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If you’ve had a stroke and like engaging with nature, Izzy and Rocksy, two friends of ARNI Stroke Rehab UK (Occupational Therapy students from the University of Southampton), would love to hear from you as they’re doing a study on how people with neurological conditions like stroke experience and engage with nature-based activities, such as gardening, outdoor walks, training in nature, conservation projects etc… please help them!

Nature-based rehabilitation (NBR) delivered as part of neurorehabilitation is a brilliant and developing approach.

To help the Southampton University students do research and create a protocol, do read on and consider doing a quick, helpful computer-based interview (no need to go anywhere) with them if you can spare the time!

The Southampton students would like to understand better, things like:

• What does nature mean to you?
• What helps or prevents you to engage with it?
• How does it support or challenge your wellbeing and daily life?

As you know, each year in the UK, around 100,000 people experience a stroke contributing to a community of approximately 1.3 million stroke survivors, more than half of whom live with a disability.

Post-stroke fatigue is one of the most common and challenging symptoms to manage. Dong et al, (2025), reported that 45.8 % of individuals in their study experienced post-stroke fatigue, highlighting the need for interventions that address depression, improve quality of life and restore activities of daily living.

Living with a neurological condition, such as stroke, involves navigating a complex mix of physical, cognitive and emotional challenges that affect everyday life, wellbeing and connection with others. Many people experience fatigue, anxiety, reduced confidence or difficulty taking part in activities that once felt meaningful.

As interest grows in holistic, person-centred approaches to rehabilitation, nature engagement is emerging as a promising way to support wellbeing for individuals living with long-term conditions.

Nature engagement is endless and broad, and it can range from a forest walk, gardening, horticultural engagement, horse riding and many more possibilities!

Research suggests that spending time in natural environments can offer meaningful benefits such as improvements in mood, confidence, social connection, and overall quality of life for people with neurological conditions. Many people describe nature as a space where they feel more motivated, more independent and more able to challenge themselves in their rehabilitation journey.

To date, despite all these findings, there remains limited research exploring the personal experiences of nature engagement for people with neurological conditions.

Izzy and Rocksy want to contribute to stroke survivors – they state that ‘understanding these perspectives is essential for developing accessible, effective and meaningful nature-based programmes that actually reflect what stroke survivors value and need’.

This study aims to gather the experiences of people who have experienced stroke and who take part in any form of nature-based activity.

The Southampton students would like to understand better, things like:

• What nature means to you?
• What helps or prevents you to engage with it?
• How does it support or challenge your wellbeing and daily life?

Your insights can help shape future stroke rehabilitation approaches and ensure that nature-based programmes are designed with lived experience at their core.

Your insights will help us understand what makes it easier or harder to take part in these kinds of activities and how they can be made more accessible for everyone.

What will happen to me if I take part?

• If you agree to take part, we will ask you to fill in a consent form and a short form to provide background information about you.
• You will be invited to a one-to-one interview lasting around 45–60 minutes. This will take place online via Microsoft Teams at a time that suits you.
• During the interview, we will ask you about your experiences with nature-based activities, the factors that make participation easier or harder, and what you feel the benefits are.
• The interview will be video recorded on Microsoft teams (with your consent) to help us accurately transcribe what is said. The recording will be securely deleted once the transcription is complete. We will remove any identifying information about you from the transcript.
• This transcript will be securely stored on a University of Southampton SharePoint site, accessible to the research team. You do not need to answer any questions that make you feel uncomfortable. You can take breaks or stop the interview at any time..

Are there any benefits in my taking part?

Yes! Your views will contribute to raising awareness and improving understanding of how nature-based interventions are experienced and delivered.

The Southampton students hope that your participation will help inform future practice and promote greater inclusivity for people living with long term neurological conditions. Please contact them on either im2g23@soton.ac.uk or ra11g23@soton.ac.uk

The findings from this study will also be used to teach undergraduate students about the value and application of nature based programmes.

The aim is to gain insight into barriers and enablers that impact engagement in nature-based programmes, and to understand how these activities can be improved and sustained to better support the wellbeing of people with long-term neurological conditions.

The project is not funded in any way.

* Researchers: Izzy Mason, Undergraduate Researcher (BSc Occupational Therapy) University of Southampton and Rocksy Antonygnaneswaran, Undergraduate Researcher (BSc Occupational Therapy), University of Southampton.

* Supervisor: Long-time friend of ARNI Stroke Rehab UK Charity: Dr Leisle Ezekiel (lezekiel@soton.ac.uk)

Dong, Y., Tang, L., Salwismawati Badrin, Salziyan Badrin and Wu, J. (2025). Factors associated with post-stroke fatigue among stroke survivors: a cross-sectional study. PeerJ, 13, pp.e19052–e19052.

For many stroke survivors, regaining arm and hand function is a difficult and often frustrating process. Traditional rehabilitation methods, while foundational, can be intensive, repetitive, and limited by therapist availability. In the months immediately following a stroke, the brain exhibits enhanced neuroplasticity; a critical window for recovery that requires as much task-specific practice as possible in order to take advantage it. Increasingly, a wave of new technologies is revolutionising upper limb rehabilitation, offering innovative and engaging ways to target and extend this time-window as much as possible by supplementing conventional therapy.

Virtual Reality (VR) is transforming monotonous exercises into interactive games, boosting patient engagement and motivation. Studies have shown that when used alongside traditional therapy, VR can significantly improve motor function and quality of life for stroke survivors.

Immersive or non-immersive VR systems—using head-mounted displays, computer screens, or tablets—place patients in virtual environments where they can practice real-world tasks. A patient might use a motion-tracking glove to “catch” objects in a virtual space, or practice hand movements in a simulated kitchen to promote greater engagement. Real-time feedback can be delivered; gamification, and task-specific training in a safe, controlled environment can increase exercise intensity and provide an enjoyable experience.

Robotic devices can also supplement therapy by assisting with intensive, repetitive exercises that might otherwise be too demanding for therapists or patients. The best results often occur when robotic therapy is combined with conventional methods, and different robots are suited for varying needs.

Robotics can deliver a higher dosage of repetitive, task-oriented exercises and provide consistent, objective data to track progress.

Rehabilitation robots can be broadly categorised into two types based on their function and how they interact with the stroke survivor: end-effector devices, which are independent of the patient and attach at a single, distal point, such as the hand… and are effective for training movements in a horizontal plane but are less capable of controlling and isolating the movement of individual joints. Exoskeleton devices, however are wearable, powered devices resemble and attach directly to the human arm, with their joints aligned to mimic human joints, which allows for assisted movement of specific joints in the hand, wrist, elbow, and shoulder.

Upper limb exoskeletons operate in several modes to help with different stages of recovery: 

• Assistive mode: For patients with very little to no movement, the exoskeleton fully supports the limb and helps the patient perform the desired motion.
• Assist-as-needed (AAN) mode: As the patient recovers some motor function, the device detects their initial movement intention and provides support only when needed to complete the task.
• Corrective mode: This mode provides force to gently guide the limb back toward the correct trajectory if the patient’s movement deviates from the desired path.
• Resistive mode: For patients with significant motor recovery, the exoskeleton can provide resistance to help them regain strength and better control their movements. 

Functional Electrical Stimulation (FES) uses electrical pulses to activate muscles artificially, helping to practice functional tasks like grasping and reaching. When coupled with voluntary movement, this technique can help promote neuroplasticity, the brain’s ability to reorganize itself. Surface electrodes can be placed on the skin, or in more advanced setups, integrated into electrode arrays on a fabric sleeve or orthosis.

Some systems are also triggered by electromyography (EMG) or brain-computer interfaces (BCIs), allowing the patient’s intent to control the stimulation. By actively involving the patient’s brain and body, FES reinforces connections between intention and movement, which is crucial for recovering motor control.

Portable, wearable sensors and smart devices enable rehabilitation to extend beyond the clinic and into the home. This provides continuous monitoring and feedback, which is key for maximizing recovery through high-intensity, repetitive practice.

Wearable sensors take the form of wrist-worn sensors or special gloves can track arm movements and provide real-time feedback through a tablet or app. Gamified devices have also been available for many years. Both the following are produced by long-term colleagues of ARNI: GripAble, is a great example which turns exercises into engaging, fun activities for at-home use. And Neuroball is used to play video games that track hand and arm movements. It’s designed to motivate users to complete hundreds of physical therapy repetitions from home. Such examples help to maintain patient motivation and exercise adherence outside of supervised sessions.

To sum; technology is not seen currently by experts in stroke as a replacement for therapists, but as a powerful partner able to deliver high dosages of repetitions in order to complement therapy or retraining interventions. By combining these advanced tools with expert guidance, survivors can achieve levels of recovery that were once impossible.

We predict that that the future of stroke rehabilitation will continue to see these technologies becoming more personalised, accessible, and integrated into a holistic approach that can help stroke survivors ultimately to reclaim function and independence as they seek to retrain & recover autonomy in the community.

Do you have shoulder dysfunction and/or pain as a result of your stroke, or know someone who does? 

Studies estimate that 50% of stroke survivors experience proprioceptive impairments in their upper limbs. These may include limited range of motion, muscle weakness, joint instability, and pain, all of which can severely affect independence and quality of life and are interlinked with motor, sensory, and musculoskeletal changes. 

Shoulder dysfunction and pain are among the most common and disabling consequences of stroke. Everyday tasks such as dressing, eating, or reaching for an object become difficult or even impossible. Balance and coordination problems are also prevalent and deeply interconnected with shoulder dysfunction. People recovering from stroke often experience fatigue, weakness, and joint stiffness that make conventional rehabilitation programs difficult to access or sustain.

Shoulder pain

If you have hemiplegia in your arm from your stroke, there is a good chance that you may also suffer from shoulder pain. Shoulder pain can disrupt your daily activities and make it difficult to sleep. The shoulder is a ball-and-socket joint that allows motion in any direction. Because it’s so mobile, it’s also vulnerable to injury.

Some people have shoulder pain as early as two weeks after their stroke, but it’s more common for it to start about two to three months later. The evidence indicates that 80% of patients with post-stroke shoulder pain have resolution within 6 months. Shoulder pain can have consequences on not only the use of your arm and hand, but also other aspects of your rehabilitation, such as transferring from a bed to chair or maintaining balance.

There are many things that can cause shoulder pain including (but not limited to) poor arm function, spasticity, subluxation, bursitis, and tendonitis. Bursitis is a shoulder disorder that occurs when the bursa sac (the padding between the bones and tendons in the shoulder) becomes inflamed. In some cases, bursitis can lead to ‘frozen shoulder’; a condition that causes it to lock up, significantly affecting how much you can use it. You may be given a sling in hospital to try and reduce shoulder pain, but currently there is no clear evidence that sustained sling usage significantly corrects shoulder pain.

Shoulder subluxation

Shoulder subluxation is a partial (minor) dislocation of the arm at the shoulder joint that often occurs after a stroke. In most cases, extreme muscle weakness can result in the muscles not being able to hold the weight of the arm at the shoulder, resulting in the humerus (upper arm bone) dropping down out of the shoulder joint. It can also cause the shoulder blade to lose its normal position. Muscles affected by spasticity around the shoulder joint can also pull the humerus and shoulder blade into abnormal positions.

If your arm is affected by subluxation, your physiotherapists will let you know, and you may well be able to see the difference in level between your more-affected and less-affected shoulder in the mirror. It’s important to protect your shoulder from injury and try to keep your more-affected arm in as normal a position as you can manage.

When resting, your more-affected arm can be kept in a comfortable position which prevents or lessens subluxation. Make sure no-one lifts you from a seated or lying position underneath your arms. This can cause damage. Instead, try learning with a therapist, as soon as you can, how to get yourself from both a seated to standing position and from the floor to standing without involving your more-affected arm much.

There is evidence that starting with a sling suspension system and conducting active shoulder exercises may be effective in reducing shoulder subluxation, improving proprioception and upper extremity function. However, after discharge, survivors often retain slings for lengthy periods in the community simply because they have no clear guidance concerning whether it’s possible to reduce (or stop) using one altogether. And if so, when to do it. Please understand that a sling won’t help you in the long run and may well hold back your recovery.

Understandably, improvement of post-stroke shoulder subluxation is shown to improve performance of task-specific, functional activities. So, you must seek the advice of a therapist or your GP concerning how and when to reduce sling usage. Careful retraining without one is the probably the only way, combined with exercises such as those listed below, that you’re going to fully correct shoulder subluxation.

Range-of-motion exercises for the shoulder joint should include flexion-extension, abduction-adduction and external-internal rotation. Careful weight-bearing exercises for the affected upper extremity can be very beneficial for you but pulling motions, like rowing, must be avoided. Training with a linear shoulder robot can improve shoulder stability, motor power, and result in improved and retained functional outcomes. Electrical stimulation is also shown to be consistently effective at reducing subluxation…

But what if therapy didn’t have to feel like therapy? An invitation extended to you if/as appropriate for you!

A New Way to Move: Non-immersive Virtual Reality Rehab from Home

A collaborative team from University of Exeter and University of Leeds is exploring a novel solution: using a web-based game that can be accessed from any device with a camera to help improve shoulder movement, balance, fatigue, and pain in chronic stroke survivors.

The study is part of the eMBraCE activity programme, which aims to see whether digital, game-based exercises can help chronic stroke survivors regain shoulder movement and improve their balance while reducing pain and fatigue.

The idea is simple but powerful: deliver fun, engaging therapeutic activities through a game, allowing users to do short bursts of guided movement in the comfort of their home. No special equipment is needed — just a laptop, tablet, or smartphone with a webcam.

This study is proof of concept that aims to see whether even short-term use of such a game can make a measurable difference. And now, they are inviting participants to get involved too.

One of the things they will measure is electromyography (EMG) signals from the skin surface. This will tell them about electrical activity produced when muscles contract. They plan to use this to assess how the nervous system is adapting to control movement in different pain conditions.

 Frequently Asked Questions (FAQ)

What is the purpose of this study?

This study is part of the eMBraCE activity programme. It aims to see whether digital, game-based exercises can help chronic stroke survivors regain shoulder movement and improve their balance while reducing pain and fatigue.

Who can take part?

You are eligible if:

• You’re aged 18 or over
• You are a stroke survivor, living with long-term effects
• You can walk independently, with or without a walking aid

What will I be asked to do?

You’ll attend a session at the VSimulators facility in Exeter or University of Leeds. The session takes about 2 hours, including preparation and testing.

During the session they will ask you to:

• • • • • Wear some small boxes or wired sensors that measure your muscle activity
        • Perform basic movements like standing, walking, turning, and lifting
        • Use a web-based game designed to help guide shoulder and balance exercises
        • Fill out questionnaires about your experience and symptoms

Are there any risks or discomforts?

Risks are minimal. You may feel some fatigue or mild discomfort during the exercises, similar to any physical therapy session. The team will be with you throughout to ensure your safety and comfort.

Will I be paid for taking part?

There is no payment, but the team offers up to £50 reimbursement for your time and travel costs.

How is my personal information handled?

Your data will be pseudonymised (de-identified) and stored securely. You can choose whether or not any images or videos taken during the session can be used in publications or presentations. Opting out will not affect your participation.

Can I withdraw from the study?

Yes. You may withdraw at any time, even during the session, and can request your data be deleted if you wish.

If you are interested in taking part or would like to have some more information feel free to contact study researcher Tom Richards: t.richards2@exeter.ac.uk

Dukelow, S. P., Herter, T. M., Moore, K. D., Demers, M. J., Glasgow, J. I., Bagg, S. D., Norman, K. E., & Scott, S. H. (2010). Quantitative Assessment of Limb Position Sense Following Stroke. Neurorehabilitation and Neural Repair, 24(2), 178–187. https://doi.org/10.1177/1545968309345267

Cardiovascular exercise is defined as any type of exercise that gets your heart rate up and keeps it up for a prolonged period of time. It isn’t difficult to do and there are lots of options.

Walking, jogging, running, cycling, stepping, swimming, boxercise and rowing are examples for those who haven’t suffered a stroke. Options for stroke survivors are narrowed somewhat from these choices but at least one or other of the above can probably be achievable, either supported or unsupported.

When you do these types of activities, your respiratory system starts working somewhat harder as you begin to breathe faster and more deeply. Your blood vessels expand to bring more oxygen to your muscles, and your body releases natural painkillers (endorphins).

Your GP no doubt has already told you that if he or she could put cardiovascular exercise into a drug, it would be one of the most effective medications to prevent and/or treat patients with cardiovascular and/or cerebrovascular diseases. But cardiovascular exercise, despite the known benefits, is still known to be under-utilised by clinicians as a ‘prescription’ during rehabilitation.

Being unfit and inactive is clearly a risk factor for stroke. But you may also have noticed that it’s a consequence of your stroke, even if you were reasonably fit pre-stroke. Being inactive for a long period of time after stroke is related to a multitude of physiological consequences that can result in reduced fitness, increased risk of cardiovascular events, sickness or even death.

The great news is that exercise training is a really potent stimulus for improving fitness after stroke and it doesn’t have to be at all onerous. It can be made to be fun and satisfying to do.

National guidelines emphasise the importance of at least 150 minutes of moderate exercise per week. Nevertheless, by the time all therapist help has finished, you may still lack a clear, results-producing, progressive programme that you can plan, perform, record and evaluate over the long term. Don’t feel guilty if you haven’t done anything much since your stroke. Let’s start the journey of putting it right.

There is growing evidence to suggest cardiovascular exercise promotes neuroplasticity. In the brain, certain molecules and hormones power plasticity and cardiovascular exercise has been shown to increase how many of these molecules we have floating around in our blood. This is vital, as neuroplasticity mediates cognition and the re-learning of movement after stroke. So, not only can cardiovascular exercise increase the number of connections in your brain and improve your road to recovery, it can do so while creating a healthier cardiovascular system. Exercise also generates a boost of crucial neurochemicals in the brain as well as affecting the autonomic nervous system (ANS).

Cardiovascular exercise strengthens your heart’s efficiency. It also increases the amount of blood that leaves your heart with every beat (stroke volume), meaning your heart doesn’t have to beat as many times per minute.

Your heart essentially doesn’t have to work as hard, which in turn increases its efficiency. The increase in capillary density also allows for greater exchange of those essential nutrients your body requires. Cardiovascular exercise therefore can decrease arterial stiffness. This allows for the blood to be pushed along your arteries through proper dilation and contractibility, with an adequate amount of pressure.

Cardiovascular exercise is the first step to keeping or creating a healthy heart and arteries while the second intervention is diet. There is now a substantial body of evidence to support the importance of cardiovascular exercise for mobility, health and well-being as part of rehabilitation for stroke survivors.

Research has demonstrated that at least 80% of recurrent vascular events after an initial stroke or TIA could be prevented through cardiovascular exercise, education and lifestyle changes.

A recent systematic review has shown that exercise interventions can result in clinically meaningful blood pressure reductions, particularly if initiated early and alongside education about healthy lifestyles. The use of cardiovascular exercise to improve your heart and lung health is well established. However, of extra relevance for you is that motor control, cognition, fatigue, depression and sensory functions are all posited to improve via regular practice. Definitely worth taking some time per day to do!

The evidence for exercise after stroke has resulted in the development of stroke-specific community exercise programmes. The system is analogous to the very well-established rehabilitation services for cardiac disease patients which usually start after usual rehabilitation has ended. Collaborations between health boards and council-run leisure centres have resulted in the establishment of exercise referral schemes, which have provided a range of stroke-specific cardiovascular exercise programmes delivered to smaller and larger groups.

Additionally, some UK charities offer free or minimal-cost group exercise classes. Both modes are often well run, low in frequency (once a week for possibly one hour in duration), low in cost and usually beneficial (dependent on every possible variable, from venue accessibility to the character of the instructor).

Be careful however, not to think of such classes as the only retraining you need to do. Fitness classes can be beneficial but you’ll soon spot that those purporting to give you some rehabilitation ‘mixed in’, actually won’t be very effective at doing so. My advice would be to keep fitness and rehab efforts separate. What you need to be doing in terms of exercise is probably to regard it as comparable to a prescription of medication.

Most people end up finding it much easier and more efficient just to invest in some equipment and exercise at home daily. Stationary exercise machines such as bikes are great for this.

Those that are known as recumbent or semi-recumbent bikes (depending how reclined it is) would be my first choice for a ‘beginner stroke survivor’. These types of gym bikes can be picked up relatively affordably from a variety of places and often aren’t cheap but they hold a considerable re-sale value.

You can even prop your ipad on the display ledge and watch videos or listen to music to help the pass the time. You might possibly find it difficult to keep your more-affected foot on the pedals due to weakness and/or loss of feeling and sensation in your legs. If you’re experiencing such problems, look at the internet to see if you can get a customised pedal made. This kind of job is often most efficiently carried out by a clever bicycle fixer in a dedicated bicycle shop or even a mechanic or engineer. Such people will be really great at problem-solving and coming up with the best device for you. If all else fails, it’s even possible to adhere trainers to pedals and slip your feet into them! Trainers with strong Velcro tops work well for this.

Many people will want to do some form of cardiovascular exercise daily. Go for it. If this is not achievable, it’s advised that you complete 10-60 minutes, 3-6 days per week, depending on your status and the intensity of the exercise being completed. This may sound like a lot to do, but it does need to be contemplated. And it doesn’t have to be onerous at all.

Intensity of exercise is dependent on your heart rate or the amount of effort you feel you’re exerting. The more intense the activity, the higher your heart rate will be. And the less time you’ll probably need to train for. You’ll soon find that you can create a weekly plan which allows you to slot in some frequent but short sessions of cardiovascular exercise.

How about also incorporating a variety of exercise into your lifestyle? Particularly exercises like walking and swimming, which can be done with friends or family, and are a great way to socialise while achieving some exercise. Sometimes you won’t be able to get out and about as often as you need, to do a form of exercise. So, as mentioned earlier, it’s a good idea to plan how you’re going to get it done by yourself at home.

Try to monitor yourself while exercising, so that you can follow your own progress and also know when you need to push yourself a little further. There are several ways you can do this. Heart rate monitors are a great way to keep track of the intensity you’re working at. Speak with your GP to find out what heart rate you should be working at for your age.

Pedometers are readily available and using one is simple way to monitor how many steps you do daily. A ‘wearable’, such as a FitBit, can track activity, sleep and heart rate over time, and is worth getting to provide extra real-time info.

A big tip from Tom: make sure to record and celebrate any and all successes. Try to pinpoint how you achieved new action control in your ADLs. This is often via something achieved in your retraining. Start to become aware of these. Get this data recorded somehow.

I created special training diaries to all my patients and make sure they’re completed. It makes retraining (and the planning for it) far less abstract and becomes surprisingly easy to do. These are available to buy if you want one or two, by the way, from us at the ARNI Stroke Rehab Charity – see the ARNI shopping selection

Good luck with your cardio training; please comment below if you’ve found the above helpful and tell us in your comment what you personally like to do for cardio exercise as a stroke survivor.

Have YOU got any tips and survivor ‘tricks of the trade’ you can share to help anyone reading? Gratefully received!

Much, much more info like the above can be found in the Had a Stroke? Now What? book. Get your copy from ARNI if you’ve not got yours already: all profits go straight to help stroke survivors….

There has been attention given by researchers in stroke across the globe to tie down what we really ‘mean’ by the terms ‘rehabilitation’ and ‘recovery’.

In neuropsychological terms, if the phenomenon of creativity is first under examination, we might discover the descriptor term: ‘4 P’s of creativity‘: the person, process, product and press. The ‘press’ being the ‘environment’ where the creator is creating/inventing/innovating (these three terms also have different definitions).

Also, note as an aside that if ‘Press’  may involve ‘where one creates’ / where/who is around to help you do stuff / what sources can you look at / involve with etc etc, it does rather shine a light on the importance of being cognisant of not just ‘where one is’ (eg, in a flat, in a tower block, in the suburbs of London) but how one can bring maximal resources to bear to help your own situation.

For example; can you set up some effective home training gear? Can you get help from a qualified therapist or instructor to come to you to help in the early days? Can you get to a stroke rehab class if there’s one worth bothering with? Can you investigate interventions.. and learn about everything from CIMT to finding and utilising a specific kind of AFO which won’t restrict neuroplasticity but will support it whilst supporting you? Etc.

If one looks at how these 4 P’s of creativity map over to definitions produced by a global expert panel in 2017 (Bernhardt et al),which included long term supporter & friend, Professor Nick Ward at the Institute of Neurology, UCL, one can see that in the framework above, recovery is the product. A ‘product in perma-flux’! I’ve placed a blue line around a sentence from the paper which bears repetition.

After your stroke, the aim of rehabilitation is to help you overcome and cope in the long term with the damage caused. You’ll be helped to relearn or adapt skills so that you can be as independent as possible. Arguably the concept which will bear the most importance upon your rehabilitation potential from now on is ‘neuroplasticity’; 

Your brain attempts to repair as much as possible after stroke, but there is a downside. During this period of repair, the neurons that surround the infarct are not able to do their job of conducting impulses.

Only once corrective metabolic activity recedes, swelling declines and ‘stunned’ neurons reawaken. This resolution is usually complemented by neuroplasticity. There is then available a period of optimal learning; when the area surrounding the lesion is at its most ‘plastic’. Although, it must be understood that that your although your ‘plastic potential’ declines, it will never be lost.

A town-planning analogy may be considered; in the same way a city has many streets and roads that link different suburbs, your brain has many connections that link different parts of your brain. There are many different exits and junctions that can take you wherever you need to go in the quickest way possible.

The more a road is used or the more popular it may become (ie, if a new short-cut to a motorway has just been loaded to the sat-nav technology), the more traffic may build suddenly up along that route, so the council may strengthen the existing road to cope with the traffic and/or add more lanes or new routes to cope with the increased traffic (new connections). It will also add speed-bumps no doubt!

Your brain can substantially reorganise itself in response to the input it is, or isn’t, receiving after stroke. Your brain has the ability to seek out older, less-used, ‘secondary’ roads if the ‘main roads’ are blocked or damaged.

Neuroplasticity allows us to compensate for irreparably damaged neural pathways by strengthening or re-routing remaining ones. The more you use these pathways, your brain will respond by upgrading them so that they’re more efficient at handling the traffic and the quicker the information is sent. The more the pathways (or ‘roads’) are used, the more adequately functional a task, ability or skill may seem to become.

Have a think about this; recovery is a journey. Rehabilitation is the road. Re-training is the vehicle and YOU are the driver. You’ve got a destination to go to, but it’s an on-going one, like a tour!

You absolutely, unequivocally, must drive yourself through your weeks, months and even a few years of rehabilitation to continue your recovery. The good news is that this road isn’t going to be boring, at all. On the contrary, the weather may be changeable at times but you’ll have lots of company on the way and there will be loads of great shops to try new rehab and/or self-management gear at and pubs to make pitstops at!

This is why repetition in rehabilitation post-stroke is so heavily emphasised. The more you repeat activities, the more likelihood you have potentially to gain back some of the function you may have lost due to your stroke. There is now a strong consensus among rehabilitation experts that the most important element in any recovery programme is carefully directed (well-focused and appropriately dosed) repetitive practice.

A big secret to success with your upper limb for example (dependent on presentation) is, after early intensive recovery efforts have moved you to a certain standard of functional movement, to start ‘creating’ things with the thought of ‘formal rehab’ firmly in the background.

The choice or choices of hobby you take on to pursue over the long term would be set up first to ensure that your more-affected upper limb, from shoulder to fingertips, is maximally involved. The requirements of painting a picture involving your more affected hand and acquiring skill at this practice is one example. Or setting out to make cards to sell for charity or on Ebay!

One problem that many researchers find is that individual creative efforts like these don’t readily lend itself to measurement, however contributory they are to your overall rehab. And creativity notoriously suffers under measurement and control during trials. This is one of the reasons why you won’t find ‘off-the-shelf’ custom self-rehab programmes. They are by nature all generalised. They have to be.

And furthermore, motivation must ‘run like a ribbon’ through the creative process. This must be intrinsic to the creator – there must be a NEED to create, to problem-solve until an objective is complete. This need stokes interest, drive, enthusiasm, desire, perseverance, passion and persistence.

So remember, the ARNI 4 retraining elements are meant to be initially explored with the help of a therapist or trainer if possible, then individualised by you, the creator, as soon as appropriate.

A good start is to try to take onboard, and adhere to, these 9 golden rules:

1) Time matters: neuroplasticity is a process rather than a single event, with windows of opportunity opening for different skills at different times. In rehabilitation, starting earlier is usually better than starting later.

2) Repetition matters: you must do a task over and over again to actually change your brain.

3) Specificity matters: you must skillfully practice the exact tasks you want to improve.

4) Salience matters: to change the brain optimally, the skills you’re practicing must ideally have meaning, relevance, or importance to you.

5) Intensity matters: more repetitions in a shorter time are necessary for creating new connections.

6) Train to transfer: practicing one skill can often result in improvement of a related skill.

7) Use it or lose it: the skills you don’t practice often get weaker.

8) Use it and improve it: the skills you practice the most, you get better at the most.

9) Age is a number: younger brains tend to change faster than older brains, but significant functional improvements are possible at any age.

10) Engage with others: get as many other people involved with your rehab over the long term as you humanely can!

Dr Tom Balchin, who founded the Action for Rehabilitation from Neurological Injury (ARNI) Charity nearly 25 years ago, has been made an Officer of the British Empire (OBE) in the New Year’s Honours List.

At ARNI, we are all absolutely delighted for him.

All those who know him will know how dedicated and passionate he is, and continues to be, about helping people who have suffered a stroke to recover as much as possible.

Dr Tom had a severe stroke in 1997. Stemming from his own self-recovery and despite retaining ‘drop-foot’, he created a unique ‘approach’ (a series of linked evidence-based physical rehabilitation strategies & interventions) to stroke rehabilitation.

His ARNI Approach has become well known world-wide for its amazing successes in terms of guiding stroke survivors to regain movement and managing limitations.

Over the years, Dr Tom has helped many thousands of people personally (and via his books and login videos). And he has taught many hundreds of specialists (his ‘ARNI Army’ of over 150 specialist qualified neurorehabilitation trainers and therapists) who each help lots of survivors on a daily basis.

To do this required Dr Tom create what has become the only existing national accredited qualification in rehabilitation after stroke for specialist personal trainers and therapists.

The ARNI Trustees said to us on hearing the news:

‘Dr Balchin has grown this Charity from just an idea to help people like himself, and has done it always voluntarily. We think he is a quite remarkable man who is fully deserving of this very significant national Honour.’

If you know Tom, have been helped by one of his specialists or in any other context, please write to him on tom@arni.uk.com

Even better;

• ARNI Stroke Rehabilitation Charity needs to further its reach in order to help as many other survivors who may not have heard about Tom and his Charity.
• If you are in a position to write up a quick article and paste it to an authoritative page in an Institution you may represent, please do…
• And/or send this to someone in the media who you know, we would be so very grateful to you.
• By doing this, you may be able to indirectly gain support for stroke survivors out there who would not have contacted ARNI without you highlighting for them.

There is a page (click picture ‘Meet Dr Tom‘) with further text that you or another can cull some text from.

Or that a writer or reporter can gain a better understanding.

And of course, he/she is so welcome to email Dr Balchin OBE directly and/or speak with him.

Approximately 70% of stroke survivors experience a weakened arm immediately after the stroke and for 40%, this persists beyond 6 months¹. Arm weakness can have a very large effect on the individual’s routine daily activities such as eating, dressing, washing, cleaning, and shopping and can also reduce potential employability.

Stroke survivors have identified arm weakness as a high priority for clinical research which aims to produce better functional outcomes in the upper limb². Current physical therapies are limited in their success and are also very time demanding. Therefore, effective augments to use alongside rehabilitation are sought.

In a recent trial³ it was shown that stimulating the vagus nerve (VN) whilst carrying out rehabilitation exercises led to better arm recovery compared to the control group (no stimulation – rehabilitation only). However, this trial used a surgically implanted VN stimulator which required surgery under general anaesthesia and, the rehabilitation therapy was mostly delivered in hospital.

Now a new national groundbreaking multi-centre trial called TRICEPS, led by Professor Arshad Majid and researchers from the Sheffield Teaching Hospitals NHS Foundation Trust, is investigating whether arm recovery after stroke can be improved by using a non-invasive VN stimulator.

The trial uses a device which is worn as an earpiece (image 1 and 2), whilst self-delivered rehabilitation exercises are carried out at home. Surgery is not needed as a branch of the VN, located within the ear, is stimulated through the skin (Transcutaneous Vagus Nerve Stimulation, TVNS).

Using brain scanning and blood tests the trial also aims to explore how TVNS helps the brain to repair its function after stroke.

How can I get involved?

Sheffield Teaching Hospitals and NHS Trusts nationally are looking for stroke survivors (aged 18+) with persistent arm weakness following an ischaemic stroke, which occurred between 6 months and 10 years ago. 

The trial involves wearing a TVNS earpiece and wristband (Image 1 and 2) whilst doing rehabilitation therapy at home. Some participants will also be asked to wear the device while performing their usual daily activities.

If YOU would like to join in, you’ll be asked to attend a face-to-face appointment at their nearest research centre at the start of the trial, followed by two further appointments at 3 and 6 months.

What support will there be?

• Participants will be given specific instructions regarding the device and the rehabilitation exercises.
• The 12-week rehabilitation therapy plan will be tailored specifically to each participant.
• A member of the clinical research team will organise phone or video calls with participants throughout the 12-week treatment period.
• If required, these may be completed face-to-face at the research facility. 
• Some research centres are able to offer home visits.
• Participants will be reimbursed for travel costs incurred as part of the trial.

I am interested, where can I take part?

The trial is open at 19 NHS centres across England and Wales.

A full list is available on the trial website here www.triceps-trial.com

How do I express interest?

Please contact the central research team in Sheffield who will carry out a quick preliminary assessment of eligibility by phone and refer you onto your nearest research site.

Central TRICEPS Research Team contact:

Email: triceps@sheffield.ac.uk

Phone: 07935 514510

1. https://www.nice.org.uk/guidance/ng236/chapter/Recommendations#intensity-of-stroke-rehabilitation
2. French et al., “Repetitive task training for improving functional ability after stroke,” 2016, doi: 10.1002/14651858.CD006073.pub3.www.cochranelibrary.com.
3. Dawson, J ∙ Liu, CY ∙ Francisco, GE ∙ et al. Vagus nerve stimulation paired with rehabilitation for upper limb motor function after ischaemic stroke (VNS-REHAB): a randomised, blinded, pivotal, device trial   2021; 397:1545-1553

Are you a stroke survivor with balance difficulties? If so, you’re NOT alone!

Balance and gait are essential components of functional movement, yet balance and mobility problems are among the most frequent and disabling effects of stroke, with 7 in 8 strokes affecting those over 44 years of age.

Balance (both standing and walking) training is the only effective treatment for balance disorders, as recommended by the National Institute for Health and Care Excellence (NICE) UK.

The evidence shows that training balance and gait during stroke rehabilitation is crucial for improving mobility, reducing the risk of falls, enhancing quality of life, promoting brain plasticity, and preventing secondary complications.

The newest (April 2023) stroke guidelines state: (click text)

1. ‘People with impaired balance at any level (sitting, standing, stepping, walking) at any time after stroke should receive repetitive task practice in the form of progressive balance training such as trunk control exercises, treadmill training, circuit and functional training, fitness training, and strengthening exercises.

2. Further, that people with impaired balance after stroke should be offered repetitive task practice and balance training as the principal rehabilitation approach, in preference to other therapy approaches including Bobath‘.

By incorporating these activities into a rehabilitation programme, stroke survivors can improve their overall recovery, regain their independence reducing feelings of depression, whilst increasing participation in daily and social activities and improving their quality of life.

(click text) HOW TO REGAIN BALANCE ARNI BLOG POST for more.

However, access to specialist balance rehabilitation services can be poor in the UK, due mainly to the lack of enough specialists and sufficient health resources. Current programmes can be sub-optimal in that they are not truly multisensory, do not include any cognitive component (which is a key factor in determining both static and dynamic balance), and do not address real life symptoms reported by patients as challenging.

Many specialists in stroke posit that Telerehabilitation could address many of these needs. 

The new (April 2023) stroke guidelines state (click text): ‘People undergoing rehabilitation after stroke should be considered for remotely delivered rehabilitation to augment conventional face-to-face rehabilitation’

ARNI Stroke Rehabilitation Charity adheres to these guidelines: we have offered a very successful speech, language and cognition rehabilitation / therapy remote service, simply using Zoom, for the past four years with survivors applying from around the world .

Click text to this page on the ARNI site: TALK WITH OUR SLT SPECIALIST ABOUT ARNI SPEECH, UNDERSTANDING & COGNITION SERVICE FOR FREE NOW

This page also shows the evidence summaries (meta-analyses of available recent studies which are as powered/controlled as possible) which reveal (for speech and language therapy at least) that Telerehabilitation is proven to be just as effective and far less costly in real-terms than in-person, face to face treatment.

We have reported before how ARNI supporter Professor Doris-Eva Bamiou, together with the University of College London and global partners, have been conducting a large-scale global research project to improve balance and quality of life in stroke survivors which involves software and required kit, but is designed to be for use at HOME, where the vast majority of re-training can take place most regularly and over the long-term.

We stroke survivors are generally ‘in it for the long-haul! Clinicians like Professor Bamiou understand this, hence her energy & activity leading a team of professionals to improve the lives of stroke survivors. The ARNI Institute supports her efforts. Please read below about a chance to get involved!

If you’re between 40-80 years of age, have suffered a stroke and are interested in contributing to improving balance, walking, mobility and quality of life for stroke survivors, please do read on!

A GREAT OPPORTUNITY FOR YOU: the team’s ambition is to optimise balance rehabilitation opportunities by providing you with a comprehensive, individualised tele-rehabilitation balance physiotherapy programme and the new HOLOBalance system, which includes multisensory balance and gait exercises, physical activity and cognitive training and exergames to improve balance function in older adults with stroke. And then to monitor your progress.

This  12-week intervention will then take place in the comfort of your own home with remote monitoring by a trained physiotherapist.

Here’s the inclusion criteria… please consider applying if you:

• Are between 40-80 years of age.
• Are able to understand and consent to participation.
• Live within Greater London area.
• Have received a diagnosis of ONE of: 1) stroke, 2) mild cognitive impairment, or 3) long covid-19
• Can independently walk, with or without, a walking stick for a minimum of 500-meters.
• Have no significant visual impairment.
• Do not have any other co-existing neurological conditions (ie. Multiple Sclerosis, Parkinsons’ Disease).
• Do not have any language or communication deficits impairing your ability to communicate and/or express their thoughts 
• Are willing to provide feedback on the usability, functionality, and acceptability of the kit, including appearance, proposed training and testing regime.

What will happen during the study?

1. You will receive an initial screening call to determine your eligibility.

2. Upon meeting the initial inclusion criteria, you will be invited to the clinic at 33 Queen Square, Clinical Neuroscience Centre, London, WC1N 3BG to complete the remaining eligibility screening, including the mobility, function and cognitive tests.

3. If you are deemed fully eligible, you will be randomised into either the intervention group or control group to complete a home-based balance rehabilitation programme.

4. The intervention group will complete a home-based, remote balance rehabilitation program using augmented reality, with body motion tracking for real-time feedback.

5. The control group will complete either the OTAGO home exercise programme, or a Vestibular rehabilitation program for Dizziness.

6. The program is to be completed 5-days/week over 12-weeks, with weekly phone calls, and programme reviews every 3-weeks.

Participation is entirely voluntary, and all data collected during the focus group will be kept strictly confidential and anonymous. 

How can you find out more/register interest?

If you are interested in participating and would like to find out more, please contact Brooke Nairn, Research Physiotherapist, UCL, Institute of Neurology & The Ear Institute on b.nairn@ucl.ac.uk

This study is funded by UK Research and Innovation UKRI, Reference Number 10062111 (under the European Union HORIZON 2021 scheme).

Over the 23 years of service to the public, we have trained many thousands of people over the long term, and usually every day we have a kind thank you coming in via email. These are most treasured, because to be thanked continually for the difference our instructors make, reminds those who run ARNI what a valuable and unique national service has been created and continues to exist with kind support from personal donations.

Furthermore, that we have continually worked since 2001 using the most current evidence-based concepts/interventions (and have been able to at any time, point to the continually updated meta-analyses of the major studies to prove this is so) has been imperative in creating our reputation.

As has the privileges of being able to work alongside and have the support of so many world-class leaders in neurorehabilitation research and practice across the UK universities in order to ensure our patients have the best knowledge they need (from application of techniques and strategies, to customising the most applicable augmentations to therapy & training) to make positive progress at all stages and to figure out what to do when rehabilitation stalls so that they may get back onto their recovery pathway again.

Many stroke survivors, since the earliest days of the charity decided to thank us for successful rehabilitation by writing testimonials of the time that they were with us. These are great indications of the personalised care you will receive at ARNI. Press here to view. These are valuable sources of real-life experiences, and indicative of what you can expect from ARNI.

Here’s the very latest one:

ANDREW (BY MARION). September 2024.

‘I found out about ARNI when I was calling around local physios trying to engage a mobile therapist for my step father, Andrew. It was proving impossible to find anyone willing to make visits to a residential care home. But one smart receptionist at a Lincoln practice knew about ARNI and told me I could contact the charity directly without a referral.

I hadn’t heard of ARNI before. My late mother had a stroke in 2012 and another in 2022. Why had I never heard of ARNI? The NHS gives short term physio support after a stroke. But if recovery is taking a little longer for you, then you risk being prematurely abandoned. Told you have reached the extent of your recovery. This is nonsense. You have just reached the extent of NHS funding.

Andrew, 5 months post stroke, was spending 90%+ of his day in bed at the Nursing and Care Home where he is at. Demotivated. Believing he was as good as he could be. Grieving for the loss of his wife. Anticipating the same outcome for himself. On a slippery slope.

When I made my enquiry I couldn’t believe how straight forward the process was. The immediate answer was, ‘yes – we can help’. The registration and paperwork was simple. An ARNI physio was identified and Natalie agreed to work with Andrew on weekly visits.

Three months into physio with Natalie and Andrew spends 90% of his waking day out of bed. A complete turn around.

He can mobilise unaided around his bedroom. He walks with a frame to the dining room for three meals a day. He is motivated to participate in social activities with other residents. He can take himself for a walk around the garden unaccompanied. Now he has the confidence to accept invitations to go out and can be collected by friends and go to public places.

ARNI, through Natalie, has given enormous hope to an 81yr old who thought he was destined to the same demise as his wife, who never regained mobility despite being desperately motivated to do so. Judith was a bed escaper! The response to this was to put the bed on the floor and lay out crash mats. The NHS assessment was that it was unsafe to allow her to try to walk. If only we’d known about ARNI then.

I firmly believe that ARNI services should be universally accessible and recommended by the NHS. There was no signposting from the medical profession. This is information that people who have had a stroke need to know.

According to Andrew, Natalie can read his mind. She knows when his blockers are emotional, not physical, and she knows how to motivate him beyond those. Truly, the intervention of ARNI has been life changing. An enormous relief for family who live hundreds of miles away. An inspiration to Andrew, and a long term hope of an active future’.

As far as any of the Testimonials one can find on the ARNI site are concerned, which go back to the earliest days of the charity, there are no miracles at all.

Only the successes (and failures) that came about when determined people who’ve had a major medical life incident made the effort and said to themselves ‘I’m not going to stay like this anymore…’ . They made the effort to enquire, do their research, took the decision to get the ARNI books, video streams via login, ask to be matched to an ARNI therapist, and most importantly, STAYED ON THE ‘RETRAINING TRACK’ afterwards.

We find that a majority continue on the self-rehab track they’ve developed, often because they grew to enjoy the process of working hard towards their own rehabilitation and realised via training at ARNI that this kind of intense interest in progressive self-development and self-improvement is highlighted in the neurorehabilitation evidence to be one of the keys to successful recovery from brain injury.

We feel that not one of these people did not recognise, by the end of the period that they chose to stay at ARNI, that the effort they put in translated directly towards their own progress in terms of functional improvement in movement, and increasing strength in both body and mind.

Furthermore, working with colleagues in neurorehabilitation research and practice across the UK universities and clinics to ensure our patients have the best knowledge they need (from application Of techniques and strategies, to customising the most applicable augmentations to therapy & training) to make positive progress at all stages (and to figure out what to do when rehabilitation stalls, in order to get back onto the recovery pathway again.

This is why from the earliest days, ARNI has concentrated on one-to-one re-training, so that survivors can move on to the next methods of long term rehab (back to life again – and joining in with community activities, involving in stroke survivor exercise groups etc and as appropriate.

Please call ARNI for Stroke Rehabilitation to find out more.