Life after stroke: How to improve movement and control

Those who have suffered loss of limb function after the trauma of stroke now have new hope in the form of emerging therapies, promoting significant improvements in movement and control.

Nearly 60,000 Australians had a stroke last year alone, and this number will rise as our population ages. Unfortunately, those who survive can be left with severe damage in the area of the brain regulating movement. This is known as PSS, or post-stroke spasticity, which can have both physical and mental consequences.

It’s an incredible burden for sufferers and carers, not to mention the social stigma attached to these types of conditions. So it’s with great hope that we discuss available treatments to help those affected by PSS.

Common symptoms of PSS include:

Muscle stiffness and a feeling of tightness, especially in the upper limbs;
Loss of control of small movements, like flicking the pages of a book;
Loss of normal limb movements, like picking up a jar;
Muscle overactivity leading to a reduced ability to relax. Overactivity of the muscles can be associated with very tight or flexed muscles;
Muscle spasms like quick jolts of the muscles;
Changes in limb posture; and
Muscle fatigue, which feels like the muscles are sore, limp and tired.

People who have had a stroke and who experience any of these symptoms must attend rehabilitation via a neurologist or rehabilitation physician right away.

Learning to live with PSS

John Olver, Professor of Rehabilitation at Monash University, said:

"In my opinion, the greatest challenge for people who have developed post-stroke spasticity is to maintain the range of movement and function in affected limbs."

After a stroke, most people will be impaired on one side of their body, known as hemiparesis. While not everyone will develop spasticity, nearly everyone will suffer motor problems. As the time after a stroke increases, so does the chance of eventually developing some spasticity.

If someone is experiencing pain after a stroke, it’s vital they monitor their symptoms and go to regular check-ups.

Professor Olver said:

"It is important for people who have suffered a stroke to monitor themselves for symptoms, as early intervention with physical and perhaps pharmaceutical treatments can prevent permanent effects such as, in the case of post-stroke spasticity, joint contracture and permanent loss of function."

Ian Cameron, Consultant Physician of Rehabilitation Medicine, said it is imperative for patients "to maximise recovery, to limit disability and to be involved in activities to prevent a further stroke."

There are ways to ensure a person with PSS or their carer can ensure the best possible outcome as time progresses.

Taking control: You can check yourself

You are in the best position to monitor, observe and report any post-stroke symptoms to your healthcare team. The first three months are the most important, so be vigilant and get on top of any changes as they may occur.

Spasticity is more commonly formed in the upper limbs, namely the biceps, wrist, thumb and finger flexors, although there are cases where lower limbs are involved, so keep this in mind.

Professor Olver said:

"In many cases the first symptom of PSS will be tightness or stiffness in muscles, which the patient can find restricts movement. In some cases, pain will occur as a result of muscle spasm."

In this way, control is in your hands and there are ways to get the best from your treatment.

What to expect at the doctor’s

Muscles are tested with specific "rating" tools, such as a Modified Ashworth Scale. The more the muscle "resists" the therapist’s attempt to move it, the higher the degree of spasticity.

The degree of spasticity can change with various positions, tasks and movements, and therefore a well-rounded review using multiple tests, settings and movement-related tasks will be conducted by your specialist. Expect a thorough assessment when you attend, and questions such as:

How are you coping physically with your condition?
How are you coping mentally with your condition?
Are you experiencing pain or discomfort?
Are you having difficulties sleeping or performing day to day activities?
Are you aware of any increased muscle stiffness?

How is PSS treated?

Professor Cameron said:

"The major treatment aims for post-stroke spasticity are to relieve symptoms if that is what the person wants, and sometimes to try to improve functioning."

Whether or not medication is used, physical therapy should always be a part of any treatment for this condition. Medications are usually only given when there is considerable pain or discomfort or if the condition is affecting their personal care, as side effects may outweigh the benefits.

The current leading pharmacological intervention for treating spastic muscle is botulinum toxin type A (Botox, Dysport) injections directly into the muscles of concern. This safe and well tolerated treatment has been shown to significantly reduce both upper and lower limb spasticity resulting from stroke, and has been reported to improve quality of life, especially if treatment is started early.

Professor Cameron said:

"The therapies that are the most successful for post-stroke spasticity are the ones that are geared to attaining a functional goal that is important to the person who has had the stroke."

This way, you can make sure that your therapy will target the specific movements you know you will need in day to day life.

Stretching, vibration and splinting the muscles have also been shown to work. EMG biofeedback also helps, allowing people to control their muscle tension by learning to be consciously aware of it.

Stay vigilant

All the evidence really points towards monitoring the changes in control and function in post-stroke patients so that treatment can start immediately if symptoms worsen. Don’t be afraid to be diligent and exact about reporting symptoms and asking questions – because this will be the best way to ensure one’s life after stroke can be maintained as well as possible.

References

National Stroke Foundation Australia. Facts, figures and stastistics [online]. National Stroke Foundation Australia; 2010 [cited January 2010]. Available from URL: http://www.strokefoundation.com.au/facts-figures-and-stats
Wissel J, Ward AB, Erztgaard P, Bensmail D, Hecht MJ, Lejeune TM, et al. European consensus table on the use of botulinum toxin type A in adult spasticity. J Rehabil Med. 2009;41(1):13-25.
Zetterberg L, Aquilonius SM, Lindmark B. Impact of dystonia on quality of life and health in a Swedish population. Acta Neurol Scand. 2009;119(6):376-82.
Sommerfeld DK, Eek EU, Svensson AK, Holmqvist LW, von Arbin MH. Spasticity after stroke: Its occurrence and association with motor impairments and activity limitations. Stroke. 2004;35(1):134-9.
Patel AT. Early diagnosis of post-stroke spasticity and treatment options. Brain Trauma: Stroke; Touch Briefings. 2009: 47-51 [online]. Touch Neurology; 2010[cited March 2010]. Available from URL: http://www.touchneurology.com/files/article_pdfs/patel_0.pdf
Lundström E, Terént A, Borg J. Prevalence of disabling spasticity 1 year after first-ever stroke. Eur J Neurol. 2008;15(6):533-9.
Rosales RL, Chua-Yap AS. Evidence-based systematic review on the efficacy and safety of botulinum toxin-A therapy in post-stroke spasticity. J Neural Transm. 2008;115(4):617-23.
Patrick E, Ada L. The Tardieu Scale differentiates contracture from spasticity whereas the Ashworth Scale is confounded by it. Clin Rehabil. 2006;20(2):173-82.
Ward AB. Spasticity treatment with botulinium toxins. J Neural Transm. 2008;115(4):607-16.
National Stroke Foundation. Clinical Guidelines for Stroke Rehabilitation and Recovery [online]. Melbourne:National Stroke Foundation; 8 September2005 [cited January 2010]. Available from URL: http://www.strokefoundation.com.au/post-acute-health-professional
Scheinberg A. Clinical use of botulinum toxin. Aust Prescr. 2009; 32: 39-42.
Levine P. Testing spasticity: The Modified Ashworth Scale [online]. Merion Publications: Advance forPhysical Therapy and Rehab Medicine; 2 June2009 [cited January 2010]. Available from URL: http://physical-therapy.advanceweb.com/Article/Testing-Spasticity-The-Modified-Ashworth-Scale.aspx