidepressants, antiepileptics, and antiarrhythmics have shown efficacy in reducing CPSP in some patients, with amitriptyline and lamotrigine being effective treatments. Antidepressants such as amitriptyline and nortriptyline can be used as first-line treatment, while antiepileptics, including lamotrigine, gabapentin, pregabalin, and carbamazepine, can be used as an alternative or additive therapy. For patients resistant to first- and second-line treatments, opioids or tramadol may be prescribed, but caution is advised due to the risk of physical dependency.

Headaches

Causes of Headaches after a Stroke

There are several reasons why you might experience headaches following a stroke. In some cases, the causes may be similar to pre-stroke headaches, such as:

• Migraines
• Stress
• Lack of sleep
• Fatigue
• Caffeine withdrawal
• Alcohol consumption
• Dehydration

Additionally, if you had a haemorrhagic stroke, which involves bleeding in the brain, it may take some time for the headache to subside during the recovery process.

Treatment for Headaches after a Stroke

However, it is important to note that taking painkillers too frequently (more than about 10 days a month) can lead to medication overuse headaches. If this occurs, treatment typically involves discontinuing all pain relief medication for a period of time, usually around 12 weeks. It is crucial to consult a doctor before stopping any medication to avoid potential withdrawal symptoms.

Palliative or hospice care

Palliative care is an important option for people recovering from a stroke and their families. It can help improve their quality of life by providing relief from symptoms, stress, and suffering. Palliative care is patient- and family-centred and can be provided at any stage of a serious illness and in any care setting.

For stroke patients, palliative care involves supporting collaboration between patients, families, a stroke team, and other healthcare professionals, such as neurologists, neurosurgeons, primary care providers, nurses, and therapists. It is essential to have a well-coordinated medical team to personalise care, optimise quality of life, and focus on what is most important to the patient and their family.

• Patient and family-centred care: Palliative care should involve patients and their families in decision-making and focus on their preferences, needs, and values. Healthcare professionals should seek to understand which aspects of recovery are most important to the patient and their family.
• Prognosis and end-of-life planning: Open and sensitive discussions about prognosis, physical or mental losses from the stroke, and, if necessary, end-of-life planning are crucial. Healthcare providers should guide patients and their families through choices about life-sustaining treatment options, weighing the pros and cons of CPR, ventilators, feeding tubes, surgery, and do-not-resuscitate orders.
• Symptom management: Palliative care aims to provide relief from distressing symptoms, which can be diverse due to the involvement of the neurological system. These symptoms may include pain due to involuntary muscle contractions, dyspnea (shortness of breath), nausea, vomiting, constipation, bed sores, anxiety, restlessness, and depression.
• Early initiation: Accessing palliative care as soon as it becomes appropriate is essential. For acute stroke, palliative care becomes relevant during the initial recovery period when the full effects of the stroke are not yet clear. For chronic stroke, palliative care may be considered when the patient continues to decline in health despite intensive care.
• Collaboration with palliative care specialists: Healthcare professionals should engage palliative care specialists when complex issues arise or even proactively to address symptoms and provide support.

Frequently asked questions