Stroke recovery

--What is stroke?

A stroke can occur in two ways: either by a blockage (ischaemic stroke) or a bleed (haemorrhagic stroke) from a blood vessel in the brain. If the blood supply is not restored, the nerves in the brain soon die, causing permanent damage to the brain. This causes problems with body functions that are normally controlled by those cells.

Stroke is common, affecting approximately 60 000 Australians each year and 1 in 6 people will experience a stroke in their lifetime. It is the second leading cause of death, and the leading cause of disability in Australia. With good medical care and rehabilitation, most people recover to some extent following stroke, but many people experience ongoing problems that affect their daily activities.

There are a number of health and lifestyle factors that increase the risk of having a stroke. Increased blood pressure, high cholesterol, diabetes and conditions related to the heart can put you at increased risk. People who smoke, drink heavily, are physically inactive, overweight or have inadequate fruit and vegetable intake are also at a greater risk. The risk of stroke increases when multiple risk factors are present,

However, there is often no one cause of stroke and people can have a stroke with few or none of these risk factors. Stroke can also occur in younger people. Physiotherapy may help to prevent stroke by reducing a number of these risk factors.

--How does a stroke change me?

Movement is commonly affected following stroke, typically down one side of the body, with the arm affected more than the leg. Speech, sense of feeling, vision, balance, thinking and memory can also be affected. The effects of stroke occur suddenly, and in the days and weeks after that, recovery will start to occur and some functions will improve.

Although brain scans will be taken early after the stroke to assist with the medical management, the extent of the damage to the brain seen on scans is not a good predictor of outcomes; the ability to move in the days after the stroke is a much better indicator of eventual recovery.

--What does stroke recovery entail?

The most dramatic recovery takes place in the initial days following stroke, as the swelling in the brain goes down. Over the next few months the recovery will continue and people who take part in early and comprehensive rehabilitation have much better outcomes.

This rehabilitation involves both medical and allied health staff, such as physiotherapists, and aims to maximise the functions that have been lost. Rehabilitation is generally intensive and stroke survivors need to be actively involved, practising and performing exercises for 2-3 hours each day. This may happen in a rehabilitation centre or at home with a team of therapists to facilitate the recovery.

Stroke survivors may be told that recovery stops after 3 or 6 months, but research suggests that significant recovery is still possible years after the stroke, with the right advice and exercises.

--How can physiotherapy help with stroke recovery?

Recovery from stroke requires input from a team, involving doctors, nurses, physiotherapists, occupational therapists and speech pathologists.

The role of physiotherapy is to assist with recovery of movement and sensation, so you can perform everyday activities again. Rehabilitation activities vary considerably, depending on what has been affected by the stroke. Broadly speaking, there are three main goals that people may have following stroke:

Recovery of arm function

Two-thirds of stroke survivors have difficulty using their arm following stroke and many never regain any use. Your physiotherapist can give you appropriate exercises at each stage of your recovery and can help you move your arm and recover some movement, even if it is very weak. There are a number of different approaches to recovering arm function, which have been supported by excellent research trials. The National Stroke Foundation has guidelines to follow with recommended exercises such as strengthening and repetitive practice of tasks, and those not recommended, such as use of pulleys. Your physiotherapist will also be able to advise on managing pain after stroke.

Recovery of walking

Most individuals recover the ability to walk following stroke, but may require an aid such as a walking frame or a stick. Physiotherapists are experts at working out the correct assistance required for walking and using hands-on techniques and specific exercises to improve your walking post-stroke.

Recovery of balance

Following stroke you are at greater risk of falling as balance is affected. With appropriate exercises prescribed and supervised by your physiotherapist, and careful assessment of the factors contributing to your balance problems, your steadiness can be significantly improved post-stroke.

Physiotherapists also play an important role in preventing strokes from reoccurring. They can assist with lifestyle modifications to potentially avoid a secondary stroke, which is highly impactful to improve health and prevent disability.

--How effective is physiotherapy in recovering from stroke?

There are a large number of research studies that support physiotherapy interventions to improve arm function, balance and walking following stroke. There are very clear guidelines, which recommend those approaches with the best research evidence.

Physiotherapists use a variety of assessment tools and measures to determine the most effective treatment plan. Research suggests that physiotherapy is highly effective in retraining functional movements. This may include task-specific training, where specific tasks are practised according to your ability and goals, and assisted treadmill training where you engage in high repetitions of stepping practise to relearn walking. Research is ongoing in determining what dose, frequency and mode of therapies works best.

Generally, the more active and engaged you are in therapy sessions, the better your overall recovery. 

--Should I be worried if my recovery is slow?

Recovery can be impacted by other illnesses that may exist before the stroke, such as heart problems, and also the type of functions lost following the stroke. For example, the stroke can affect thinking and memory skills, which can make it difficult for you to fully participate in rehabilitation. Often these other issues will become clear in the early weeks following the stroke. Your rehabilitation team can develop a plan to maximise your recovery and manage the other health conditions.

Often you will feel like your recovery has stopped or slowed down. Your physiotherapist will regularly measure your progress, using standardised tests, which can be a good way to track recovery over time. This can also demonstrate that recovery is still continuing and at what pace. Recovery often does slow down after several months following the stroke, but with the right therapy, support and mindset, it does not have to stop.

--What can I do at home?

Research shows that the more active the involvement in physiotherapy, the better the recovery. It is therefore very important that you have daily exercises to improve sensation, strength, balance and movement.

This may include chair-based exercises, such as practising standing up, or bed based exercises such as lifting your bottom and moving your legs. As a general rule, exercises need to be individually prescribed, tailored, and regularly progressed so that they are safe and effective. Expert advice from your physiotherapist with experience in stroke (neurological physiotherapist) is critical to develop a home exercise program.

Fitness-based exercises such as walking, cycling and swimming are also important as they help maintain a healthy circulatory system and can help with weight loss. There are also community support groups available, and further information and online forums on the Stroke Foundation website. 

--How long until I improve or recover?

Recovery following stroke relies on nerve cells in the brain taking over the function of those that were damaged, or the growth of new cell connections that occur in response to training and therapy. This process is called neuroplasticity and can occur at any stage following stroke and can continue given the right conditions.

Your neurological physiotherapist can guide you towards safe and effective ways to direct neuroplasticity and functional recovery. They will create a movement program that is targeted, intensive, meaningful and transferrable to a range of situations so your brain can learn to move more normally again.