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Stroke | Cerebral Vascular Accident (CVA)

Definition

A stroke, also referred to as a cerebral vascular accident (CVA), happens when the blood supply to the brain is interrupted, causing the brain cells in that region to become damaged or die. It can be caused by either a blood clot in the brain or bleeding in the brain. There are more than 150,000 strokes or cerebrovascular accidents (CVA) reported in the UK every year. Ischaemic strokes are the most common form of stroke.  

Symptoms

Common problems encountered after a stroke include difficulties with speech, cognitive, emotional and visual issues, as well as more physical and balance-related difficulties.

Although some people will have a complete recovery, two-thirds of people who suffer a stroke will have some form of long-term problem (lasting more than one year) and this can often involve a person’s ability to walk.  When a stroke has an impact on mobility, it will tend to affect only one side of the body, as usually only one side of the area of the brain is damaged. Often, a person will be left with weakness and or spasticity in their affected side. They can also have problems with coordinating their movement.

Symptoms/causes

Ischaemic strokes occur when a blood clot blocks the flow of blood and oxygen to the brain. The clots form where the arteries have been blocked, or narrowed, by fatty deposits. As one gets older, the arteries can narrow, but lifestyle factors can accelerate the process. The culprits are smoking, high blood pressure, obesity, and diabetes, high cholesterol levels and excessive alcohol intake.  

Complications and related diseases

The amount a stroke affects someone is determined by the size and position of the original brain injury. If there is significant weakness and spasticity, mobility and gait will be severely affected. The loss of balance due to poor proprioception and the inability to feel where their feet are will cause increased problems with standing, walking and, sometimes, even sitting. If left untreated the rehabilitation process is harder to manage and it is more difficult to achieve improvements.

One of the main problems associated with long-term stroke rehabilitation is the contracture of muscles due to spasticity. This can lead to painful deformities of both the lower and upper limbs. For example, they can prevent people from being able to stand or open their hands. Another concern is the patterns of movements that people adopt to manage their condition. Bad habits can form and these are then difficult to unlearn.

Tests and Diagnosis

Assessing an individual following a stroke requires a neurological examination. This includes: analysing joint ranges of movement; joint stability; muscle strength; spasticity; standing posture/alignment; and a gait assessment.

Orthotic Treatments

A wide variety of upper and lower-limb orthotic devices are used successfully by people encountering the physical effects of stroke. These can be used during rehabilitation in the year or more, following the stroke in conjunction with physiotherapy in the post-rehabilitation period. Orthotics are used to help support one part of the lower limb while strength and movement are returning to the muscles near them. These must be adapted and matched to the exact needs of the user since muscle control can change rapidly and complications such as swelling can also quickly change. Secondly, spasticity or muscle imbalance can result in poor joint positioning and a shortening of one or more muscles. Typically, part of the calf muscle becomes shorter, forcing the toes downward and making the ankle give way to the outside. This shortening effect can be prevented by using a properly-formed resting splint. Shortening that has already occurred may sometimes be improved through the use of a dynamic contracture orthosis, which acts like a spring to apply a constant stretch on the affected muscles. Ultimately, our goal is to optimise the patient’s gait so that it looks as normal as possible. More and more we are using a particular orthosis to do this, it is called the Neuro Swing. It is designed with an ankle joint that allows the patient some freedom of movement and it can be fine-tuned incredibly accurately in our gait lab. More traditional AFOs have the drawback of blocking good movement along with the bad. At LOC, we only fit bespoke ankle-foot orthoses. These are designed and manufactured specifically to the individual’s requirements from a plaster cast of their leg.

Further information

There are a large number of therapists who can have a role to play in rehabilitation following a stroke. We work with physiotherapists, occupational and speech therapists who we are confident to recommend.
Milestones Neurorehabilitation Clinic Neurolink Physiotherapy Birkdale Paediatric

Clinic Locations:

Kingston upon Thames (HQ) Bristol Cambridge Manchester    

FAQs:

What does AFO stand for?

An AFO is an Ankle Foot Orthosis which as the name would suggest encompasses the ankle and foot. The objective is to control the position and movement of the ankle. AFOs are used to support weak limbs; they can also be used to immobilise the ankle and lower leg to correct foot drop. When set up correctly they can also have a great influence on the knee and hip joints. They are the most commonly used Orthoses.

How long do you wear an AFO?

The length of time that one needs to wear an AFO very much depends on the condition being treated. If it is a long-term condition like cerebral palsy or post-polio syndrome it is likely to be years as the condition cannot be cured. Your orthotist will advise you.

How should an AFO fit?

A patient’s comfort in their AFO is vital for compliance with the prescribed wearing regime. So there are a number of steps the orthotist should take to ensure a comfortable fit: the patient’s heel should fit fully into the heel cup without excess space, the contours of the plantar surface of the AFO should match the patient’s foot, for children there needs to be up to half an inch growth room in the toe shelf length. At LOC we use our Gait Laboratories at our Kingston and Manchester clinics to fine-tune our bespoke orthotics.

How does a ground reaction AFO work?

A GRAFO is used to control instabilities in the lower limb by maintaining proper alignment of limbs and controlling their motion. It reaches around to the front of the knee extending down to the ankle. It works by altering a patient’s limb presentation to displace load and impact as well as offering further control to the knee.

How much do AFOs cost?

The cost of an AFO is dependent on the type of AFO that has been prescribed and the material that it has been made with. Carbon fibre will be more expensive than metal or plastic for example. LOC’s bespoke AFOs cost can be found on our Orthotic Prices page.

Can you drive wearing an AFO?

The ability to drive while wearing an AFO is dependent on the condition being treated and the orthosis that has been prescribed. If wearing a hinged AFO, for example, you will be able to drive, but if wearing a knee brace, you won’t. Your orthotist will advise you.

Can you get a flexible AFO?

The most flexible type of AFO is a Dynamic Ankle Foot Orthosis (DAFO).  It is thin and provides flexible support to the foot and ankle.

Do static or dynamic AFOs improve balance?

Both normal AFOs and DAFOs improve static balance (eg: while standing). Research among MS sufferers suggests that DAFOs aided balance while walking more than AFOs.

Do AFOs fit under trousers?

The simple answer is: yes they can. However one has to be sensible and look for wide-fitting trousers/jeans preferably of light and thin material.

What is the difference between an AFO and a DAFO?

Typically an AFO is stiff and rigid whereas a DAFO is thin, flexible and wraps around the patient’s entire foot. A DAFO provides support but also allows some range of normal movement.

What is an SMO orthotic?

A Supra Malleolar Orthosis SMO gets its name from the part of the body it encompasses. Thus an SMO supports the leg just above the ankle bone or malleoli. It allows dorsiflexion and plantar flexion(toes up and toes down) but eliminates mediolateral movement.

How long does it take for LOC to manufacture bespoke AFOs following an assessment?

It typically takes a few weeks but is slightly dependent on the chosen materials and current availability.