Flaccid Stage Treatment in Stroke


Question: What is the treatment protocol for flaccid stage of stroke? How long does this flaccid stage usually remain?

Answer: There is no set amount of time that the flaccid stage remains. For some it can resolve in days, others weeks or months. Most stroke patients I see don't remain flaccid and do gain some amount of tone which can range anywhere from minimal to severe.

During the flaccid stage, it is important to keep the arm supported and positioned well. Retrograde massage can be used to help with hand/forearm edema (unless massage is contraindicated due to CHF or similar diagnosis). You can use pillows or a tray to help support the weak arm. Slings are an option, but I don't personally like slings because they immobilize the arm and often cause poor positioning and alignment. If I do use a sling, it's usually only when a patient with a flaccid arm is walking. I like the Giv-Mohr sling for walking a patient with a flaccid arm or subluxed shoulder.

As far as exercises, it is important to do passive range of motion. Self passive range of motion exercises can be viewed at www.stroke-rehab.com/passive-range-of-motion.html. The main precaution is to be careful with overhead range of motion and only move the shoulder in a pain-free range. If the patient is unable to do passive range, the caregiver can do it. Examples of a caregiver doing passive range of motion can be viewed on video at www.stroke-rehab.com/stroke-rehab-exercises.html under the passive range of motion paragraph.

Other exercises that should be performed involve weight bearing and facilitation. Weight bearing can be done by the caregiver placing the patient's open hand on a flat surface (i.e. mat, bed, book), supporting the patient's elbow so the arm won't buckle, and having the patient lean and put weight down through the flaccid arm and hand. One can also tap the muscles to try an initiate movement. To help bend the arm, you can tap the biceps. To help straighten the arm, the triceps can be tapped. To help straighten the knee, tap the quadriceps. Weight bearing can also be practiced through the leg, but it is best to establish sitting balance first and have a physical therapist help with weight bearing through the leg to prevent the patient from falling. If the patient is unable to stand and weight bear even with the help of a therapist, a hi-lo mat can be used to start weight bearing. I often will have the patient sit on the edge of a high-lo mat that is raised with the patient's feet on the floor. Raising the mat and having the patient reaching forward allows for increased weight bearing through the legs, but this is an activity that should be done with the therapist.

Sometimes the extremities appear flaccid but actually do have a little tone and ability to move. For the arm, a hand towel can be placed on a table and the stroke patient can try to slide it forward. I often use a single tip cane, support the patient's hand on the cane and let them try to push it forward and back (the end of the cane is on the floor while I'm supporting the patients hand on the handle). Sometimes I will place the patient's hand on a table, ball or mat and see if they can hold it there without it falling or sliding off. These are a couple of beginning exercises that can be tried to see if there is any active arm movement.

Electrical stimulation can be used to initiate muscle contractions and prevent muscle atrophy in some patients. Other patients may not be able to use e-stim due to contraindications such as having a defibrillator or pacemaker so one must check with their MD first.

The last note I want to add is do not pull on the flaccid arm and make sure the arm and leg are positioned well. Often a patient will sit on the arm or have the arm/leg contorted in a bad position without even knowing it. It is important to tell the patient to frequently look at the weak extremities and see where they are positioned.

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weight bearing exercises
by: Anonymous

What are the physiological effects of the weight bearing exercises on the muscles and joints?

Answer: Weight bearing helps maintain bone density. It applies tension to muscle and bone, and the body responds to this stress by increasing bone density. Weight-bearing exercise can also help reduce the risk of fractures by improving muscle strength and balance, thus helping to prevent falls.

Flaccid Arm
by: Anonymous

Question: Can you muscle test a flaccid arm?

Answer: Manual muscle testing is considered to be inaccurate with stroke patients that have tone disorders due to the problem originating with the brain rather than the muscles. You can test someone with flaccidity, but obviously if someone has a truly flaccid arm with no noticeable contraction, their MMT score would be 0.

When I have a patient with a flaccid arm, I do check for movement at all joints in the arm as there can be flaccidity in one part of the arm and not in the other.

by: DR. SAAD

I like your way of teaching the treatment criteria for flaccid Arm

Some Treatments
by: Anonymous

This is some of treatment in flaccid Stage :
1- positioning (very important)
2- weight bearing on joints (very important)
3- Having patient to gait (with support of effected side & knee/knees if needed)
4- Movements in middle line
5- Rotational movements (trunks,?)

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Edema of Fingers in Flaccid Arm

Question: Will Isotoner help to reduce dependent edema in flaccid fingers of flaccid arm?

Answer: There are Isotoner therapeutic gloves that can help with swelling. Wearing of the glove can be combined with elevating the hand above the heart, and retrograde massage (stroking from the fingertips moving toward the wrist). If movement begins to return to the flaccid hand, it is important to start trying to open and close the hand and use the hand to help decrease edema.

There are some medical conditions that aren't appropriate or require close monitoring when dealing with edema management so it's important to check with your physician prior to initiating the use of edema control garments or techniques. Some examples of these medical conditions may include congestive heart failure (or other cardiac conditions with potential for volume overload), severe peripheral vascular disease, blood clots, infection, kidney disorders, and skin disorders.

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Therapy on the Weak Side

Question: My husband had a stroke a little over a month ago. It was a left MCA stroke. His right shoulder is subluxed and the arm is flaccid. He has some movement of the right leg i.e can move it sideways towards the left, and if supported, he can kick the leg out.
In therapy, they work only on his left side. Stretching, strengthening etc.

When do they start to work on the right side? It seems to me that he has some potential to regain use of the right leg and perhaps be able to walk with a walker in the future. But, if it is neglected now, wont it just atrophy and become useless?

He is only 61 years old.

Answer: I would definitely ask the therapist(s) who are working with your husband what is being done to address the right side and why they are focusing more on the left side. Sometimes therapists may appear to be working only on the strong side and actually be addressing the weak side. An example of this would be trying to weight bear on the weak leg, while lifting the strong leg. The purpose of this exercise isn't the moving of the strong leg but to strengthen the weak leg to be able to take weight and get the stroke patient to put weight on the weak side.

The same is true for the arm. The therapist may have the patient sit on a mat and have the patient lean on the weak arm while reaching with the strong arm. It appears that the therapist is working on moving the strong arm, but in reality, he or she is working on the patient taking weight through the weak arm and on sitting balance while reaching. If these are the scenarios that you are seeing, then the therapists aren't actually neglecting the weak side. However, I would say that in addition to weight bearing, the therapists should be trying to facilitate movement on the weak side.

If none of the above activities appear to be what the therapists are doing, and exercises are strictly being done with the strong side, then you should definitely express your concerns to the therapist(s). Make sure the therapists working with your husband have experience in working with stroke patients. If your husband's weak side is truly being ignored and your concerns are disregarded by the therapist, then you should consider finding a different therapist. If you're husband is in inpatient therapy and will be moving eventually to outpatient or home therapy, then it's a good time now to research or look for good therapists in your area who come with recommendations from others.

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Leg and Arm Movement

(Kent England)

Question My husband had a stroke on the 6th March 2011. He still has no movement in his left arm and left leg. What exercises can he do at home to improve this? He is currently having physio twice a week at the moment.

Answer: The return of motor function depends on the severity of stroke. There is no way to know for sure if muscle function will return, but the exercises that I use for facilitating movement are:

1) Weight-bearing activities to the arms and legs with the assist of a therapist
2) Electrical Stimulation (only if approved by the patient's physician and there is no contraindications for the patient)
3) Facilitation techniques - i.e. such as quick stretch and tapping of muscles to facilitate movement

You can also try robotic assisted therapy which can be found in some therapy clinics (i.e. Hand Mentor, Foot Mentor, Amadeo, Pablo, etc.)

I'm sure your physiotherapists are doing everything they can to help. Good luck!

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Quick Stretch

Question: What is "quick stretch" exactly? Is it what it sounds like .... Quickly stretching a muscle?

Answer: Quick stretch is used in stroke rehabilitation sometimes to facilitate muscle movement. It does involve quickly stretching a muscle. I use it frequently to facilitate the triceps to move the elbow into extension (straightening of the elbow). The quick stretch often elicits a spasticity response in the stroke patient which can be useful when trying to get the patient to move. I find it most helpful when patients have flaccid paralysis and are just beginning to show some trace movement.

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I Had Left Side Stroke

by Tauqeer Ahmed

Question: My question is my left shoulder had pain my arm is not moving up &down and my left leg is not so balanced. What is your answer?

Hi Tauqeer. I address these issues in the questions above and on the following pages of my website so please review them for the answers to your question:




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Try massage
by: Nursing researcher

Slow stroke back massage is very beneficial in your case

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Right side brain stroke affecting left side.

Question: My mothers stroke has left her left side partly paralyzed. She can move her left arm somewhat, but cannot move her left leg. Also has a problem with balance and cannot sit up by herself What therapy or exercises could help her.

Answer: I've added your question to this page so that you can see the answers above. Hopefully that will help.

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Signs of Early Movement on the Weak Side
by: Anonymous

If you begin to see signs of early movement on the weak side, try AAROM exercises. These can be done with an arm skate or by having the therapist and patient work together to range the arm. Also, some patient may benefit from having a full length mirror placed in front of them while performing exercises and ADLS, as most stroke patients have visual/perceptual issues, motor planning deficits, and cognitive impairments. A visual aide is sometimes helpful for direct feedback and minimizing distraction.

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Flaccid Stage Duration

Question: I have a patient of left side hemiplegia.After 12 days of CVA he till persist in flaccid stage. This stage may remain for how much longer?

Answer: Unfortunately, I cannot answer your question. Some people stay in the flaccid stage for only a few days and others have flaccidity for months. At some point, most stroke patients will begin to develop tone in their arm. Sometimes functional movement will be regained and sometimes tone and spasticity can set in without the presence of functional movement. Only time will tell.

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subluxed shoulder
by: Anonymous

Can subluxed shoulder worsen the recovery of flaccid stage???

Answer from stroke-rehab.com: Subluxation usually occurs with flaccidity and is due to the weakness of the muscles. Obviously it would be better if subluxation could be prevented, however, I have seen patients with subluxation go on to have a good recovery. I have also seen others with subluxation have pain and poor recovery. I tried to find research that used subluxation as a predictor of recovery of the arm, but I did not find anything after a quick search. You could perform a more extensive search to get an evidenced based answer as I am only answering based on my experience with stroke patients. Research has shown that if the arm stays flaccid and impaired over the first month with little improvement that the outcomes are less favorable.

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by amrit sharma

Question Patient is 55yr old and suffering with right side hemorrhagic stroke. Four months have been passed and there is no tone in left arm. Tone is only present when pain stimulus is given....so kindly suggest solution for it.

Answer I try to elicit contractions by tapping muscles while simultaneously trying to get the patient to move (e.g. I tap the biceps and ask them to try and bend the arm). I also use e-stim to facilitate muscles if the patient is a candidate for using e-stim. Other techniques I use is weightbearing through the arms/elbows and also trying to elicit movements in various positions. Lying on the back tends to increase extensor tone or straightening of the arm and lying on the stomach tends to increase flexor tone of the arm. Some of the first movements I see from many stroke patients is elbow extension by lying them on their backs, supporting the shoulder at 90 degrees of flexion and then tapping the triceps to elicit elbow extension or straightening. This works with many of my patients.

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Flaccid Arm....
by: Anonymous

Question Patient is 78 years old, and had a right side hemorrhagic stroke 5 months ago. Left arm is still completely flaccid with no movement at all, but left leg works at about 50% of the right leg. Is there any hope that some movement will return to the left arm?

Is there a link between hemorrhagic stroke and flaccid limbs? I see several people here mentioning them, and they are rare compared to clots.

Answer: I haven't read any studies regarding the incidence of hemiplegia/flaccidity for hemorrhagic stroke versus ischemic stroke so I can't say if it is more prevalent in one versus the other. The determining factor in whether one has paralysis is what part of the brain is affected not the type of stroke.

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Hemiplegia and Flaccidity Problem

by Ammulya

Question:Hello, I am seeing a patient that experienced a left capsuloganglionic bleed. She was admitted in the hospital for 2 months. She had right shoulder subluxation and flaccidity of the arm. After 2 months, she is still having the flaccidity. I am doing the teatment according to the flaccidity protocol like passive moments joint approximation, and tapping. Can you please suggest to me what to do other than this to improve her muscle tone?

Answer: Although 2 months may seem like a long time, I have seen patients who continued through the flaccidity stage for months before any tone was seen in the arm. I would absolutely continue what you are doing, provide weight bearing through the arm, and I also would try mental imagery and mirror therapy. If the patient doesn't have contraindications, you could try adding electrical stimulation (e-stim).

Also, when applying tapping and other facilitation techniques to the arm, I recommend putting the patient in the supine position (on their back). I have found more favorable results for eliciting movements from this position due to reflexes, especially for elbow extension. Once the patient sees some muscle activity, he or she often becomes more motivated to try and move. When I have a patient with severe hemiplegia, I usually start the person in the supine position and then progress to sitting during a session. Once the triceps starts producing movement, I can usually get the patient to reproduce this movement in sitting, but it takes that initial facilitation in the supine position for the patient to make the connection. The easiest way to identify movement of the arm from the sitting position, in my opinion, is through placing the hemiplegic hand on a ball or cane (with support from the therapist) and have the patient try to elicit arm movements. This is obviously based on my own experience and not any scientific study, but I like to go with what gets results for my patients, and this technique has worked for me.

I recommend that you teach the caregivers (or family members) of the patient techniques to facilitate tone or movement and emphasize to them to keep doing it daily. When a patient has severe hemiplegia with lingering flaccidity, tone may not show up for a while. Therapy may have already been discontinued by the time the tone presents itself so it's important to teach caregivers and patients facilitation techniqes and a home exercise program. Also, let the patient know to ask for more therapy if they are discharged but later begin to see tone in the arm as this is a change in their condition.

There is the possibility that the patient's arm will continue to be flaccid, but that is rare in my experience. Most stroke patients will go on to experience some form of tone. This doesn't mean they will gain functional movement or overcome paralysis, but it's definitely easier to elicit movement if you are seeing tone or active muscle contractions.

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Trace muscle grade

by Nellie
(Jackson, Mississippi)

Question: The therapist told me I had trace muscle movement in my left arm following a stroke. I am currently doing out patient therapy now, but what treatments are the best to use for "trace muscle grade"?

Answer: I like to do facilitation techniques to the triceps to elicit elbow extension or straightening. If you lie on your back, you can have your therapist or caregiver support your upper arm (toward the shoulder) and tap the triceps located in the back of the arm. As the person taps your triceps, you attempt to straighten your elbow and hold it straight. Make sure the person is supporting the upper arm toward your shoulder as you will not be able to hold the entire arm up on your own. As you are able to "learn" the movement, you will get better at it and should be able to straighten the elbow on your own without the helper tapping the triceps. You can then progress to sitting and trying to do elbow extension movements such as pushing a cane forward and back. You can have someone help hold your hand on the cane or wrap it to the handle with an ace bandage if you do not have enough grip to hold on. Above are some pictures demonstrating these exercises.

I also recommend using electrical stimulation unless you have contraindications (e.g. pacemaker, defibrillator, skin issues). Check with your therapist and MD to see if electrical stimulation would be right for you. There are companies who rent out home units that you can use on a daily basis at home if prescribed by your MD.

The third recommendation I have is just attempting to move the arm anyway you are able. If you have trace finger movements, keep working on trying to move the fingers. You can facilitate movement by tapping the muscle belly that causes the desired movement (e.g. tap on the back of the forearm to open the fingers and on the other side of the forearm to facilitate making a fist).

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Left Eye and Mouth Not Functioning

by John
(Musina Limpopo, South Africa)

Question: I am 26yrs old suffering from the left side of my face not functioning. Please help me - I dont know what to do.

Answer: Have you seen a physician? If it's only your face that is affected, it may be another condition such as Bell's Palsy or Ramsey Hunt Syndrome that effect the facial muscles. Stroke can also affect these same muscles. Either way, if you haven't seen a physician, please see one right away to determine what is wrong. A stroke may start out with certain symptoms and then become worse and even fatal without treatment.

For retraining facial muscles, you could use the same exercises that are used after Bell's Palsy. You can find some of these facial exercises at www.bellspalsy.ws/exercise.htm. You can also consult a physical, occupational or speech therapist who specializes in facial neuromuscular retraining to help you with exercises or use of biofeedback/electrical stimulation if appropriate. If you do seek out a therapist, make sure he or she has experience in facial retraining as this is a specialized area.

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Arm and Hand Movement only when yawning
by: Anonymous

Question: I was in a car accident, my blood pressure shot up so high during the impact, 210/178. What makes this so sad, is the fact that my blood pressure runs on the normal range. This cause my brain to bleed.

I had hemorrhage stroke at age 53, three months ago.

My shoulder has subluxation and it was very is very painful I received a steriod shot to help the pain..

My right side is paralyzed, but recently, I've made progress, of walking without a cane around the house.

I still cannot move my right arm, wrist or fingers. (flaccid).

However, my arm moves when I yawn from the elbow, and my fingers move straight out involutary.

Is this a sign that my arm is waking up? I start back outpatient physyical Therapy this week, and I am hopeful.

Do think E-Stim will help, I don't have any medical conditions that prevent me from using it.

Answer: Stroke is considered an upper motor neuron disorder. After having stroke, it is not uncommon for patients to have flaccid paralysis, involuntary movements, spastic paralysis, and/or varying degrees of movement. Your neurologist may be able to tell you what area of your brain was damaged and possible outcomes. Lesions in certain areas can severely limit fine motor outcomes and some lesions are more likely to result in spasticity or severe paralysis. If you can find out specifics as to where the lesion occurred in your brain, then you could look up information about effects of lesions in this area.

When someone does not have movement, I do like to try e-stim. I also recommend giving mental imagery and mirror therapy a try as well. You can visit http://www.strokengine.ca/intervention/. It lists various therapies. I would advise you to click on the mental imagery, mirror therapy, and functional electrical stim for upper extremity to see what research has shown about their effectiveness.

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Flaccid Paralysis Question

Question: I had a medically-induced stroke that. It was caused by interruption in the blood supply to my brain. I am left with the following;
1. a ringing in my ear
2. I can't walk- i am in a wheelchair
3. I have a feeding tube
4. My hand and arm have flaccid paralysis
5. I can't talk- when I do its nasal and I cannot be understood

If you have any suggestions especially for the flaccid paralysis, i would appreciate a reply.

Answer: I have added your question to this page regarding flaccid paralysis so hopefully, it will give you some ideas.

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