Physical Therapy Guide to Stroke
Stroke (when a blood vessel in the brain is blocked or ruptured) is the third leading cause of death in the United States, and is a leading cause of serious, long-term disability in adults. Stroke can happen to anyone at any time—regardless of race, sex, or even age—but more women than men have a stroke each year, and African Americans have almost twice the risk of first-ever stroke than Caucasians. Approximately two-thirds of those who experience a stroke are over 65 years of age. Almost 800,000 people in the United States have a stroke each year. Physical therapists provide treatments for people who have experienced stroke to restore their movement and walking ability, decrease their disability, and improve their quality of life.
If you have 1 or more of the following symptoms, immediately call 911 or emergency medical services (EMS) so that an ambulance can be sent for you:
- Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body
- Sudden confusion or trouble speaking or understanding
- Sudden trouble seeing in one or both eyes
- Sudden trouble walking, dizziness, loss of balance or coordination
- Sudden, severe headache with no known cause
If You Think Someone Might Be Having a Stroke
Act F.A.S.T.! Emergency treatment with a clot-buster drug called t-PA can help reduce or even eliminate problems from stroke, but it must be given within 3 hours of when symptoms start. Recognizing the symptoms can be easy by remembering to think F.A.S.T.
F=Face. Ask the person to smile. Does one side of the face droop?
A=Arms. Ask the person to raise both arms. Does one arm drift downward?
S=Speech. Ask the person to repeat a simple phrase. Does the speech sound slurred or strange?
T=Time. If you observe any of these signs, call 911 and note the time that you think the stroke began.
Research shows that people with stroke who arrive at the hospital by ambulance receive quicker treatment than those who arrive by their own means.
What Is Stroke?
Stroke is a term used when a blood vessel in the brain is blocked (65% of all strokes) or ruptures. It is also called a cerebral vascular accident (CVA). If the blood flow is stopped or altered, a part of the brain does not receive enough oxygen. Millions of brain cells die every minute during a stroke, increasing the risk of permanent brain damage, disability, or death.
- An ischemic stroke, the most common type, occurs when a blood vessel is blocked. One frequent cause of blockage is a blood clot or a build-up of fatty deposits (arteriosclerosis) in blood vessels that supply the brain.
- A hemorrhagic stroke occurs when a blood vessel leaks or ruptures because of a weakened region of a vessel or in an area of the brain with a cluster of abnormally formed vessels.
Signs and Symptoms
If you are having a stroke, you might:
- Feel a sudden numbness or weakness of the face, arm, or leg, especially on one side of the body
- Be confused about where you are or what you're doing
- Have trouble speaking or understanding what others are saying
- Have trouble seeing in one or both of your eyes
- Have trouble walking, be dizzy, or lose your balance
- Have a sudden, severe headache that seems to come out of nowhere
Some people experience a transient ischemic attack (TIA), a "mini-stroke" that produces stroke-like symptoms, but no permanent damage because the blood flow is altered for only a short period of time. Recognizing and seeking treatment for TIAs can reduce your risk of a major stroke.
Stroke can cause a range of long-term problems, such as:
- Inability or difficulty moving one side of the body (hemiparesis or hemiplegia)
- Severely limited movement or stiffness in the arms and legs (spasticity)
- Balance problems
- Weakness on one side of the body
- Off-and-on numbness
- Loss or lack of sensation
- Sensitivity to cold temperatures
- Memory loss
- Slowed or slurred speech
- Difficulty remembering words
How Is It Diagnosed?
Physicians or emergency medical personnel will assess a stroke based on the signs and symptoms. Stroke is often confirmed by examining the patient, using clinical tests and taking images of the brain, usually with a CT scan or MRI. Since research has proven that early treatment can reduce the effects of stroke and save lives, efforts are being made to get persons suspected of having a stroke to a hospital stroke unit, rather than the emergency department. Physicians may use a classification system, called TOAST, to determine the type of stroke, so that treatment can begin quickly.
How Can a Physical Therapist Help?
Physical therapists are part of the stroke rehabilitation team. Rehabilitation begins very soon after a stroke; your physical therapist’s main goal is to help you return to your activities at home, at work, and in your community.
After examining you and evaluating your condition, your physical therapist will develop an individualized plan to help you achieve the best possible quality of life. The plan will focus on your ability to move, any pain you might have, and ways to prevent problems that may occur after a stroke.
One of the first things your physical therapist will teach you is how to move safely from your bed to a chair, and to perform exercises in bed. As you become more mobile, your physical therapist will teach you strengthening exercises and functional activities.
Later, your physical therapist will:
- Help you improve your balance and walking.
- Fit you with a wheelchair, if needed.
- Provide training to your family and caregivers.
- Train you in how to use devices that can help you keep mobile when a stroke has affected your ability to move, walk, or keep your balance: orthoses, prostheses, canes, walkers, wheelchairs, and perhaps even robotics.
Treatment for stroke varies. Your specific treatment will depend on the results of your physical therapist's evaluation, and on how long it's been since you had your stroke. Recovery from a stroke depends on the size and location of the stroke, how quickly you received care, and your other health conditions. Your physical therapist will help you regain functional skills to allow you to participate in your specific life activities.
Relearning How to Use Your Upper Body, How to Walk, and How to Perform Daily Activities
Your physical therapist will design an exercise and strengthening program based on tasks that you need to do every day, selecting from a variety of treatments. Physical therapist researchers are at the forefront of innovating many of these techniques:
- Constraint-induced movement therapy (CIMT). CIMT is used to strengthen an arm affected by the stroke. Your physical therapist will apply a mitten or a sling on your strong arm to keep you from fully using it. This constraint "forces" you to use your arm or hand affected by the stroke to perform daily tasks, which helps build your strength and control. CIMT requires that the constraint be used for several hours a day, several days a week to be successful.
- Functional electrical stimulation (FES). This treatment helps move your muscles if they are very weak. For instance, your physical therapist might use FES to treat a painful or stiff shoulder.
- Motor imagery and mental practice. These tools are used to help strengthen the arms, hands, feet, and legs. Working with your physical therapist, you will "rehearse" a movement without actually performing it, which stimulates the part of your brain that controls the movement.
- Positioning. Proper positioning helps reduce any muscle pain, spasms, slowness, or stiffness that can result from stroke. Your physical therapist will teach you how to safely move ("transfer") from a sitting to a standing position, and how to support yourself when sitting or lying down, using foam wedges, slings, and other aids.
- Virtual reality and interactive video games may be used to provide experiences similar to real life. Using a keyboard and mouse, a special wired glove, or sensors on your body, you can practice daily tasks as your therapist helps you "rewire" your brain and nerve connections. Your therapist may teach you how to continue these activities at home.
- Partial body weight support (BWS). BWS is used to help support you as you walk, usually on a treadmill. Your physical therapist will gradually decrease the amount of support as your posture, strength, balance, and coordination improve.
- Biofeedback. This treatment helps make you aware of how your muscles work and how you might be able to have better control over them. Your therapist will attach electrodes to your skin to provide measurements of muscle activity that are displayed on a monitor. Your physical therapist will work with you to help you understand and change those readings.
Your needs will change over time, and your physical therapist may consider using aquatic therapy, robotics, or support devices to assist in your recovery. Even after rehabilitation is completed in a facility, your physical therapist will continue to see you as needed to assess your progress, update your exercise program, help you prevent further problems, and promote the healthiest possible lifestyle.
Can This Injury or Condition Be Prevented?
The American Stroke Association has estimated that 80% of strokes can be prevented. Some risk factors for stroke can't be changed—such as family history, age, gender, race (stroke death rates are higher for African Americans, even at younger ages), and previous heart attack or stroke. Many causes of stroke can be reduced by lifestyle changes:
- Contact a physician if you suspect you have high blood pressure, and take your medication as prescribed. High blood pressure (hypertension) causes approximately one-half of all strokes.
- If you are a smoker, join a program to quit smoking. The CDC (see below link) offers resources for quitting.
- Reduce high cholesterol by following the recommendations of your health care provider.
- Manage diabetes by following recommendations and taking prescribed medication.
- Obtain treatment if you have been diagnosed with carotid artery disease.
- Engage in daily physical activity for general health and to reduce obesity. Your physical therapist is an expert at designing a health and wellness activity plan specifically for you.
- Reduce your alcohol intake.
Real Life Experiences
Diane is a 67-year-old retired teacher who recently celebrated her birthday with a group of friends, one of whom had experienced a stroke. Diane listened as her friend described the symptoms that made her call 911.
Just this week, Diane recognized that she might be having a stroke when she was making her lunch and suddenly dropped a spoon she was holding in her left hand. She couldn’t pick up the spoon and her entire left arm felt weak. She immediately called 911 for help, and by the time the ambulance arrived, she was seated because she didn’t think her left leg could support her weight.
Diane was immediately taken to her local hospital's established stroke unit. The medical staff used clinical and imaging tests to confirm an ischemic stroke. Diane was treated with medication to dissolve the blood clot and restore blood flow in the brain. Because Diane immediately received treatment, there was minimal damage to the brain. The next day, a hospital physical therapist visited Diane in her room.
Diane reported only mild weakness and numbness on the left side of her body. After assessing Diane, her physical therapist designed a strengthening and walking program based on her needs. Diane learned how to safely get out of bed and use a walker for moving short distances.
Diane was moved to the rehabilitation unit in the hospital, where she began walking and balance training on a treadmill with some support to prevent falling. As she improved her walking skills, the support was reduced. Diane was discharged from the rehabilitation unit when she was able to use a cane for walking. She continued out-patient physical therapy.
Diane's physical therapist designed an individualized treatment program that included coming to therapy for strengthening and balance activities for independent walking. He also prescribed community activities that Diane could participate in with a friend to supervise her, to help her gain endurance in various environments.
Eight weeks later, Diane was able to walk independently, climb stairs, and fully return to her community activities. Upon her discharge from physical therapy, her physical therapist reminded Diane of the importance of daily physical activity to maintain her health, and encouraged her to remember the warning signs of another stroke. He assured her that he and her medical team would always be ready to help!
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat a variety of conditions or injuries. You may want to consider:
- A physical therapist who is a board-certified clinical specialist in neurology (called NCS) or who completed a residency or fellowship in neurologic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
- A physical therapist who is experienced in treating people with problems related to stroke. Some physical therapists have a practice with a neurologic focus.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with stroke.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for a visit with their health care provider.
The following articles and websites provide some of the best scientific evidence related to physical therapy treatment of individuals with stroke. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. Whenever possible, article titles are linked to a PubMed* abstract of the article or to free full text so that you can read it or print out a copy to bring with you to your health care provider.
Centers for Disease Control and Prevention (CDC). Stroke. Accessed September 28, 2015.
National Stroke Association. Myths vs facts. Accessed September 28, 2015.
National Stroke Association. Stroke treatment. Accessed September 28, 2015.
American Stroke Association; American Heart Association. Impacts of stroke (stroke statistics). Accessed September 28, 2015.
Mayo Clinic. Stroke rehabilitation: what to expect as you recover. Accessed September 28, 2015.
National Institute of Health; National Institute of Neurological Rehabilitation. Post-stroke rehabilitation. Accessed September 28, 2015.
National Institute of Neurological Disorders and Stroke. Stroke rehabilitation information. Accessed September 28, 2015.
American Stroke Association; American Heart Association. Stroke treatment. Accessed September 28, 2015.
American Stroke Association; American Heart Association. Spot a stroke. Stroke warning signs and symptoms. Accessed December 7, 2015.
Centers for Disease Control and Prevention. I'm ready to quit! Smoking cessation programs. Accessed December 7, 2015.
PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Authored by Judith Deutsch, PT, PhD, FAPTA and APTA's Section on Neurology. Revised by Venita Lovelace-Chandler, PT, PhD, board-certified clinical specialist in pediatric physical therapy, and Yasser Salem, PT, PhD, board-certified clinical specialist in neurologic and pediatric physical therapy,. Reviewed by the editorial board.