Physical changes

The effects of a stroke can touch every aspect of your life. A stroke does not affect any two people in exactly the same way. That’s why you, and those who care for you, need to find an approach that works.

While every stroke is different, here are some of the most common changes:

• Walking and moving
• Using your hands and arms
• Eating and swallowing
• Bowel or bladder control and toilet safety
• Expressing yourself and understanding others
• Energy level
• Pain

Walking and moving

After a stroke, you may have trouble walking, getting up from a chair, or other physical activities. The cause is loss of strength, feeling, and coordination, usually on one side of the body. Problems with coordination and balance also occur.

Looking at your abilities

To find out more about your abilities, your healthcare team may test:

• how well you can safely walk in a straight line
• how well you can move from sitting to standing, from bed to chair, in and out of the bath, and on and off the toilet
• the strength and flexibility of your muscles
• the range of motion of your joints

Helpful tips

Moving around safely
Your healthcare team may recommend devices such as a cane, walker, or wheelchair, and grab bars or special seating in the washroom.

Getting your strength and abilities back
Stronger muscles help support your joints and give you more “staying power” when you are moving around. Your rehab program might include exercises to help you build stronger muscles. This not only helps you regain your abilities, but also prevents stiffness and tightness from non-use.

Preventing damage to your joints
Fluids can pool in your joints if you are not using or moving an arm or leg. This can cause swelling, pain and skin problems. Your healthcare team might suggest things like these:

• When you are sitting or lying down, keep your affected leg supported on a stable surface.
• If you are sitting or lying for long periods of time:
  • Exercise in place – for instance, bend, stretch and circle your ankles. Press your feet against a hard surface, If you can, get up on your toes.
  • Be careful not to cross your legs for a long period of time.
  • Do not wear tight socks or hose.
• If it is hard for you to move an arm or leg, have someone help you move it.
• Leg massages help to keep the blood flowing and reduce swelling.

Who can help?

Both the physiotherapist and occupational therapist play a big role on your healthcare team. They will show you safe ways to help get as much function back as you can.

StrokEngine provides information on stroke rehabilitation and interventions from quality articles, websites and systematic reviews. Visit StrokEngine to learn more about lower extremity strength training.

Using your hands and arms

After a stroke, you may have trouble moving your hand and arm. This is because of loss of strength, feeling, and coordination on one side of the body. 

Looking at your abilities

To find out more about your abilities, your healthcare team may test:

• how well you can use your hand and arm muscles
• the strength and flexibility of your muscles
• the range of motion of your joints
• finer movements and coordination in your hand.

Helpful tips

Getting your strength and abilities back
Stronger muscles help support your joints. They give you more “staying power”, whether you are peeling vegetables or dressing yourself. Your rehab program might include exercises to help you build stronger muscles. This not only helps you regain your abilities, but also prevents stiffness and tightness from non-use.

Preventing damage to your joints
Fluids can pool in the joints of limbs you are not using. This can cause swelling, pain and skin problems. Your healthcare team might suggest things like these:

• When you are sitting or lying down, support your affected arm or hand on a stable surface.
• Keep moving your affected arm. Use the other arm to help in the way your healthcare team taught you.
• Massage your arm often.
• If needed, have family members help you with the exercises.

Who can help?

Both the physiotherapist and occupational therapist play a big role on your healthcare team. They will show you safe ways to get as much function back as you can.

StrokEngine provides information on stroke rehabilitation and interventions from quality articles, websites and systematic reviews. Visit StrokEngine to learn more about constraint-induced movement therapy.

Eating and swallowing

There are two kinds of problems with eating after a stroke:

• Dysphagia – problems chewing and swallowing
• Getting food and drink to your mouth with hand or arm problems 

Dysphagia

A stroke can affect the muscles of the mouth, tongue, and throat, as well as the muscles used for breathing. This can lead to trouble swallowing. This is known as dysphagia. It may be temporary or permanent.

If not treated, dysphagia can lead to serious health problems, such as:

• aspiration pneumonia (getting an lung infection from inhaling food)
• malnutrition (not eating enough to stay healthy)
• dehydration. (not getting enough fluids to stay healthy).

Looking at your abilities

Members of your healthcare team will check to see if you are at risk for a swallowing problem. They do this by examining the muscles of your face, mouth, and throat. They will ask you to swallow a small amount of water. You will likely not be allowed to eat or drink until you have come through this test successfully.

If the screening shows that you may have a swallowing problem, a dysphagia expert (usually a speech-language pathologist) will do a detailed exam. This might include getting x-rays while you swallow.

At the same time, your healthcare team will be looking at your overall nutritional state. For instance, are you a healthy weight? Do you have signs of dehydration (not drinking enough)?

Helpful tips

During the early stages of your recovery, your speech-language pathologist and dietitian may order meals for you that are easy to eat. This might include pureed, mashed, or minced foods. You may get liquids that are thickened to the consistency of liquid honey, because they are safer for you to swallow than water or juice. Most stroke patients go back to eating regular food as swallowing improves.

Here are some tips if you have difficulty swallowing or eating:

While you are eating:

• Sit up straight in your bed or chair.
• Take small bites. Try using a teaspoon rather than a tablespoon.
• Chew on the stronger side of your mouth.
• Chew each mouthful well before swallowing.
• Clear your mouth and throat of food after each bite.
• Do not talk while chewing.
• If drooling on the weakened side of your mouth is a problem, wipe your face often with a napkin or cloth.
• Avoid distractions while eating. Turn off the TV or radio. Avoid busy restaurants and dining rooms if you are easily distracted while eating.

After eating:

• Remove food trapped in your cheek with your finger. Use a small mirror to see where food is trapped. Brush your teeth and rinse after each meal.  
• If you get heartburn or acid reflux after eating, try to avoid:
  • spicy or highly seasoned foods
  • citrus fruits and juices, as well as other acidic foods such as tomatoes
  • drinks with caffeine, such as coffee, tea, chocolate and cola
  • peppermint or spearmint
  • high fat, fried foods.

Getting help with eating

Warning: Anyone who wants to help you with eating must first ask a member of the healthcare team to show them how to help. That is because of the danger of choking.

Getting help from the dietitian

Ask the dietitian to explain any special diet you might need. The dietitian can also teach you and your helpers how to prepare foods that are safe for you to eat. Small, frequent meals may be easier to eat and digest. Work with your dietitian to ensure meals are balanced and healthy.

Keeping your mouth clean

Good oral hygiene is important for everyone, but it is crucial in preventing aspiration pneumonia. This lung infection occurs when you inhale food. Make sure you have regular dental check-ups. If you need it, ask for help with brushing and flossing.

Getting enough fluid

Most people need at least 6-8 glasses of fluid a day. This does not include drinks with caffeine in them. Drinks without caffeine include water, fruit juices, milk, and some soft drinks. When you have trouble swallowing, there is a risk you may not drink enough fluids and become dehydrated. Getting enough to drink may be even more difficult if your liquids have to be thickened to make them easier to swallow.

Watch for signs of dehydration. If you are concerned, talk your doctor.

Signs of dehydration include:

• Urinating (peeing) smaller amounts and less often
• Dark, concentrated or strong-smelling urine
• Frequent urinary tract or bladder infections
• Thick, stringy saliva
• Constipation (infrequent, difficult or hard bowel movements)
• Dizziness when sitting up or standing
• Confusion or a change in mental status or state of mind
• Weight loss of 1.5 kg (3.5 pounds) in less than 7 days
• Fever
• Decreased skin elasticity. You can test for this by gently pinching the skin on your arm. If it does not spring back into place, but remains “pinched up”, it may be a sign of dehydration.

Who can help?

The speech-language pathologist will be the key team member in assessing your ability to swallow. The dietitian will help you eat the right foods in a safe and healthy way. If your community does not always have these experts on staff, other members of the healthcare team can still give you the right care and support.

StrokEngine provides information on stroke rehabilitation and interventions from quality articles, websites and systematic reviews. Visit StrokEngine to learn more about dysphagia.

Getting food and drink to your mouth with hand or arm problems

Weakness or paralysis of the hand or arm that a person uses to eat is a challenge when it comes to eating or drinking.

Looking at your abilities

Your healthcare team will look at your ability to eat independently based on the effects of the stroke on your hand and arm.  

Helpful tips

These eating aids can make it easier if you are using only one hand:

• plates with big rims to hold food in
• dishes with gripper pads on the bottom to keep them from slipping
• cup or container holders
• modified cups with a cut-out or partial lid
• knives, forks, and spoons with built-up or bent handles
• cutting utensils made for one-handed use, such as a rocker knife
• a cheese knife or pizza cutter.

Who can help?

Your occupational therapist or another member of your healthcare team can tell you what eating aids may help you and where to get them.

Bowel or bladder control and toilet safety

Stroke patients may face two challenges: 

• Incontinence Many stroke patients have trouble controlling their bowels or bladder. This can be very distressing if you need help getting to the bathroom, especially if you are having trouble communicating. The good news is that over time, many people regain bowel and bladder control. 
• Getting on and off the toilet safely The effects of a stroke may make it harder for many stroke patients to get on and off the toilet safely.

Looking at your abilities

Your healthcare team will assess your ability to go to the bathroom. If you have problems with incontinence, the healthcare team will try to find the cause. It may be an effect of the stroke, or it could be caused by something else, such as a urinary tract or bladder infection.

Who can help?

Nursing and occupational therapy staff can help you manage these challenges after a stroke.

Helpful tips

Bladder control

• Try going to the bathroom at regular intervals (for instance, every 2 hours).
• Get lots of fluids during the day, but limit fluids before going to bed.
• Keep a commode or portable urinal or bedpan next to your bed at night.
• Have a night light in your bedroom.
• Use disposable bed pads or wear absorbent underclothing.

Sometimes, people will try to prevent bladder problems by drinking less. This is not a good idea. Most adults need 6-8 glasses of fluids a day. Drinking too little can lead to dehydration. It can also increase the risk of urinary tract infections.

Loss of bladder control can also be a sign of a urinary tract infection. Talk to your healthcare team if you notice any of these signs:

• a sudden change in your toilet habits, such as needing to urinate much more often
• burning or pain when urinating
• cloudy, strong-smelling urine

Bowel control

• Talk about your diet with the nurse or dietitian on your healthcare team. For instance, you may need more fibre in your diet.
• Certain drugs can affect your bowel habits. Speak with your doctor or pharmacist.

StrokEngine provides information on stroke rehabilitation and interventions from quality articles, websites and systematic reviews. Visit StrokEngine to learn more about urinary incontinence.

Helpful tips to get on and off the toilet safely

These devices help to make it safer and easier to go to the toilet:

• higher (raised) toilet seats
• commode chairs
• portable urinals or bedpans
• grab bars on the wall next to the toilet. 

Before you install grab bars, consult with an occupational therapist to make sure that they get installed correctly.

Expressing yourself and understanding others

If a stroke damages the language centre in your brain, you may have trouble expressing your thoughts and understanding what others say. You may find it harder to read or write. Or, you may find it harder to pronounce words clearly.

The medical names for speech and language problems caused by a stroke are:

• aphasia
• apraxia
• dysarthria

Aphasia

Aphasia makes it hard to express and understand language, both spoken and written. The amount of disability depends on where the stroke took place in the brain and how much damage there was. Aphasia often happens to people who have had a stroke in the brain’s left hemisphere.

There are two broad types of aphasia:

Expressive aphasia means you have trouble getting the message out. You know what you want to say but the words do not come out right.

Receptive aphasia means you have trouble taking the message in. You may not understand what people are saying to you

Within these two broad types, there are several kinds of aphasia:

Wernicke’s aphasia – With this type of aphasia, you may find it quite easy to speak, but you may use the wrong words and be hard to understand. You may also have problems understanding what is being said to you, as well as problems with reading or writing.

Broca’s aphasia – You may only be able to get out words in short bursts. Your vocabulary may be reduced and you may be difficult to understand. However, you may still be able to read and understand what people are saying.

Anomic or nominal aphasia – You can read and understand what other people are saying, but you have trouble naming people, places, or things (nouns). This can make it hard for people to understand what you mean.

Global aphasia – In this case, there may be a complete, or near total, loss of the ability to use language. You may not be able to read or write, and it may be hard to understand other people or to express yourself. This extreme type of aphasia is often seen right after a stroke.

Dysarthria

Dysarthria is caused by weakness, slowness, or poor coordination of the muscles used for speaking. Your speech may be slurred. It may be faster, slower or have more pauses than normal. You may have trouble making your speech softer or louder. The tone of your voice may be flat.

Apraxia (also called dyspraxia)

This is caused by loss of muscle control and coordination rather than muscle weakness. Apraxia can affect some or all of the movements you need to make when you speak. It can limit your ability to make speech sounds and form words. It can also affect your use of hand gestures, such as waving goodbye or blowing a kiss.

Looking at your abilities

To find out how the stroke is affecting your ability to communicate, speech-language pathologists will assess:

• how you speak spontaneously
• how well you can repeat words, phrases, and sentences
• your understanding of words and sentences
• your ability to link a name with an object
• your reading and writing skills.

Helpful tips

There are many things you can do or tools you can use to help you communicate. They can be simple things, such as:

• gesturing or using a form of sign language
• keeping a pencil and pad with you to write messages
• pointing to pictures or picture cards to show what you want
• pointing to letters or words on an alphabet or language board
• using Scrabble® tiles to spell out words.

There are also more high tech devices. For instance, some stroke patients use their computers to “speak” for them. Or, they may have special computer software to help them speak.

Communicating with someone with aphasia

Aphasia means that you have difficulty with language, not with thinking, planning or making decisions. You are still the same person inside. If you have aphasia, share these ten tips with your family and others who care for you. It may help them to communicate with you better.

1. Include the stroke patient in social gatherings or conversations. Don’t let them begin to feel lonely and cut off. If needed, make sure their hearing aids are in and their glasses are on. 
2. Phrase questions in a simpler way so they can be answered with a “yes” or “no”, or a nod or shake of the head. Keep in mind that sometimes stroke patients may get these responses confused. Try using pieces of paper with “yes”, “no” and “I don’t know” written on them. Ask the patient to point to the correct response. 
3. Speak in a natural voice. Do not shout or talk too fast. Pauses and speaking at a moderate pace may help the patient understand you. 
4. When talking with a stroke patient, turn off the TV or radio.  
5. Keep conversations clear and direct. Say one idea at a time using short sentences or phrases. Only one person should speak at a time. 
6. Provide instructions one at a time. 
7. During the early stages of recovery, when giving the stroke patient choices, limit the number of choices to two. For example, ask the stroke patient, “Would you like coffee or tea?” Try writing down the key words. If the person is having difficulty reading, use simple line drawings beside the written words. In time, as the person recovers, you can try adding more choices. 
8. Short, concrete, common words may be easier to understand. For example, say “leg” instead of “limb”, “bread” instead of “nutrition”, or “house” instead of “residence”. 
9. Do not rush a person with aphasia. Be patient, and give time for the patient to take in what you are saying or to come up with the right words. 
10. Try to confirm that you understood what the stroke patient said.

Who can help?

Speech-language pathologists play a big role in assessing how well you can communicate after a stroke. They also help you develop communication strategies that work for you. As in all stroke care, the whole healthcare team will support you in this.

Many people find it helpful to join an aphasia or stroke support group. Ask your healthcare team how to find one in your community.

StrokEngine provides information on stroke rehabilitation and interventions from quality articles, websites and systematic reviews. Visit StrokEngine to learn more about aphasia.

Energy level

Recovering from a stroke and having to learn new ways to do things can be tiring.

Helpful tips

Eating well

• Make sure you are eating enough to fuel your body.
• Eat a healthy balanced diet that follows Canada’s Food Guide.
• Drink plenty of fluids.

Planning

• Plan your day to take advantage of the times when you have the most energy.
• Everyday, make a to do list and decide which jobs are the most important to you. On days when you feel tired, do only the things you must. On high energy days, you can work your way a little further down the list.

Resting

• Take short rest breaks when you become tired.
• If you nap during the day, keep your naps short. Save your longest sleep for the night.
• Try to go to sleep and wake up at the same time each day.

Staying active

• Try to be as physically active as you can. Ask your healthcare team what activities are good for you.
• Do something you enjoy every day.
• Know when to ask for help. Don’t think you have to do everything yourself.

The Canadian Association of Occupational Therapists provides information to help people develop the skills for living productive and satisfying lives. Visit OTworks.ca for more information on how to manage changing energy levels.

Pain

After a stroke, you may have muscle stiffness in your affected limb. This is called spasticity. A spastic limb is hard to move. It may hurt when you or someone else moves it.

It is common to feel shoulder pain on the side affected by the stroke. This happens when one arm is weak and hangs down without any support. It can lead to a painful shoulder problem called frozen shoulder. That’s why you should keep your arm supported when you are standing or sitting up.

In rare cases, pain can result from damage to a part of the brain called the thalamus. This is called thalamic pain syndrome. It is hard to control or treat.

How to lessen the pain

Move as much as you can

In most cases, a stroke does not completely paralyze the muscles. Work with your therapist to get back as much movement and control as you can. The right kind of activity helps to reduce the pain, even if you do not regain all your normal movements.

Posture and support

Pain can be caused by the stress on the muscles and joints because of muscle weakness and stiffness. Keeping your body and joints properly lined up and supported can go a long way to preventing pain.

Lift and transfer safely

You should never be lifted by your affected arm or shoulder. This could cause serious damage to your arm or shoulder. Ask your therapist to show you the right way so that you can make sure you are lifted properly.

Who can help?

Your physiotherapist and occupational therapist can help you get back mobility and manage pain. You may get special exercises to retrain the weak muscle and help control your posture and movement. Your family or friends may be able to help you with these. Your physiotherapist can give them ideas.

What to do if the pain gets worse

Tell your doctor or therapist about your pain, especially if it comes on suddenly.

Follow their advice. Stay active in any ways that help prevent your joints from getting too tight or stiff.