Arm, hand and shoulder problems after stroke

Arm problems are very common after stroke: the most recent National Stroke Audit found that sixty-nine percent of stroke patients in hospitals problems with their arm, hand or shoulder, collectively known as the upper limb.

These problems can last for a long time, partly because hands and arms are so complex, and we use such a large part of our brains to control them. But also, in the early days after a stroke more attention is often given to the legs and walking. Even in hospital, getting around is seen as essential, while people can learn to cope with one arm.

However, arms are needed for daily life and doing the things that are meaningful to you. Allied health professionals like occupational therapists or physiotherapists can help you develop a rehabilitation program to meet your goals of getting back to these activities.

If you’re not currently seeing any of these allied health professionals, you can talk to your GP about getting a referral to one under a Chronic Disease Management Plan, or a referral to a community rehabilitation centre. Alternatively, if you have private health insurance you might have extras cover for allied health services, or you can ask if your hospital cover funds outpatient rehabilitation sessions. Universities also often have research projects or student clinics that can provide treatment.

Due to the complexity of upper limbs, there are many difficulties you can have. These might include:

• Weakness in your shoulder, elbow, wrist or hand, or your arm may be paralysed completely. Paralysis on one side of the body is called hemiplegia, while weakness on one side is called hemiparesis.
• Difficulty planning arm movements, which is called apraxia, or difficulty coordinating arm movements.
• Changes in the muscles, such as high muscle tone that makes your muscles stiff and tight. This is called hypertonia or spasticity. Alternatively, your muscles may be floppy or loose, which is called low tone or hypotonia.
• Subluxation, where weakness or low tone may cause your arm to drop out of your shoulder socket slightly.
• Contracture, where your muscles become shorter due to being tight or weak. This can result in the joint becoming fixed in one position.
• Changes in sensation, such as loss of feeling, pins and needles, or increased feeling (hypersensitivity).
• Swelling due to fluid building up because your hand or arm does not move as well as it used to. This is called oedema.

Treatment and recovery

When you see a physiotherapist or occupational therapist, they will test your arm strength, movement and feeling. They will then work with you to develop a rehabilitation program based on your needs and goals.

The treatment in this program will include practising movement and everyday tasks. Repetition is key to improvement, so you may do particular movements many times. It may also include mental practice or rehearsal, in which you imagine you are doing an activity without actually doing it.

If you have mild to moderate weakness, you may be given constraint-induced movement therapy. This is involves using a mitt or sling on your good arm to encourage you to use your affected arm.

Your therapist may also recommend video games to help you practise using your arm.

For weakness, you may also use an electromyography machine (EMG) to record activity in your muscles, or low-level electrical current – known as electrical stimulation or ES – to stimulate a weak muscle.

You may also use mirror therapy, which involves a mirror placed between your arms on a table. When you see your good arm move in the mirror, it tricks your brain into thinking your affected arm is moving.

If you are having difficulty planning movement, you might talk about, rehearse and practise the steps that make up that movement. Your therapist may also do the movement with you.

If you have spasticity or high muscle tone, an injection of botulinum toxin A, aka botox, may help. Electrical simulation may also be used.

For subluxation or shoulder pain, you may need electrical stimulation, a sling, wheelchair attachments or strapping. You will also need to learn the best ways to move and protect your arm. If the pain does not improve, you may need a specialist pain management doctor or clinic.

If you have had changes in sensation, you might retrain your senses by feeling different materials, objects and textures to re-learn what they feel like.

To reduce swelling, you may need exercises, electrical stimulation, massage or pressure garments. Supporting your arm in a raised position when resting can also help.

Most improvement usually happens in the first six months, but you may continue to improve for many years. It’s important to keep doing your exercises and using your arm as much as possible. You might find it helps to join an exercise group, or to ask your family and friends to help you practise doing things and keep active.

To manage everyday tasks you might need to use equipment or find different ways to do things. You may also need to protect your arm from injury. Your therapists will provide advice on the right strategies and equipment for you.

You can find a physiotherapist via the Australian Physiotherapy Association. Call 03 9092 0888 or visit www.physiotherapy.asn.au

Find an occupational therapist via Occupational Therapy Australia. Visit www.otaus.com.au

StrokeLine’s health professionals provide information, advice, support and referral. StrokeLine’s practical and confidential advice will help you manage your health better and live well.

Call 1800 787 653. Email strokeline@strokefoundation.org.au