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As a stroke survivor, you probably heard the term ‘goal setting’ from your multi-disciplinary team who helped you in ‘the early days’. This is because goal setting is considered ‘best practice’ in clinical stroke rehabilitation and its benefits are well recognised. Let’s have a look now about how to translate this practice into something that you can do by yourself when you get home, by yourself or with collaboration from a family member or friend.,

First, it is recognised that even though goal setting is embedded within community-based stroke rehabilitation given by NHS, practice does vary and is potentially sub-optimal. Further, to date, few randomised controlled trials have been completed to demonstrate that goal setting makes a unique contribution to stroke survivors’ rehabilitation outcomes.

You have received 6 weeks of community therapy, or you may have had much more, but many people after stroke feel that therapy ended much quicker than you may have liked. And if this therapy is now in the past, you will may possibly feel that it hasn’t optimally prepared you to try and haul yourself through the aftermath of stroke: ie, coping and trying to flourish as a stroke survivor, minimising multiple physical and psychological problems you may have been left with.

Unsurprisingly, a common denominator of many stroke survivors is that they believe (important to stress ‘believe’) that they have not been shown how to rehabilitate themselves effectively going forward.

Most usually understand that they need to ‘retrain’ themselves somehow, and are keen to go for it. And their supporters are keen to help them achieve their goals. But the same people hit a common wall, because they cast about in vain to find the best single way forward. It can take years for stroke survivors to exhaust presented (often very expensive) options, not realising that they had considerable power all that time to change their ‘status quo’, by planning and working out how to deliver self-set goals.

Often, not easy to do – but not particularly difficult either. Where does this leave ‘goals’? Will those things that the multi-disciplinary teams agreed with you to achieve in the community be the same kind of things you need to work out in the ‘real world’ and tackle as you move further away from from your time of stroke?

And how are goals supposed to be set and stuck to without that ‘negotiationary’ aspect to the process that the therapists helped you with in hospital and during  community therapy?

All reasonable questions – let’s break it down to component parts: 

Overall, most stroke survivors want to  ‘normalise and de-medicalise’ their lives again. They can set goals to do this.

Goals are things you would like to achieve. Many stroke survivors will want to restore lost function, and be able to do the things that they could do before their stroke. These are broad aims that may seem unachievable, and they may not know how to start, but defining goals can help then to break these aims down into smaller, more achievable goals.

Goal setting involves some planning and thought, but usually does not take overly long to do. It basically provides you with the steps to move from where you are now, to where you want to be. You’ll find it to be an empowering process, giving you the chance to take control of your rehabilitation.

To do this, you’re going to ‘get specific’ and ALSO ‘get broad’. Stroke survivors often have very individual hopes for the here and now, and also for the future, in terms of the goals they would like to achieve.

So. once all your therapy finishes, how do you do it? All good questions. To find out the answer, let’s get back to basics.

Where to start.

1 – Identify your goals!

When thinking about goal setting, the first thing to do is identify your goals, ask yourself ‘What do I want to achieve?’

When setting personal goals, specificity is king. For example, just challenging yourself to “do more work” is way too vague, as you’ve got no way of tracking your progress, and no endpoint. Simply put, if your goals aren’t quantifiable, achieving success can be challenging.

SMART goals can  the answer, as you can break them down into five quantifiable factors.

Try and look at goals in this way: they should be specific, measurable, achievable, realistic/results-based/relevant and timely (SMART). These specific goals should be meaningful to you, and be a mix of highly achievable and reasonable. That said, its good to throw a few unlikely ones in to the mix, which you can do your best at achieving.

Include short-term, mid-term and longer-term goals. Rehabilitation is a journey and takes time. Your goals will reflect this.

By the way, goals that move you forward are almost ALWAYS ABOUT YOU.. DOING THINGS. Not THINGS BEING DONE UNTO YOU.

And in the meantime so much can happen or, in particular, not happen.

Let me stress that you don’t have to become fanatical to achieve success in stroke recovery. Many stroke survivors are living day to day feeling frustrated with their lot. But frustration doesn’t negate intrinsic motivation. This motivation is drive you stimulation/drive you to start, and persevere.

Here some examples of common goals;

• To walk indoors independently
• To walk upstairs safely using a hand rail
• To dress upper body independently, threading t shirt over weak arm
• To stand to pull up trousers
• To be able to cut a slice of bread
• To butter toast
• To manage independent exercise programme
• To maintain range of movement in hand, wrist and elbow
• To open a tablet bottle
• To remember when to take my tablets
• To know what my medication is for
• To get in and out of the car safely
• To be able to type an e-mail accurately
• To practice golf on a driving range

EXAMPLE: So, perhaps you would like to walk upstairs independently. Great! That might be a longer-term goal.  First you must be able to stand with support. Then, you need to be able to lift one leg and support your weight with the other leg. Then you need to move yourself up a step.  Review what you can do now and work from there.  Stepping up could be a very difficult thing to do straight away, so your short-term goals might include specific exercises, for example marching, or squats, that strengthen the muscles that you need to climb the stairs. Once you have mastered this, you could increase the repetitions, or move on to stepping up to a low step. Then increase the height of the step, or the number of steps, and so on, until you complete the longer term goal of walking up stairs independently.

Whatever your personal goal, the trick is to break it down into smaller, achievable tasks.

Big Tips from Tom –

• Be ambitious but get someone to help you regulate your ambitiousness: in practice, ‘run it past someone who knows you well”,
• Reveal your limitations: if one of your primary goals is not to reveal your limitations for as many hours of the day as is possible, this can create an anti-risk paradigm towards your recuperation and self-training, it is highly unlikely you will do what it takes to progress.

Prioritise what you want to achieve. Hey, you don’t have to think about working out how to master everything at once… too many goals and trying to accomplish them is far too overwhelming and exhausting. Work out what you want to aim for first, and move to step 2.

2– Make a plan

Once you have identified your goals, you can start planning for their achievement and work out how to incorporate this into your routine.

How will you measure your progress, and over what time-scale? For example, you decide to master a few smaller steps before reaching for the staircase. But, how will you know when to move onto the next challenge? You might get bored with stepping up a few steps, and run the risk of becoming disheartened or become content to just do that, losing sight of your original longer-term goal. Instead, your goal could be to step up 10 small steps after 4 weeks. This is a time-specific and measurable goal. It keeps you focused and gives you something specific to aim for.

When you can measure goals, you can appreciate your progress, and this is so motivating! Thousands of people have found this very thing out after stroke. Just what you need to keep you moving forward.

Involve family, friends and carers.  Their input is valuable, and you might want their help. They might think of things that you haven’t thought of, or provide that supportive arm, and it can helpful to get their perspective. They will be part of your journey. Time to start on that journey – move to Step 3.

3 – Do it! 

Armed with your planner – do your ‘retraining’, practising formally and also by simply doing activities of daily-life. Record what you’re doing. Don’t overload yourself, but make sure you challenge yourself.

A great tip for you would be: in retraining situations it is important to advance quickly toward practice of whole tasks with as much of the environment context made available as possible. For example, say, a goal of yours is to improve the action control of your paretic foot for being able to cope whilst walking outside, unsupervised and with no supports. The best retraining you can get is to ask a trainer or friend to plan a route for you to go with him or her, so that you can trial it safely and under careful supervision. You can work on leaving a stick behind or reducing the use of an AFO according to your current levels of ability.

A unifying similarity amongst successful stroke survivors is not cognitive or affective (relating to moods, feelings, and attitudes), but willingness to strive for goals deemed ‘unachievable’ for them by those around them (as worked out in your Steps 1 and 2).

CLICK PIC OF STROKE SURVIVOR DOING THE THREE PEAKS CHALLENGE WITH ONE OF OUR ARNI INSTRUCTORS, KIERON FRANKLIN FROM POOLE, WHO HAS TAKEN SOME OF HIS STROKE SURVIVORS ON THIS FOR THE LAST 2 YEARS. DONATE TO ‘MOUNTEMBER 2019‘ IF YOU’RE FEELING GENEROUS!

Tip – motivation is key – if you’re not intrinsically motivated, you’ll have no incentive to push beyond generally accepted boundaries.

4 – Review your goals regularly.

Life may take you in another direction, changing the attainability or suitability of your goals. You may be working towards them faster or slower than you anticipated, or may find that other goals have taken priority. Whatever is happening in your life, it is perfectly OK to adapt or change your goals to suit you where you are now.

Keep talking with the people close to you, try to stay positive and motivated. Also, help/guide others who are going through a similar experience, if you come into contact with them in person or online – this actually has an effect to keep YOU motivated…

5 – Identify barriers to effective goal setting, then adapt and overcome.

Barriers could include communication difficulties, cognitive impairment, fatigue, mood disorders, other health conditions and even a lack of knowledge or understanding of your problems/condition.

If you feel you may have these, or other barriers, don’t let it stop you setting your own goals.

Take time to ensure that your goals are what you want to achieve. Try to enlist the support of positive people who will take the time to work through what you want to achieve, whether they are family or carers, or therapists/instructors. Positivity breeds positivity.

Be aware of your limitations, but almost everyone can improve and become more functional. Listen to your body and adapt your goals accordingly. You could just break them down to smaller tasks, or do them a different way.

If you are too fatigued, don’t struggle. Rest and return to the task more refreshed.

Educate yourself; there is a wealth of information available about stroke and self-help online and through books.

You can read more about goal setting in The Successful Stroke Survivor, as well as lots of innovative ways to encourage rehabilitation after stroke.

What if I need more help?

Working with a therapist or trainer can be really motivating. This collaboration combines your initiative and drive with the knowledge and experience of a professional. For example, ARNI instructors are specifically trained in methods of stroke rehabilitation and will work with you to identify goals that are functional and personal to you, and together you will strive to achieve them. Empowering you to take control of your rehabilitation.

CALL ARNI now on 0203 053 0111 or write in to receive an info pack through the post. 

A change in cognitive ability is common after a stroke. Did you know that as many as two-thirds of stroke survivors may experience cognitive impairment as a result of their stroke.? If this is you, or you know someone who seems possibly to be going through such difficulties, here’s 18 steps you can take to try and improve cognition difficulties after stroke:

First, what is cognition?

Put simply, cognition is thinking; it is the processing, organising and storing of information – an umbrella term for all of the mental processes used by your brain to carry you through the day, including perception, knowledge, problem-solving, judgement, language, and memory. The brain’s fantastic complexity means that it can collect vast amounts of information from your senses (sights, sounds, touch, etc) and combine it with stored information from your memory to create thoughts, guide physical actions, complete tasks and understand the world around you.

A stroke can affect the way your brain understands, organises and stores information. This brain injury can result in damage to the areas of the brain that are responsible for perception, memory, association, planning, concentration, etc. The severity and localisation of the stroke will effect the type and level of difficulties experienced by an individual, and will vary from person to person.

It can be difficult to plan and organise daily tasks. The brain is constantly working in the background, allowing us to complete a task based on prior knowledge, experience, and learned behaviour.

You don’t have to consciously think how to boil the kettle, change TV channels or put on your socks before your shoes: you just do it. But damage to the brain can result in problems with these planning and execution mechanisms.

You might not be able to think how to do a simple task, or you may get the sequence wrong (for example, shoes before socks). You might have trouble with orientation, which could include not knowing the date, day of the week, or even who you are with. Problem-solving too can become difficult. Making decisions, solving problems, understanding numbers and managing money can be a challenge.

Good cognitive function also relies on memory. The brain uses 2 types of memory to hold information, the long and short term memory. Short-term memory is the temporary store for small amounts of information. This information is kept readily available and can be recalled quickly. For example, a phone number can be remembered long enough for you to dial it. Long-term memory is where you keep your experiences, thoughts and feelings from the past and things stored here can be stored indefinitely. Memory problems could result in difficulty storing or recalling information. This could include problems remembering appointments, important dates or in the case of short term memory, what you were about to do, or what somebody just said to you.

Problems with concentration are common. Concentration is required for effective cognitive function, as many of your thinking process require concentration. Concentration requires our brain to filter out much of the information coming in from your conscious thinking, so you are not distracted by it.

Stroke can impact on this ability because of damage to the areas of the brain responsible for this, and also because tiredness, pain and emotional problems have an effect of the ability to stay focused and concentrate. This could result in difficulties when trying to follow a television programme, or conduct a conversation with a friend. Multi-tasking too is difficult.

18 Things to try

1. Cognitive problems are confusing and frustrating. But, there are some things you can to do help. Most improvements occur in the first 3 months after a stroke, after which they slow down, but the brain will keep creating new neural pathways after this time.
2. To help with memory and perception problems, try using a diary, day planner, calendar or notepad. Writing down appointments and creating to-do-lists can help you to remember them.
3. Photos and pictures can help to ‘trigger’ your memory.
4. Check your calendar, newspaper or diary to help you remember the day and date.
5. Make notes of important conversations.
6. Use notes, lists  and labels around the house and help prompt you to remember. Mobile phones are a great resource. Set alarms, reminders and memos to remind you throughout the day.
7. It is important not to overload yourself, finish one task before you start another. Plan your day and prioritise tasks.
8. Try slowing the activity down, working through a step at a time.
9. Keep instructions clear and short, no more than 5 or 6 words to a sentence, and only 1 or 2 instructions at a time.
10. Paraphrasing during a conversation can help you to remember what has been said. This repeating back what they have said in your own words helps to ensure you have understood them correctly.
11. Busy and noisy environments can make it difficult to think.
12. Limit the number of things you have to think about at any one time, for example, turn off the TV or radio when someone is speaking to you. This should reduce distractions and help you to focus on what they are saying or follow the programme.
13. Being in a quiet room can also help you when reading or learning something new. Reducing visual distractions may also help you to concentrate. Keeping the area around you as clutter free as possible could help you to focus.
14. Keep to a routine, for example, dressing in the same order may help you relearn the steps.
15. Engage in activities which help to stimulate problem solving skills. Examples include board games (connect 4, chess), crosswords, puzzles, and brain teasers. There are a variety of phone apps which can help to engage the brain.
16. Stress and tiredness can make cognitive problems worse.
17. Take plenty of breaks and incorporate time in your daily schedule to rest or relax. This is important to allow you to recharge and could be quiet time, meditation, engaging in a hobby or going for a walk.
18. Exercise and listening to music may also have a positive impact on cognitive function.

Get in touch with ARNI Stroke Charity to see how we can help. We can certainly help to sign-post you to to some of the experts in cognition that we know and/or ask questions on your behalf..

Stroke is one of many conditions that can lead to seizures, or epilepsy. You may think of these as ‘having fits’. In the UK this condition affects just under 1% of the population. Around 5% of people who have a stroke will have a seizure within the following few weeks. These are known as acute or onset seizures and normally happen within 24 hours of the stroke.

The good news is that your risk of having a seizure lessens with time following your stroke. But, you’ve really got to take care. I see people regularly who have fits for the first time. It’s never fun, but luckily, as someone who has had controlled epilepsy for over 20 years I know exactly how to identify these very early (it’s not that hard really). Quickly get the person to the floor, gently, into the recovery position and call for an ambulance. If you have a list of all their medications on hand to tell the paramedic, that would be ideal.

You are more likely to have had one if you have had a severe stroke, a haemorrhagic stroke or a stroke involving the part of the brain called the cerebral cortex. My own epilepsy came only after subarachnoid haemorrhage, (an uncommon, very serious and often fatal type of stroke caused by bleeding on the surface of the brain)

The causes of seizures are complex. Cells in the brain communicate with one another and with our muscles by passing electrical signals along nerve fibres. If you have epilepsy this electrical activity can become disordered and a sudden abnormal burst of electrical activity in the brain can lead to a seizure.

There are over 40 different types of seizures that can occur, but the most common ones are partial seizures or generalised seizures.

Partial or focal seizures only occurs in part of your brain. You may remain conscious and aware of your surroundings during a partial seizure (called a simple partial seizure) or you may become confused and unable to respond (a complex partial seizure). The symptoms you experience during a partial seizure will depend on which part of your brain has been affected. You may feel changes in sensation such as a tingling feeling, which spreads to other parts of your body.

Commonly people experience a rising feeling in their stomach (a bit like when you go over a humpback bridge). This is called an ‘epigastric rising sensation’. You may also experience uncontrollable stiffness, twitching or turning sensation in a part of the body such as your arm or hand, and/or disturbances in your vision, such as seeing flashing lights.

People can actually be taught to ‘ward off fits’! I learned the hard way how to do this. It’s a real trick of the trade you can use as a stroke survivor! Jut get in touch with me and I’ll tell you how I do it. 2004 was the last time I personally had a fit. I developed a 3-stage process which is remarkably successful. Part psychological and part-physical, it just works for me and might work for you too.

Since 2004 and 2019, I’ve controlled my fits and manipulated the levels of the drug in my body so that it can cope with changing body-weight. Putting on muscle was the main reason why I had to increase the dosage of my pills. More on anti-convulsants (or anti-epileptic drugs) below.

Generalised seizures involve both sides of your brain. There are several types of generalised seizures. Tonic-clonic seizures are the most common and widely recognised type. During a tonic-clonic seizure you lose consciousness, your muscles go stiff and you usually fall backwards. I used to fall forwards. I know this because I used to wake up not knowing what had happened to me, but seeing a massive carpet-burn on my forehead. You really do basically stiffen up and go down like a brick! 

After losing consciousness, your muscles tighten and relax in turn, causing your body to jerk (convulse). Your breathing may become difficult and you may lose control of your bladder. This convulsive phase of the seizure should only last a minute or two.

Other types of seizures include tonic seizures (where your muscles go suddenly still but you do not have convulsions), clonic seizures (you have convulsions but no muscle stillness beforehand), atonic seizures (you suddenly lose all muscle tone and go limp), or myoclonic seizures where you experience a brief muscle jerk similar to the jerk you sometimes get as you fall asleep. A secondary generalised seizure is when a partial seizure spreads to both sides of the brain. Stroke-onset seizures are often of this type.

Most seizures stop by themselves and last between two and five minutes. After a seizure you may feel tired or confused. The time it takes to recover varies from person to person. Sometimes after a seizure associated with stroke, you will have temporary weakness, which may last for a few hours.

If a seizure lasts for 30 minutes or longer, or you have a series of seizures without consciousness being regained in-between (status epilepticus), your body struggles to circulate oxygen properly and this is an emergency. Your family or carer should call emergency services immediately if you have a seizure that lasts for more than five minutes or if one seizure follows another without you regaining consciousness in-between.

IMPORTANT: If you think you have had a seizure, and are not in the hospital, you should see your GP immediately, and then referred as soon as possible to a specialist. You may not be able to remember the seizure so if someone else witnessed it, it might help if they see the specialist with you. The specialist will ask you questions about what happened. This may be enough to make a diagnosis. However, further tests may be needed, particularly if the seizure did not involve convulsions.

You may have an electroencephalogram (EEG), which involves placing electrodes on your scalp and is painless. These measure electrical activity in your brain and can identify any unusual patterns. An EEG only shows what is happening in your brain at the time it is done, so a normal EEG does not necessarily mean that you do not have epilepsy.

It’s a good idea to keep a ‘seizure diary’ with the dates and times of your attacks, what happened, and any possible triggers, such as alcohol, or stress. It means you can narrow it down to factors such as: ‘am I missing taking my pills by half an hour to an hour?’,  or ‘have I just been in very stressful situation?’ Both of these were big triggers for me. Flashing lights can be a trigger (photosensitive epilepsy) though this is not common as people think.

There is currently no cure for epilepsy, but medication can usually control seizures and allow you to lead a normal life. Which treatment you have will depend on the type of seizures you’ve had, how frequent they are, other effects of your stroke, for instance if you have problems swallowing, and any other medication you are taking.

Anti-epileptic medications (AEDs) work by preventing excessive build-up of electrical activity in the brain, which is causing the seizures. Unfortunately, the normal activity of the brain can be affected, leading to drowsiness, dizziness, and confusion amongst other side effects. Once your body is used to the medication, these side effects may disappear.

Your doctor may start you on a low dose and increase it gradually to reduce the chances of unpleasant side effects. If you can’t tolerate the medications, then you must tell your GP as there are choices of treatments, and the science is progressing all the time. There are many safe and reliable AEDs available, and you will find one that suits your individual case.  The choice of AED used for you will depend upon your type of epilepsy, sex, and any other medications you may be taking. I take the above medication: the good thing about these is you can get the Chrono-Release version, which release the medication throughout the 12 hour intervals per day you should take them.

Many people, including myself, get back to extremely busy schedules after stroke, and simply take their pills. One tip is that often AED dosages are often quite highly-tuned. If you put on bodyweight, you may begin to have enough in your system without realising. This was a total ‘game-changer’ for me and has been so for many others. It’s also a good idea, if you are having fits, to get a medical bracelet which identifies you as someone who experiences epileptic fits..

Important tips:

1. Develop your own ‘early-warning system’ and find out how to ward off fits as they come on.
2. Find an excellent Epilepsy Consultant: they are worth their weight in gold.
3. Never suddenly stop taking your medication: this will cause you to have seizures and possibly develop prolonged seizures (status epilepticus). Although studies show that the risk of having a seizure-related accident decreases as the length of time since the last seizure increases, there are still a great deal of road traffic accidents found to have been caused by people coming off anti-convulsants. Medication should only be stopped with medical supervision.

So, what’s the point of task-specific practice and why should you do it? Dutch researchers (Kollen, Kwakkel & Lindeman) way back in 2006 reviewed ALL available published clinical stroke rehabilitation trials, of which at the time of writing there existed 735. They selected 151 studies including 123 randomised controlled trials and 28 controlled trials. In their consideration, the rest either did not meet the inclusion criteria or lacked statistical and internal validity, reflecting the poorer methodological quality of many of the clinical intervention studies under consideration. The Dutch researchers concluded in their analysis that traditional treatment approaches induce improvements that are confined to impairment level only and do not generalise to a functional improvement level. In contrast, they concluded that evidence existed that: ‘more recently developed treatment strategies that incorporate compensation strategies with a strong emphasis on functional training, may hold the key to optimal stroke rehabilitation’.

In summing up their findings, they reported that ‘intensity and task-specific exercise therapy are important components of such an approach’. I have found that there is a strong case for implementing and balancing both into an Approach, with the addition of strength training. It’s what I did (and still do) to retrain, manage and ‘negate’ my own physical limitations. And it is how so many others are being taught how to get some significant results in terms of upper limb capacity AND performance (in ADLs).

Although still under investigation for strong evidence of efficacy for stroke rehabilitation, task-specific practice can be said to be one of the best weapons we have to help retrain the brain. It means simply to train the action to be performed in a natural environment. For example, if you wanted to lift a mug and drink from it, you should take a mug and practice lifting and drinking from it, over and over again … and attempt to improve progressively and consistently. The retraining that you are going to do holds this method up as a very BEST paradigm to be following, and one around which lots of other improvement interventions can be introduced/tried, from active orthotics to technology and drugs.

Functional task-practice must not only reinforce recovery milestones, such as sitting balance, standing upright and the ability to walk but also tackle behaviours that are introduced after stroke. You need to be doing the task you want to do. So, for those with significant spasticity in the upper limb, to retrain the ability to open a glasses case to get your specs, for instance… you practise opening up a glasses case.

Get a ‘How-To’ Video. This online DVD about Real-life Upper Limb Self-rehab will show you lots of ways for people who are retraining at home to ‘retrain’ for normal tasks which involve reaching, grasping and releasing.

Task training is critical because it will ‘force’ you to practice using your more-affected limb. This is why the Evidence-Based Review of Stroke Rehabilitation (EBRSR) concludes that constraint induced movement therapy (CIMT) in clinical settings, for those who meet the qualifying criteria, shows strong evidence of benefit in comparison to traditional therapies in the chronic stage of stroke. CIMT is a great example of task training for the upper-limb. 30 to 66 % of stroke survivors report no longer being able to use the affected arm despite trying to rehabilitate and are in danger of avoiding using it (‘learned non-use’ or inattention/ neglect of the limb). Several factors might explain this phenomenon. First, you may see no reason to try and use your bad arm and therefore remain ignorant of underlying motor potential. Second, you may not know how to use any emerging isolated movement for functional performance.

In fact, emerging movement often overlooked: it is considered non-functional. But this is wrong. You actually need to try and regain an increase in active range of motion (AROM) in as many planes and pivots as possible.  Increase in non-functional AROM increases strength and muscle bulk, encourages muscular activity which promotes vascular return, decreases the potential for soft-tissue shortening, and damage with resultant pain and stiffness – and increases osteoblastic activity on the affected and often osteoporetic) side.

What you need to know is that now, eclectic therapists are seeking to fight on two fronts: teaching compensatory strategies for the sake of function and training the affected side to re-establish cortical control over the affected extremities by the ‘original’ neurons. This means that actually, compensatory strategies are not ‘bad’. Rather, they are now being recognised as critical to recovery.

Indeed, as action control is incrementally unmasked on the affected side, emerging movement should be recognised, celebrated, encouraged and built upon. The trick is making sure that compensations & recovery are both worked on, although the work will be separate in the short-term. In the long-term they will meld indistinguishably.

So, try to do MORE with your more-affected upper limb by yourself each day (ie work towards a new goal, and check retention during your ADLs constantly afterwards (because you can lose ability, just like strength (which is shockingly easy to lose). Repeated attempts to use your affected limbs in training creates a form of practice that can potentially lead to further improvement in performance. The ideal is to find oneself in a ‘virtuous circle’, in which spontaneous limb use and motor performance will reinforce each other and re-teach your body to control the position of an affected limb.

In formal retraining situations it is important to advance quickly toward practice of whole tasks with as much of ordinary environment context made available as possible. For example, say, a goal of yours is to improve the action control of your paretic foot for being able to cope whilst walking outside on the pavement, unsupervised and with no supports. The best retraining you can get is to ask a trainer or friend to plan a route for you to go with him or her, so that you can trial it safely and under careful supervision. You can work on leaving your stick and/or supports behind or using/wearing them according to your current levels of ability.

Many stroke survivors can be assisted to retrain by advising them to have one place and a set amount of times per week in which they devote time to their retraining. I tend to promote the importance of setting up a small matted ‘training area’ in your house, which needs only to be a few square metres wide. You also need a chair and a small table with a task-board, more advanced challenge board and other small items on it.

You need to finding your own task specifics, according to your goals. You also need to work on ‘close-simulations’. Even though simulations are probably not as effective for motor learning as performing the actual task, and remember, we are after significant performance improvement via task practice, you can see that this approach gives you some great advantages. It keeps you in the training area, keeps you working on-task and keeps you safe. And then outside of the training area, you need to make an effort to practice the tasks (or the components of them that you can manage), as part of your ADLs, noting changes when you can.

One great example: I created ‘DJ-Therapy’ to get my upper limb working again. I basically made up a hugely successful paradigm which was suitable for me. How I did it is all listed in The Successful Stroke Survivor.

You can read how I started it ‘off-decks’, then used the decks themselves to absolutely superb effect – ‘training’ 5 or so hours per day. It was never ‘training’ per se, for me, however.

Making training ‘not training’ is one of the biggest secrets to getting optimal success with upper limb function. I wish more people would have a go at this idea. Have a think about what might be suitable for YOU to keep YOU practising and interested.

Messages from this post are:

• Get clued up to understand how to set up a training methodology (a good number shown on these DVDs, for example)
• Get some help from a physio, OT or trainer.
• Perform as many specific, whole tasks of your choice inside a safe training area as you can.
• Work on the ‘edges of your current ability’
• If the task is not appropriate to perform in your training area, you should try and to practise for it using close simulations in your training area first.
• Progress on task performance must consistently be checked outside your training area.
• If you can, you should try and pinpoint new action control in your ADLs to something you are doing in retraining
• And repeat! Many many many times. And have fun with it. Make things. Create.

• Investigate to see if you can find any appropriate technology for stroke rehab.
• For upper limb problems, if in England, see if you can be referred into the Queen Square Upper Limb service in London for an intervention (this requires a referral from your GP).
• Also for upper limb problems, get assessed to see if any anti-spasticity medications are appropriate and could help.