Stroke rehabilitation

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The following leaflets are available in this series. The Stroke Association What is a stroke? Preventing a stroke When a stroke happens After a stroke Stroke rehabilitation The Stroke Association also produces factsheets on specific stroke issues. To find out how to order leaflets or factsheets, or for more information on strokes, phone 0845 3033 100, email [email protected] or visit our website at www.stroke.org.uk. We distribute two million free leaflets and factsheets every year. Help us to continue this vital service by making a donation on our website or by phoning 01604 623943. If you have any complaints about The Stroke Association, please contact us immediately on 0115 8402683. We will happily discuss and try to sort out any problems.
The Stroke Association is registered as a company limited by guarantee in England and Wales number 61274. Registered charity number 211015 and registered charity in Scotland number SC037789. Copyright The Stroke Association June 2008

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The Stroke Association

At 29 I had my first stroke. Two years later it happened again, only this time it was worse. I lost both sight and speech, and I couldnt stand. Brad Francis

Every year, an estimated 150,000 people in the UK have a stroke. Thats one person every five minutes. Most people affected are over 65, but anyone can have a stroke, including children and even babies. Around 1000 people under 30 have a stroke each year. A stroke is the third most common cause of death in the UK. It is also the single most common cause of severe disability. More than 250,000 people in the UK live with disabilities caused by a stroke. If it happens to you, or someone you care for, youll want to know as much as you can about what happens afterwards how to work towards getting back to normal life as much as possible, or learning to live with the long-term effects of a stroke. This leaflet looks at the ways in which people who have had a stroke can regain skills and adapt to life after a stroke, and the professionals who can help.

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I was in my office, when suddenly the light went out. My colleagues got the medics a few minutes later, and that helped with the brain damage. They worked on me in the ambulance for an hour before taking me to the hospital. David Diston

A stroke is a brain attack

A stroke is what happens when the blood supply to part of the brain is cut off. Blood carries essential nutrients and oxygen to the brain. Without the blood supply, brain cells are damaged and may die. Because the brain controls everything that the body and mind does, damage to the brain can affect: body functions moving, swallowing, breathing, seeing and hearing; and mental functions thinking, speaking learning, feeling and understanding. People who have had a stroke often have a combination of problems, such as weakness on one side of the body and difficulty communicating. Every stroke is different and people are affected in different ways. The symptoms of a stroke can last for a short time (a transient ischaemic attack (TIA) or mini-stroke), or they may last for a longer time leading to long-term disabilities.

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The Stroke Association

Recovery means getting better, rehabilitation means learning ways to overcome or adapt to the effects of a stroke.

Recovery and rehabilitation

Recovery begins as people get better from the immediate effects of a stroke. Over months and even years, other areas of the brain might learn to take over from the dead areas. About a third of people who have had a stroke are left with disabilities. Rehabilitation is the process of overcoming or learning to cope with the damage the stroke has caused. It is about getting back to normal life and achieving the best level of independence you can, by: relearning skills and abilities; learning new skills; adapting to some of the limitations caused by a stroke; and finding social, emotional and practical support at home and in the community.

The stroke team

Rehabilitation starts in hospital, with the multidisciplinary team involved in care. The team includes specialist doctors, nurses and therapists. See The Stroke Association leaflet When a stroke happens for more information on the hospital team.

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Stroke rehabilitation

Physiotherapy uses exercises and massage to keep muscles and joints working properly.

Physiotherapy
A stroke can cause weakness or paralysis in one side of the body and problems with balance or co-ordination. Physiotherapy helps to regain as much mobility and muscle control as possible. Physiotherapy begins very soon after a stroke, at home or in hospital. If the person cannot move, the therapist first makes sure they are correctly positioned in their bed and changes their position regularly to stop their muscles and joints from getting stiff. If the person who has had a stroke finds it difficult to stay upright in bed or in a chair, the physiotherapist will work with them to regain balance. When they are ready, they might move on to standing with the support of equipment or other people, and then to moving around safely. Treatment for weak or paralysed limbs starts with small guided movements and practising simple tasks. As the person begins to improve and build up strength, they will be shown larger movements and more complicated exercises that encourage both sides of the body to work together. This will help them to stop overusing the side of their body that is unaffected by the stroke.

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The Stroke Association

The aim of occupational therapy is to find practical solutions that let the person live as full a life as possible. Referral to an occupational therapist may happen in hospital, or through professionals in your community such as your GP or social worker.

Occupational therapy
Problems with movement, co-ordination and perception can make it hard to perform everyday activities things we take for granted like washing, dressing, eating and going up stairs. The occupational therapist helps the person with these basic tasks and other activities, such as shopping and cooking. The occupational therapist can help the person return to their normal hobbies and leisure activities or to take up new ones, learn skills they might need to return to work, or overcome problems with memory or concentration. Occupational therapy uses a range of techniques suited to different situations and disabilities. These may include learning to eat or dress with one hand, using memory aids such as lists or a diary, or practising physical or mental skills through crafts and board games. Therapy usually starts with simple activities, then moves on to more complicated ones as the person progresses.

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Stroke rehabilitation

Language often improves more slowly than other difficulties, but it continues to improve for longer. It is important to stay positive and keep up with regular therapy.

Speech and language therapy

A stroke can affect communication skills the ability to speak, read, write and understand. The speech and language therapist assesses each persons difficulties and develops appropriate techniques. Aphasia Aphasia (also known as dysphasia) is difficulty using and understanding spoken and written language. A person who has aphasia may know what they want to say but cant find the words. It may be hard for them to understand what others are saying, even if their hearing and thought processes are not affected. Therapy can help people recognise words or find other ways to communicate, like using gestures, word-and-picture charts, symbols or computers. Dysarthria, dyspraxia and dysphonia Dysarthria is when a stroke affects the muscles in the face, making it difficult to form words. Dyspraxia is difficulty with complicated tasks, which means that the person may find it hard to speak or understand conversation. Dysphonia is when a stroke affects the muscles in the voice box, changing the way the voice sounds and making it hard to moderate the voice.

The Stroke Association

Tips for safe swallowing Make mealtimes quiet and relaxed dont rush. Have small, frequent meals. Only take a teaspoon at a time and make sure you have swallowed it before having any more.

Swallowing
A swallow test is one of the first hospital assessments. Initially this involves seeing if the person can swallow a little bit of water without coughing or choking.

Dont mix food and drink in the same mouthful. Dont try to talk when you are eating. Sit upright for half an hour after each meal.

If the person has difficulties swallowing, they will be seen by a speech and language therapist, who can assess the problem and work out a diet that is easy to eat. Some people will need pured solid food and thickened drinks. A dietitian will make sure the diet has all the right nutrients. Whether the person who has had a stroke is feeding themself or having help, they will have to learn how to sit correctly and proper eating methods to prevent food and drink from getting into their windpipe (this is called aspiration). In severe cases, if a person cannot eat by mouth, special feeding techniques might be used. Nasogastric feeding is when a tube is passed up the nose and down the throat to get food into the stomach. Percutaneous endoscopic gastrostomy (PEG) is a feeding tube that goes into the stomach directly through the abdominal wall.

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Stroke rehabilitation

I was walking to work, and suddenly I went blind in one eye. I stood still for five minutes to work out what was going on. My vision came back and I felt light-headed. I went to the canteen and thought I was going to pass out. Claire Simpson

Vision and eyesight

Often a stroke causes double vision, blurred vision or partial blindness. Sometimes people cannot see anything on the right or left (hemianopia), which can lead to difficulty with balance, co-ordination or recognising familiar things or people. A physiotherapist or occupational therapist can help with movement and exercises to compensate for, or cope with, areas of blindness. A clinical psychologist can help with problems to do with processing information, like recognising familiar things or people. An ophthalmologist or optician can recommend vision aids like glasses or an eye patch. An orthoptist can help with eye-movement problems and explain ways of coping with reading difficulties.

Sensation
A stroke can cause disturbances in sensation, such as a decrease or increase in sensation, unpleasant feelings of hot or cold and tingling, like pins and needles. Physiotherapy might be able to ease some of these feelings.

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The Stroke Association

The most common types of continence problems include: urgency feeling a desperate need to pass urine; frequency needing to pass urine often; incontinence not managing to get to the toilet in time; and bedwetting while asleep (called nocturnal incontinence).

Using the toilet (continence)

Having problems controlling the bladder and bowels is common after a stroke. Incontinence may be caused by nerve damage, loss of muscle control, change of diet and being bedbound. Communication and mobility problems can make it worse the person may find it difficult to make other people understand that they need the toilet, or they may not be able to get to the toilet in time. Most people regain control quickly, but help is available from the following if necessary. A continence adviser a specialist nurse who can develop a rehabilitation plan, including bladder retraining to help hold on, pelvic floor exercises to strengthen muscles, and continence aids like pads and bed covers. A physiotherapist who can teach exercises to improve walking and using a commode or toilet. An occupational therapist who can advise on how the persons home can be adapted or what equipment would make it easier to use the toilet.

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Stroke rehabilitation

A combination of medication and psychological therapy or counselling is often the most effective treatment for depression.

Psychological changes
Feelings of anger, despair, frustration and grief are all normal for people who have had a stroke and their families. Changes in areas of your life, such as health, sexual relationships, work, money and dealing with a loss of abilities and confidence can lead to anxiety and depression. The tiredness that usually follows a stroke can also make depression worse. The person may find it hard to control their emotions. Dramatic mood swings and sudden outbursts such as crying or laughing at the wrong time can be due to the damage the stroke has caused to their brain. Helping to understand, and cope with, these symptoms and feelings is an important part of rehabilitation. If symptoms are severe or last a long time, a GP may refer the person to a clinical psychologist or psychiatrist for expert advice.

Mental processes
It is common for a stroke to cause problems with mental processes such as thinking, concentrating, remembering, making decisions, reasoning, planning and learning. A clinical psychologist can help assess these difficulties and find ways of overcoming them. For example, people who have memory

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The Stroke Association

He has lost confidence, he cant walk, his speech isnt very good, and he has poor short-term memory. Its a real struggle. Susies husband John was 59 when he had a stroke.

loss might need to keep notes to remind themselves to do routine things. Someone with concentration problems may need to learn to take things more slowly and avoid distractions.

Helping rehabilitation
Unfortunately, however natural it is to feel depressed and anxious, negative feelings will get in the way of progress. Its important for the person to focus on what they want to achieve and stay positive. Here are some tips. Practise the tasks therapists have taught between therapy sessions but dont exhaust yourself. Understand why each task has been set. This will help keep you motivated. Remember that recovery can be gradual and even when progress is slow it is worth persevering. Dont push people away. Talking to others, or even just being with other people if you have difficulty communicating, can stop you becoming isolated and withdrawn. Stay healthy. Plenty of sleep, a good diet and regular physical exercise are all important. Dont despair if you dont fully regain your previous abilities. Enjoy the best quality of life and independence that you can.

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Stroke rehabilitation

Tips for carers

Be patient. Rehabilitation is a slow and often frustrating process. Dont worry if there are days when little progress seems to be made. Be positive. Constant encouragement and praise are needed to keep up everyones spirits. Get the right balance between helping and encouraging the person to gain independence and confidence by doing things for themselves. Set a daily routine that everyone can stick to. Build in short but regular periods in the day to practise exercises and learn skills. Make time for yourself. Seeing your own friends and having your own hobbies is an important way to keep up your strength and patience.

Support at home
Family and friends can help in many ways. For example, they can: help practise exercises between therapy sessions; give emotional support and keep the person motivated towards long-term goals; adapt to the persons needs, for example, speaking more slowly and using gestures if they have communication problems; and learn techniques for dealing with difficult situations, such as how to help the person get up if they have a fall.

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The Stroke Association

For information and advice, and to find out about services near you, call the Stroke Helpline on 0845 3033 100. You can also find more information about useful products and services on our website at www.stroke.org.uk.

Rehabilitation in the community

Help is available if you need practical advice or simply someone to talk to. Stroke clubs are a good way for people who have had a stroke and their families to socialise, build up confidence and talk to other people who have had similar experiences. There are stroke clubs available in England, Wales and Northern Ireland. A GP can help with medical problems and make referrals to other specialists. The Stroke Associations Rehabilitation and Support Services are available in some areas. Social workers and therapists can give information on making adaptations to the home and finding special aids or equipment.

Gadgets, equipment and home adaptations

A physiotherapist, occupational therapist or social worker can assess a persons needs and arrange for: mobility aids, such as a walking stick or wheelchair; adaptations to the home, such as ramps and handrails; and specialist equipment and gadgets, to make it easier to manage tasks at home.

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Stroke rehabilitation

The Stroke Association

Working for a world where there are fewer strokes and all those touched by stroke get the help they need.

Every five minutes someone in the UK has a stroke. A stroke doesnt discriminate. It can happen to anyone at any time in their life. Strokes are sudden and their consequences can be devastating. The Stroke Association is the only UK charity solely concerned with helping everyone affected by stroke. Our vision is to have a world where there are fewer strokes and all those touched by stroke get the help they need. Stroke Helpline: 0845 3033 100 Website: www.stroke.org.uk Registered office: The Stroke Association Stroke House 240 City Road London EC1V 2PR. Email: [email protected] Textphone: 020 7251 9096
The Stroke Association is a UK-wide organisation with offices in Scotland, Wales, Northern Ireland and the nine English regions. You can find more contact information on our website.

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Stroke rehabilitation (6)