Physiotherapist 2017-06-30T15:31:40+00:00

Jon Graham – Physiotherapist

Questions submitted by younger stroke survivors and answered in the Different Strokes newsletter by Jon Graham, Physiotherapist and Stroke Expert.  Jon specialises in the rehabilitation of individuals with Neurological Conditions and works with many young stroke survivors.

Please note that while our panel endeavours to give the best advice based on info provided, it is always advisable to have a face-to-face consultation with a practitioner about any health issue that concerns you. Comments expressed are general in nature and are not intended to provide specific advice.

If you would like to submit a question to be answered by one of our experts, please email experts@differentstrokes.co.uk or write to Different Strokes, 9 Canon Harnett Court, Wolverton Mill, Milton Keynes MK12 5NF.

You may also like to read our Frequently Asked Questions About Stroke (link to this section in Helping Each Other) to see what other younger stroke survivors are saying.


Face drop

Question:

“My recent stroke has caused my face to drop on one side. As a result I have trouble eating and am dribbling. My face feels like it has been numbed by the Dentist.  Are there any exercises or massage that would help speed recovery?”

Answer:

Jenny Carkeet of Physiofunction on behalf of Jon Graham: It is common following a stroke for your face to drop on one side causing facial asymmetry, difficulty in forming words and dribbling when eating and drinking.

In the initial few weeks it is important to:

  • massage the face with strokes towards the ear
  • support the cheek on the affected side with your hand whilst talking
  • ensure that the affected side of the mouth is clean as food can become lodged between the gums and cheek
  • use a straw to aid drinking but ensure it is placed in the centre of your mouth and complete the lip seal with finger pressure
  • not to over emphasise the movements of the unaffected side.

If spontaneous recovery does not occur within the first few months and muscle wasting has occurred you may need to use Trophic Electrical Stimulation (TES) to improve the health of the muscle and to remind your brain that you have two sides to your face. A small and portable machine will deliver pulses to your face by means of small electrodes and is used between 1 to 3 hours daily.

You will need a facial assessment by either a physiotherapist or speech therapist to decide which parts of your face need treatment and agreed progression points.


Functional Electrical Stimulation (FES)

Question:

 “I am 4 years post stroke and I have a left sided weakness. I have muscle tone problems on my left arm and leg. I attend my local, weekly Different Strokes exercise class and I carry out exercises at home.

Would a muscle stimulating machine benefit me and help with my on-going muscle tone problems? If so, is there a specific machine that you could recommend?”

Answer:

Muscle stimulating machines use very small and safe electrical currents. The current is generated from household batteries in the machine and carried down wires to electrode pads that have a sticky gel surface.

These pads are positioned on the skin above the nerve that supplies the muscle and above the muscle forming a circuit. It is actually the nerve itself that is electrically stimulated through the skin, and the nerve then passes the electrical current to the muscle to make it shorten or contract. So muscles that are weak can be made to contract – for example, applying the pads on the back of the forearm will cause the muscles that lift the wrist and fingers to activate and lift the wrist up and straighten the fingers. This not only strengthens these muscles, but it relaxes and stretches the opposite muscles – those that close the hand into a fist.

The same is true for the leg muscles. This combined effect of strengthening weak muscles and stretching tight muscles mean that these machines can be very beneficial for muscle tone problems.

Although these machines are similar to TENs or TNS machines that are used for pain relief, they use different currents and it not advisable to use a TENS or TNS machine for this purpose.

Some of these muscle stimulating machines are available on the Internet and can be bought for home use; others need to be purchased on your behalf by a Physiotherapist (or Occupational Therapist).

For home use, I recommend the Intellistim BE-28E. It is affordable (approx £75) and easy to operate, even for novice users.

The devices that can only be provided by Physiotherapists typically have stronger currents and more complex features, which accounts for their higher cost: Microstim (OML), Stiwell Med 4 (Ottobock), and the H200 (Bioness).

The Microstim is very powerful and can lift the foot up at the ankle when applied to the muscles of the shin.

The Stiwell Med 4 from Ottobock is equally powerful. It is also able to detect tiny electrical signals that are produced by the affected area of the brain when the user tries to activate a weak muscle. The device then rewards the attempt by stimulating the muscle. A number of research studies have shown that this helps with recovery better than using stimulation alone. With the Stiwell Med 4, the user can even control simple games on their PC using signals from their affected muscles.

The H200 is a wireless muscle stimulating device incorporated inside a wrist splint. Some stroke survivors have found that they can use this device for functional activities, whilst others use it for strengthening or management of spasticity.

For more information, you can download an article on muscle stimulators from the Different Strokes website here

Intellistim BE-28E: www.naturesgate-uk.com
Microstim: www.odstockmedical.com
Stiwell Med 4: www.ottobock.co.uk
H200: www.bioness.com


Hand/Arm Exercises

Question:

“I had my stroke in May 2010 when I was 46. I am no longer receiving physiotherapy but have been using putty at home to try to improve the grip in my left side. I have been rolling the putty around in my left hand but wondered if there are any exercises that you could suggest that I could try that might help.  Thanks very much.”

Answer:

Regular exercise can improve grip and fine-finger control. It is important to work on both the muscles that close the fingers and thumb, as well at those that open the hand.

For strengthening the hand in general, squeezing balls can be very helpful, but you must relax the hand fully after each squeeze. Dropping and catching a juggling ball alternately between your affected hand and your unaffected hand can help with co-ordination.

For strengthening individual fingers, I recommend squeezing putty or blue tack between individual fingers and your thumb. In the same session, I recommend strengthening the opposing muscles using an elastic band: wrap it around your thumb and your index finger, and stretch the index finger and thumb away from each other. You can then repeat this with each of your other fingers.

For improving fine finger control, I recommend using a solitaire game-set with marbles or small pegs. The Early Learning Centre stores have a range of educational toys that help develop young children’s hand and eye co-ordination. These can be very beneficial for stroke survivors to improve their hand control.


Hand/Arm Exercises

Question:

“I am able to grip with my affected hand but struggle to let go. Can you recommend any exercises or equipment to help?”

Answer:

Many stroke survivors find they can grip with their affected hand, but struggle to let go. This is actually part of the recovery process. The most important exercise is using your unaffected hand to gently open your affected hand so that you gently stretch the muscles that close your hand. If your hand closes immediately after you release it, you may need to repeat this stretch a number of times, e.g. 15-25 stretches over 5 mins.

Try placing a small hand weight (0.75 – 1.5 kilogram) in the palm of your affected hand. Carefully supporting your wrist with your unaffected hand, see if you can grip the dumbbell, then try to relax your grip against the weight of the dumbbell. Take care not to drop the weight onto your foot or passing pets!

ARNI (Action for Rehabilitation from Neurological Injury) retails a device called the Neurogripper which looks like a pair of hair-curling tongs. It’s held closed by elastic bands. Squeeze the handles against the resistance of the elastic bands. When you relax your grip, the tension in the elastic bands helps to open the hand. Resistance can be altered by placing the elastic bands in different positions along the tongs. It’s available on-line at: www.arni.uk.com/PRODUCTS.html

Some stroke survivors improve their ability to release their grip and recover hand function using the Saeboflex. This is a custom-made hand splint that uses springs to help open each finger separately. Whilst they are intended for home exercise, you’d need a Saeboflex-trained Physiotherapist or OT to assess you and measure your hand for such a device. They would then provide you with a tailored set of exercises.

For further details: www.saebo.com


Hand/Arm Exercises

Question:

“My five year old son has right sided hemiplegia. For two years he has been wearing Second Skin splinting to his right hand and upper arm. The four fingers are now open and hypotonic, the thumb is tight across the inner palm of the hand. He has no grasp.

Can you please advise me of the next step to encourage dexterity and greater use of his right hand and fingers.”

Answer:

Second Skin (www.secondskin.com.au) is an innovative therapy company, based in Australia, but regularly runs clinics in the UK. It tailor-makes tightly fitting lycra garments which are worn next to the skin.

These garments can be made for: the forearm and hand; the whole arm; or in some cases a near complete body suit. The elasticity of the lycra squeezes the limb to help reduce muscle tone and improve sensation. These garments can also have plastic boning sewn into them to provide further support.

Hypotonic describes a muscle that is floppy and cannot be activated. There are a number of ways to stimulate a muscle to contract. The individual or their carer can gently tap the affected muscles or stroke them with their fingers, or brush the muscles with a soft-bristled brush or an ice cube. Gentle massage and stretching can help loosen tight muscles.

Electrical muscle stimulators (not TNS or TeNS machines) use sticky pads to convey small electrical charges from the stimulator to the muscle to cause it to contract. The sensation is often described as a strong pins and needles feeling, and may not be tolerated by younger children and indeed quite a few sensitive adults. The contractions can be strong enough to lift up the wrist and fingers if applied to the top of the forearm, or bend the elbow if applied to the biceps.

Putting objects into the individual’s hand (golf ball, tennis ball, rubber ball) and encouraging them to squeeze whilst they are being stimulated is the best way to develop grasping. The individual must be equally encouraged to release the grip.
Individuals generally re-learn how to grasp (close the hand) before learning how to release their grip or opening their hand.

Many individuals can benefit from using the Saeboflex (www.saebo.com) which is a special splint that uses springs to help the individual release their grasp. The Saeboflex is widely available in the UK and children as young as 7 or 8 can be fitted with them.

I recommend individuals consult a Neurological Physiotherapist before attempting any of these treatment suggestions, especially with regards to stretching muscles.


Hand/Arm Exercises

Question:

“I had my stroke in May 2010 when I was 46. I am no longer receiving physiotherapy but have been using putty at home to try to improve the grip in my left side. I have been rolling the putty around in my left hand but wondered if there are any exercises that you could suggest that I could try that might help. Thanks very much”

Answer:

Regular exercise can improve grip and fine-finger control. It is important to work on both the muscles that close the fingers and thumb, as well at those that open the hand.

For strengthening the hand in general, squeezing balls can be very helpful, but you must relax the hand fully after each squeeze. Dropping and catching a juggling ball alternately between your affected hand and your unaffected hand can help with co-ordination.

For strengthening individual fingers, I recommend squeezing putty or blue tack between individual fingers and your thumb. In the same session, I recommend strengthening the opposing muscles using an elastic band: wrap it around your thumb and your index finger, and stretch the index finger and thumb away from each other. You can then repeat this with each of your other fingers.

For improving fine finger control, I recommend using a solitaire game-set with marbles or small pegs. The Early Learning Centre stores have a range of educational toys that help develop young children’s hand and eye co-ordination. These can be very beneficial for stroke survivors to improve their hand control.


Hand/Arm Exercises

Question:

“I am able to grip with my affected hand but struggle to let go. Can you recommend any exercises or equipment to help?”

Answer:

Many stroke survivors find they can grip with their affected hand, but struggle to let go. This is actually part of the recovery process. The most important exercise is using your unaffected hand to gently open your affected hand so that you gently stretch the muscles that close your hand. If your hand closes immediately after you release it, you may need to repeat this stretch a number of times, e.g. 15-25 stretches over 5 mins.

Try placing a small hand weight (0.75 – 1.5 kilogram) in the palm of your affected hand. Carefully supporting your wrist with your unaffected hand, see if you can grip the dumbbell, then try to relax your grip against the weight of the dumbbell. Take care not to drop the weight onto your foot or passing pets!

ARNI (Action for Rehabilitation from Neurological Injury) retails a device called the Neurogripper which looks like a pair of hair-curling tongs. It’s held closed by elastic bands. Squeeze the handles against the resistance of the elastic bands. When you relax your grip, the tension in the elastic bands helps to open the hand. Resistance can be altered by placing the elastic bands in different positions along the tongs. It’s available on-line at: www.arni.uk.com/PRODUCTS.html

Some stroke survivors improve their ability to release their grip and recover hand function using the Saeboflex. This is a custom-made hand splint that uses springs to help open each finger separately. Whilst they are intended for home exercise, you’d need a Saeboflex-trained Physiotherapist or OT to assess you and measure your hand for such a device. They would then provide you with a tailored set of exercises.

For further details: www.saebo.com


Loss of Confidence with Walking

Question: 

“I had a CVA in 2000, aged 28. I now find I have lost confidence with walking, even short distances. When I recovered I was a very determined person, walking everywhere. I have a limp and left sided weakness. Now I get what I presume is anxiety – where my legs shake and the tone gets tight and I cannot envisage going out on my own in case I get stuck. I have visited anxiety nurses, which has helped a bit.

My questions are:

• Is it normal for stroke survivors to lose confidence?

• Would you recommend getting medication to make things a little easier to
deal with? Thanks.”

Answer:

Stroke survivors can lose confidence following a trip or fall whether whilst still in hospital or several years after they have left hospital. Other causes for losing confidence can be muscle tightness in the weaker leg or gradual loss of strength in either leg. This often happens if the total distances that the individual walks are much less than they were walking previously – or less than someone of their age who has not had a stroke would be walking.

Loss of confidence can then lead to the symptoms of anxiety that you describe. With regards to medication, this is a discussion that is best had with your GP.
However, I have found the following ideas have helped others.

Fear of falling is often made worse by worries about how you would get up from the ground. So practising getting up from the ground in the comfort of home can help reduce the anxiety about going out. If you haven’t been shown how to do this, or have forgotten, then I would recommend that you seek a Physiotherapy referral.

Practical ways of dealing with the anxiety of “getting stuck” are: building your confidence again with short walks around your immediate neighbourhood and gradually increasing the distance day-by-day, “lamppost-by-lamppost”; and also to always take a mobile phone with you with numbers of people who’d be able and happy to assist you stored on it.

“Shooting sticks” can be helpful – these are walking sticks with foldable seats as handles.  Fear of “running out of steam” can reduce confidence. Knowing that with such an aid you could take a rest at any point can help. Be sure that you are SAFE using this device as a rest before considering purchasing, and again practice using one.

Perhaps best of all is regularly attending your local Different Strokes exercise class and even practising some of the exercises at home.


Loss of Tone in Fingers

Question: 

“I am suffering from a loss of tone in my fingers, so much so that they are starting to stiffen and stick up (a form of Dystonia I think).  Are there any exercises that would help?”

Answer:

One of the immediate effects of a stroke is a lowering of muscle tone. This makes it very difficult to take up the slack in the muscles and the person struggles to perform the desired movement.

As the brain starts to recover the muscle tone increases – in many cases to the point that normal use returns. Other times, the tone can come back partially giving rise to uncontrolled movements – this frustrating condition is referred to as dystonia.

However, more commonly, either: the tone can increase dramatically with effort, coughing and sneezing and then become floppy again; or the tone remains very much increased and the muscle remains in its shortened/activated state.

If you indeed have dystonia, then gentle stretching of your fingers to bend them into a “fist” might help. I would recommend asking your GP to refer you to an Occupational Therapist who specialises in hand therapy who could show you some more specific exercises and maybe prescribe a lycra glove which will help control the dystonia.

You do not mention whether your hand is painful, or whether you also have a problem with your shoulder. Sometimes, stroke survivors with very stiff shoulders can develop a problem with the joints and circulation in their hand. If this is the case, I would recommend a thorough review by your GP.


Muscle Spasms

Question: 

 “My husband had a massive stroke two years ago and we have worked very hard with his rehabilitation. He is walking with a stick etc, positive and motivated.

His arm and surrounding muscles are fine but … his arm is being pulled in by a muscle which causes a spasm that seems to come from his chest if he sneezes or coughs. I’ve asked all the physios for exercises etc, which we do every day yet nothing seems to work very well because the spasms seem to undo all the hard work.

We don’t want baclofen or similar drugs, but want to get his arm moving more.
Can you help? All the other muscles seem fine and his shoulder is nice and loose and I can exercise his arm in all positions, his hand is relaxed too and he has the feeling back in his arm although at a lesser degree than the other arm.”

Answer:

A common problem after stroke is that people experience strong spasms following coughs, sneezes or even fits of laughter. At other times, the effort of rising from a chair or walking can also cause them.

These spasms most commonly occur in the arm. They can just affect the muscles that close the hand causing the hand to clench into a first, or they can affect the whole arm causing it to clamp tightly against the person’s body.

In the affected leg, these spasms can cause the foot to turn in or the whole leg to shoot out straight.

When these spasms occur frequently, the muscles that go into spasm can become tighter over time – even at rest. Stretching the muscles regularly will prevent this complication.

I would strongly advise that appropriate stretches are taught by a specialist Neurological Physiotherapist following a thorough assessment to avoid injury and ensure success. By improving the way the person rises from sitting, or their walking technique, these spasms can be reduced in intensity or even prevented.


Recovery Time

Question: 

“Hi there, I had my stroke on 15/1/09. I am up using a stick, my arm is still very weak – using Saeboflex. I came out of rehab on May 20th, but have gone back in.

Some people have told me that it takes the brain a year to start to heal and that they felt better after a year. Is this fact or fiction? Thanks.”

Answer:

Historically, it was believed that once the brain was damaged, it could not be healed. Research over the last 25 years has however shown that the undamaged parts of the brain can learn how to do the functions that the damaged part can no longer perform.

Immediately following a stroke the whole brain can be in shock, so even the unaffected side can appear weak. There is also swelling around the damaged area. This swelling interferes with the functioning of the neighbouring brain centres and exaggerates the initial effects of the stroke.

Much of the early recovery following a stroke is the brain coming out of shock (few days), and the swelling reducing (few days to a few months). Thereafter, recovery involves the undamaged part of the brain in learning how to perform the tasks that the damaged area used to do. This learning process can go on for many years after the stroke.

Depending on the severity of the stroke, many people “feel better” after a year, for others it may be quicker, but for some much longer.

I have seen progress in stroke survivors 5 or 10 years after their stroke. Exercising, whether as part of a Different Strokes exercise class, or using a device such as the Saeboflex has a vital part to play in recovery.


Spasticity

Question: 

“I suffer from severe spasticity in my right side (hand). What would be the preferred treatment for this?

I have been doing some research into botulinum injections but have also come across saeboflex. Which one would you recommend here?”

Answer:

Muscles require a barrage of messages from the brain to switch on and switch off. Following a stroke, parts of the brain no longer send enough messages to tell muscles to “switch off” or “relax” after they have worked. For example, the muscles that close the hand into a fist are not told “loudly enough” to relax.

Also the messages to the opposite muscles may not be sent in sufficient quantities. So the muscles that should open the hand are not told “loudly enough” to work. Sometimes they do try to work, but they can’t compete with the “power” of the muscles that have not “switched off”. The hand remains clenched in a fist. If this goes on for a number of weeks and months, the muscles that have not been switching off, remain “switched on” and also become physically shorter–this combination is often referred to as spasticity.

Botulinum is a drug that is injected into the spastic muscle by either a Doctor or a suitably trained Specialist Physiotherapist. It effectively switches off these muscles. It is like putting a child safety plug into a household electrical socket. The mains supply is unaffected, but the appliances cannot be powered by the blocked socket. It then allows the shortened muscle to be stretched more easily and the muscles that open the hand no longer have to compete with these muscles and they can get stronger. Many times, a course of injections is required as the effects of the drug completely wear off after three to four months.

The Saeboflex is a hand and wrist splint that uses springs to encourage the “switched on” muscles to relax and open the hand. By gripping soft foam balls against the resistance of the springs, the muscles that open the hand are actually strengthened because these muscles also have a role in supporting the wrist during gripping. The user though has to have some recovery in their shoulder and elbow movements, and they have to be able to partially close their hand, e.g. squeeze a ball (even a little). It is an exercise device to improve opening and closing. It is not for using as an aid for gripping during everyday life.

If the Spasticity can be overcome by the Saeboflex, then Botulinum may not be required. Sometimes though, a combination is required. For further information on the Saeboflex go to www.saebo.com. If you would like to see a video diary of someone using a Saeboflex go to www.physiofunction.co.uk/pftv.html.


Types of Therapies

Question: 

 “It might be useful for other parents to be aware of the types of therapies that are available: e.g. splints for strengthening limbs with hemiplegia, Botox injections for hands/feet with clenching problems etc. I’ve only just heard of Botox treatment for instance via other mums and Great Ormond Street Hospital have this week agreed that it could make a remarkable difference to my son’s hand clenching problems. This is almost 3 years after his stroke!”

Answer:

When Botulinum toxin is injected into a spastic (tight/overactive) muscle, the toxin blocks the connection between the muscle and the nerve endings – much like the plastic child-safety plugs for domestic electrical sockets. Hands held in a tight fist by spastic muscles can be aided by these injections. It takes 10-15 days to take effect. At this point, by using a splint for 6 hours a day, these muscles can be gently stretched.

After 2 weeks, a new splint is required to further stretch the muscles. This process, called serial splinting, continues until the desired hand and wrist position is achieved. The splints can either be custom-made from thermoplastic materials and re-shaped by an Occupational Therapist, or an off-the-shelf one can be used such as the Saebostretch (www.saebo.com ) or one of the range of OCSI splints (http://trulife.com/Brochures/ocsi-pages-brochure.pdf ). The latter do require that your therapist is experienced in adjusting thermoplastic splints. Both are comfortable and well tolerated.

Splints in themselves are not strengthening aids. However, stretching the spastic muscles can make it easier for the weaker opposing muscle to work. So if the muscles that clench the fist are stretched, muscles that open the hand can do so more easily.

If the hand is held in a tight fist, but the muscles are not spastic but are contracted (shortened), then Botulinum toxin injections will not be effective. In this case, using electrical muscle stimulation for the muscles that open the hand and lift the wrist can assist in stretching the contracted muscles. This can take many months and often still requires serial splinting. Muscle stimulators such as the Intellistim BE-28E (www.naturesgateuk.com ) can be purchased on-line. However, I recommend that anyone considering this option first consults their Physiotherapist for advice on whether it is appropriate, and then for setting up and monitoring safe and effective use of the device.