Stroke recovery: physical aspects and mobility
Physical rehabilitation in hospital
Rehabilitation of physical function after a stroke usually starts as soon as the person is medically stable. Going to the rehabilitation gym became a fundamental part of people's day in hospital and most valued the regular time spent working with knowledgeable and enthusiastic physiotherapists and occupational therapists.
Was very impressed with the knowledge and attitude of physiotherapists he saw in hospital and...
A few people felt annoyed at the lack of or delay in getting physical therapy. They felt frustrated as they later found out the importance of regaining physical function as quickly as possible to ensure maximum recovery.
She was frustrated that her husband was not helped to walk after his stroke. He later had some...
And I had carers coming in at first, you know, they came in and our own doctor came in to see [my husband] and I asked him if it was possible he could get a physio to come to assess [my husband] and he got up and tested [my husband] and he was amazed at how much power he had in his left hand and left leg, so he said, 'Oh yes, I'll definitely get a physio' so we got a physio from one of the hospitals in [the city] and, as I say, the second week she was here, she had you standing, she brought a zimmer in and'
Husband' Yeah. I mind of that now.
Wife' 'got him standing and then she got him walking. He was able to walk through to the bedroom. She even walked him outside along to the next close and back and then she was, she was like God to us, she was absolutely marvellous.
Stella feels that her rehabilitation stopped too soon and that exercises should be provided to...
With the help of her husband, Susan was able to fast-track herself to rehab while in hospital.
He was given a choice of what to work on in physiotherapy and had mainly focussed on walking...
The type of therapy varied dependent on the part of the body affected and the extent of the impairment. Those who had paralysis or weakness in both a leg and arm usually focussed on each at different times of the day or sometimes alternate days. Some had focussed more on one limb than the other.
Upper limb function
Regaining movement in a paralysed arm was difficult and often complicated by lack of sensation. Some never regained function, others were left with weakness, or felt insecure about using their hand because of lack of feeling.
Some people found it helpful to concentrate very hard on moving their fingers and hand and even to talk through the actions they were trying to perform.
She regained movement in her hand by visualising playing the piano. Her physiotherapist was very...
Yes. Yeah and Could you just describe that again, you know, how you actually...
The technique that you used?
I played the piano, from the age of 7, so it was a kind, it was almost innate to me, playing the piano, and so I decided that, obviously with paralysis after a stroke there's nothing wrong with your body, it's perfectly alright. Why your body doesn't work is your brain won't talk to your body. So I wanted to, get, into my brain. So I had to find a way into my brain. So what I did was to imagine a picture of a piano keyboard in my head. I always closed my eyes and I could see this keyboard and, with my mind, I would make my mind press a note down that I could see, and the first time I did it, I got a tiny, tiny movement in my forefinger, just miniscule. And I thought, 'Goodness me', and I pressed the note down again and I got a bit more movement and a bit more, and then, a few days later I thought, 'I wonder if I can find another finger?', so I pressed the note in, of this keyboard in my head, I pressed the next door note down, and, the finger I'd originally found shot up in the air, they were joined together but there was a tiny little movement, in the next finger. So I practised and practised on what I called neural notes basically, and, within a day, I'd isolated the second note and I could move my second finger a little bit independently of my first finger. So that's, that's the technique I used and I just used that technique with notes for every single, but it's a very, I mean, the hand is a very complicated piece of machinery so I said, 'I have to find every single joint and every single connection in my hand and the way they all work in an integrated, to form the integrated movement of a hand'.
When you said the physio, how did the physio react when you said that you were doing this?
She respected me doing it. I mean, I think she was fascinated by what I was doing. She'd never seen it before because I made it up, I invented the technique. She didn't stop me. She supported me. So what she would do is she would put my arm in a position that would facilitate or help me to then play this, keyboard, neural keyboard, in my head because obviously I'd no, no control over my arm. Yeah. And I, I didn't know I had an arm, which is the most peculiar experience with paralysis is you don't have, an arm or a leg. It just disappears. It looks like somebody else's.
Strength and movement was improved by using arm exercises sometimes with light weights or plasticine to improve hand grip. Tasks to regain dexterity included threading nuts onto bolts, lifting small objects into a dish or doing jigsaws. Whilst this could sometimes seem like child's play most realised the importance of following the therapists' instructions and working as hard as possible.
Worked with plasticine and Lego to improve hand function. Even though it was elementary she did...
Yes. He had plastic plasticine and I was working with that because the first time he came out my fingers were all curled up and I wasn't aware of my fingers being like that but then probably I was that ill and I just didn't know but gradually he, I managed to straighten them out and he was helping with these things and I think he had different kind of like children's toys it was more or less, you know [laughter] using that things, things like Lego, some things like that I think it was, you know, simple things but they did help that. Now, I graduated from that to the physiotherapy.
Some people find that they get annoyed having to do perhaps silly things with children's toys. How did you find doing that?
Well, I realised it was helping me, so I didn't mind. I thought it was just elementary but it was helping me, so I had to start from scratch [laughter].
Practiced putting bolts on nuts and picking up small objects to improve his dexterity. He was...
Did you mind having to do that?
No. I didn't mind at all. Not, not a bit of it because I knew that this was part, part of the game that if, if you kept at that, you would be able to do it if you wanted to do it but if you, if you didn't want to do it, you were wasting their time and yours. You had to work at it because I know some of them there that you know, they sort of gave up and I was determined. There's no way was I going to give up and I just worked at it with them and the girls were marvellous and they would come for you every afternoon and you would have a, you'd have an hour with them and different things you had to do, you know but I remember the bolts and nuts, you see, and that was for you pick up all the nuts and screw it on, screw it on, on to the bolt. And washers and things like that I found difficult. Eventually got better and got better and got better and then in the end of the day, they just said, 'I think you can go home'.
Therapy of the upper limb generally progressed on to practicing everyday tasks (see 'Stroke recovery: daily activities').
Standing and walking
A major focus of rehabilitation was standing and walking. Those who had experienced a major paralysis of one side of the body often started this process by regaining sitting and then standing balance. A woman explained that she sat and then stood with a physiotherapist at either side in front of a mirror to help her find her central balance point.
The first time she stood was in front of a mirror with two physiotherapists either side to help...
Because when you're normal, you've got complete balance, you know, you don't wobble around, you just walk, you're completely normal. But after a stroke, you, you've got no sense, you've got no balance, you've got no central point, so you have to learn how to stand up and see where the sort of central point is. You've got to get your balance somehow and you've got to learn how to do that and it's really difficult when only one good leg, you can feel one leg, you can't feel the other one, so you have to look down and make sure that foot is level. So you're standing on two feet equally, you can see that in the mirror, so you have to watch what you're doing. And so you learn to do that and you learn, it takes a long time but you learn to stand without actually wobbling all over the place and so you then stand with one person at the side of you and then you learn to stand on your own and you've actually, you're actually standing there without wobbling in front of the mirror, looking at yourself and that's really great.
And they, and you know, it's all sort of, you go through all the stages and then you have to, they have a long sort of walkway and it's got rails on either side and you can hang on to the rails and you have to learn how to put one foot in front of the other. A long, a very long process. You work, gradually you work up to being able to go up this walkway, which is about, oh about 15 feet long I should think with these big rails on either side and it sort of it's a sort of shiny sort of wooden floor and you just learn gradually to take one foot in front of the other and then one day you're actually able to get right up this, the length of this walkway. But then of course, you've got support, so when you come away from there, it's another thing to actually walk on, you can't, you can't walk on your own. You can't imagine really how it is not to be able to walk. You can stand but you can't walk and so you have to learn with one person either side of you to walk all over again and it's quite amazing when you take your first step. It's just absolutely thrilling to think you've made one step, it sounds ridiculous but I'm sure everybody that has been through all this will understand exactly what I'm saying and then you take your first steps, you take a little walk and I can remember. It was my party piece when all my friends used to come to visit when I was first able to take a few steps on my own.
Exercises were given to strengthen weakened leg muscles. This involved lifting the leg in a lying position sometimes with a weight attached. As balance improved some used a special board called a wobble board to improve their balance.
Even those who were unlikely to walk after their stroke were helped to stand as this can be useful in helping transfers from bed to chair or toilet and to allow standing to wash and shave. One man who had developed some spasms in his leg which were preventing him standing was being treated with botulinum toxin injections. He hoped that if they were relieved he would be able to work towards standing.
He recently started some botox injections to relieve a spasm in his leg and hopes that it may...
And what's it like having the botox injections?
I don't feel it because I've still got so little feeling in my leg, I didn't even know when he puts the needles in' And I think the botox lasts for about 2 months, so I think I go down, I've been twice 2 now, once for every period because I went the first time and went a couple of weeks ago just to have a top-up. So I guess I'll have another appointment in another 2 months now. But it certainly makes things a bit more comfortable and hopefully, I mean, he seems optimistic that it, that we could get some benefit from it, which is nice, because he's the only person, health care professional that I've seen that's said anything other than I'm going to die. So that's quite nice really that he actually says hopefully we'll get some benefit because he says hopefully he can get me to weight bear on that leg, I might be able to do, as he puts, some meaningful standing, maybe able to stand up in the bathroom to shave or something hopefully in time, which sounds like' almost like a dream really. That would be great if I could do that, so I'm not, hopefully he'll be right but I'm not pinning all my hopes on it because I don't set myself up for disappointment but hopefully it will work.
Most people were encouraged to stand and take a few steps early on. However, one woman had experienced different styles of physiotherapy, one where she was encouraged to walk quickly, and another where she did exercise to gain strength and only walked towards the end.
The first steps were often taken with the support of someone either side or in front and sometimes between parallel bars.
His first few steps supported by a physiotherapist between parallel bars were wonderful. As he...
Oh, wonderful. you know, you , it's a lovely feeling, not as good as, as moving my big toe. That was the, that was the main thing. I could actually move, get some move back standing up yes, standing up was good. I then had to just stand for about 5 minutes with somebody behind holding, all ready in case I fell and then the first steps. The first steps were done with parallel bars with somebody in front of me and the first walking up and down steps, they have, they have simulated steps in the gym, take them one at a time. First of all, you take one step, you put the good leg on the step first and then the bad leg goes on afterwards and then the good leg goes up one, the bad leg goes up one and so on.
Standing and taking the first steps was both exhilarating and for some very frightening because they felt they would fall. Many where surprised how quickly they tired after only standing or taking a few steps.
As people progressed, or if their walking was less severely impaired, they practiced walking with a zimmer frame or walking stick often one with three feet for extra stability.
Learning to use stairs was often a final step in rehabilitation. Many found the prospect frightening but with practice and special techniques were able to negotiate stairs confidently.
Was taught to use the analogy of putting her good leg first for going up to heaven and her bad...
Sticks and wheel chairs
Although many people regained mobility after their stroke some felt their balance was poor and found that a stick gave them confidence particularly over long distances. Whilst some thought a stick was useful in alerting others to their disability others did not use one because they felt it made them look old or disabled.
His stick gives him confidence for longer distances because he knows it is there if he stumbles.
Husband' Walking, I' walking road' slowly, slowly.
So you can walk?
In the house?
Husband' Yeah. Library. Library' Walk.
Wife' Around 20 minutes he can walk round.
And do you use a stick at all?
Husband' Yes. Yeah. Stick. Yes. Yes.
And what's good about the stick?
Husband' Balance. Balance stick.
Wife' Without, without stick he is' you know, stumbles sometimes. But with stick, he is more confident.
Husband' House stick not' me walking sticks.
Wife' Outside of, you know, he need it more. It's like glasses nowadays, you know, it's very important for him. One day he will forgot to take the stick and he was so upset. We went to Switzerland to see my family and he was so upset. We forgot, early morning flight, it was early morning, 5 o'clock or something, so we left the stick at home. It was so, he was so upset, then my brother bought it, stick over there and after that he become calmed down. It's like glasses, you know, it's like one of the part, one part of his, part is like that, you know. It's very important.
A number of people had initially used a wheelchair to get about but were pleased to get back to walking. Others needed to use a wheelchair for getting around. Some disliked using a wheelchair because of the loss of independence, embarrassment and a feeling that people ignored them.
Wheelchairs were not always suitable for where people lived, because they could not get around the house or because they lived on a hill.
Powered wheelchairs and scooters gave some people the much needed independence. Although a few had been provided with one, others rented or had bought one themselves.
An electric wheelchair has been excellent because it has given him independence.
This chair is a Godsend. Well, I got one from the NHS. That's' good and then I got this one from my sister and my brother in law. It was his mother's and she died and it was just sitting in the garage, so they said, 'Look sooner lying there, could you use it?', so I got this one and just, as I say, it's great for, well, manoeuvring you see around the place here and if I want, I just go away out and go for a run round the village and I go out, I work in the garage on my plants and stuff like that. Independence it gives you.
Braces and splints
Sometimes people were fitted with a special splint to straighten out their fingers. Many found these uncomfortable to wear particularly overnight and stopped using them. Others persisted with them because they could see the difference and felt it improved their chances of regaining movement.
A few experienced problems with poor gait due to a dropped weak foot and were given a support to wear which had helped although often this meant they had to wear larger shoes.
Setting goals, monitoring progress and practice
An important part of physical rehabilitation for many people was setting and working towards goals. Some were asked to set goals for their rehabilitation others were graded for their physical ability after the stroke and found it helpful to monitor how their grading improved.
In the rehabilitation gym mobility was graded from 0 to 5. He found it encouraging to look back...
Ah, yeah. There was a, there was a, there is a gym at the hospital. At the start because I couldn't move at all. They had a, I remember they have a series of numbers, zero for no movement at all and up to about 5 for relatively good moving. When I, when I first went to have my first physiotherapy, it was zero, zero all the way through and you were encouraged first of all to shuffle in and out, shuffle about in a chair, you're then, you, gradually more and more, you lay on, they put you on your back and you have to move your, your legs sideways, two legs together. You then have to move your feet and so on and gradually increase the movement according to how much mobility you had and again, this is a good way of doing it because you say, they say, 'Oh you had a, you had a zero last week, you've got a 1 this week, well done'. You know, and you, you're encouraged. You also, they also give you an aim, a goal. They say, 'Well, do you have a goal in mind? What do you want to be able to do in the next week? What do you want to be able to do in the next fortnight? What do you want to be able to do in the next month?' And you, you're encouraged to say, 'Well, I would like to be able to stand up in the next week' for example and if you can stand up, then it's rounds of applause all round, you know, and it's a very good method of making you, making sure you, forcing you to improve. Making you do this sort of thing.
Some found keeping a diary of their progress helpful. A man stressed how important it was to look back at your achievements and then think forward to the goals that you would like to achieve.
Records his progress in a diary and encourages other people to do the same.
I try and record in a diary what I'm doing and what I'm up to at any particular moment. And at one stage I used to time myself going around the park and seeing whether I could increase the speed, in fact, I've stopped doing that now because it isn't a matter of speed so much as technique. Because now I, you know, I probably shouldn't do it too fast, I should simply do it more accurately and more proficiently. But yes, I mean, I would advise people to keep a good record of their own as to where they've got to and where they've from arrived at any one moment. For one thing it'll do them the power of good to be able to set a marker on where they are now and then become increasingly aware of how they've travelled from one marker to another to another again. And by projecting that marker forward you can become more and more confident that one day you will reach the very same distance forward to the distance that you arrived from a point behind.
Practice was seen as important and some used their spare time in hospital often to practice walking. This was not always encouraged because of problems with falls and a few felt that there should be more time to practice under supervision.
Many people continued to set themselves physical goals after leaving hospital which included walking longer distances with a dog, walking to the shops or using exercise bikes. A few people were helped to do this by a community therapy team. This did not always happen and one man felt that more support should be offered once you leave hospital.
Susan would use the nurses check-list by her bed as a goal-setting tool.
Set himself goals for walking the dog and gradually increased the distance. Having a dog has...
Yeah. Well, to start with, I took him, well, from here to the bottom of the brae and back would be maybe about 100 yards and I was struggling with that. Then I just gradually increased it because I took him out down to the shop, along to the next road and back up that way. And I took him that way for about a week, then I took him the other way, the opposite way, when I went to the bottom, went down to the shop, and went the opposite way and I just gradually increased the, the distance I went with him until I'm, until I was going further, even further, just kept increasing the distance all the time and then the dog got kind of worse, so he's got as bad as I was now, so I've slowed down the walks. I'm still taking him plenty walks but just shorter ones.
Do you think Hamish has been important in, in helping you recover?
Yeah. An awful lot.
What's important about having, having the dog?
The fact that I know he's got to get out and I don't let a dog out on its own because it, to me, it's not right to let a dog out on its own. If you've got a dog, you're, you're responsible for it, therefore you should care for it and that means taking it out and going out with it. Therefore, I mean, I've got to go out with him which has encouraged me to get up and go. Whereas if I didn't have him, I wouldn't go out near so much and I wouldn't go near so far.
Some attended specific exercise classes or gyms for people who had a stroke and others found that the gym would provide a programme tailored to their disability. Some individuals felt that community exercise through local gyms and pools should be recommended by health staff during discharge planning. In some cases it was felt that health staff were unaware of programs in the community.
Last reviewed June 2017.
Last updated August 2011