Stroke Paralysis Physiotherapy

Paralysis and weakness are not the same thing

Doctors use two words. Hemiplegia means no useful movement on one side. Hemiparesis means weakness on one side, where some movement is present but it is slow, small or poorly controlled. Many people start with hemiplegia and move toward hemiparesis as the brain reorganises, though how far that goes varies a great deal.

The side matters too. A stroke in the right half of the brain weakens the left side of the body, and often brings problems with attention to the left, judgement of space and awareness of the weakness itself. A stroke in the left half weakens the right side and frequently affects speech and understanding. Families dealing with left-sided paralysis will find our guide to left side weakness after a stroke useful, and those caring for someone with a CVA with right sided weakness can read about right-sided weakness and speech changes.

The floppy stage: when the limbs feel heavy and loose

In the first days or weeks, the affected arm and leg are often flaccid. They hang, feel heavy, and do not resist when moved. This looks like nothing is happening, but it is when good handling matters most.

A flaccid limb has no muscle tone holding the joints in place. The ankle can drop into a pointed position in bed. The hip can roll outward. The fingers stay curled because nothing straightens them. Work at this stage is about positioning, gentle movement through the full range every day, getting the person sitting upright with support, and giving the brain sensory input: weight through the weak arm on a table, the weak foot flat on the floor, touch and pressure. Our page on positioning a stroke patient in bed shows the setups we use most.

Protecting the shoulder

The weak shoulder deserves its own heading because it causes so much avoidable pain. When the muscles around it lose tone, the weight of the arm can pull the ball of the joint partly out of its socket. This is called subluxation, and a physiotherapist can often feel a finger-width gap below the bony tip of the shoulder.

Subluxation itself is not always painful, but a subluxed shoulder is easily injured. The commonest cause we see is well-meaning family members lifting the person under the weak armpit or pulling on the weak hand to help them sit up. We teach other ways to do both.

• Support the weak arm on a pillow or a table whenever the person is sitting, rather than letting it hang.
• Never lift or pull the person by the weak arm. Help from the trunk and hips instead.
• In bed, keep the shoulder slightly forward with the arm supported, not trapped under the body.
• Move the arm gently and only within a pain-free range. Overhead pulley exercises are usually a bad idea at this stage.

Whether a sling or strapping helps depends on the individual, and should be decided with your physiotherapist and doctor rather than bought off a shelf.

When stiffness arrives: managing spasticity

For many people, tone returns over the following weeks and sometimes overshoots. The muscles become tight and resist being stretched, especially when the person is tired, anxious, in pain or constipated. Typically the arm pulls in with a bent elbow, a turned-in wrist and a fisted hand, while the leg straightens stiffly and the foot points down and turns in.

Spasticity is not all bad. Some extensor tone in the leg can help a person stand. The aim is to manage it so that it does not block movement, cause pain or lead to permanent shortening. Daily slow stretching, positioning, weight-bearing through the limb, active practice of the opposite movement, and splints for the hand or ankle are the main physiotherapy tools. Where spasticity is severe, the neurologist may consider medical treatments; that decision belongs to them, and physiotherapy runs alongside it.

The hand and the foot

The hand is usually the slowest part to recover, because fine control needs so much of the brain's wiring. We work from the shoulder and elbow outward, because a hand cannot be used if the arm cannot place it. Early tasks are simple: pressing down on a table to steady paper, holding a cup with both hands, letting go of a ball. The guide on arm and hand recovery after stroke covers this stage by stage.

At the other end, foot drop makes the toes catch on the floor when stepping. We train the muscles that lift the foot, sometimes with electrical stimulation, and assess whether an ankle-foot orthosis would make walking safer in the meantime. A splint is not a sign of giving up; it often lets someone walk more, which is itself therapy.

Preventing contractures

A contracture is a joint that has stiffened permanently in one position. Once it forms, it is very hard to reverse, and it can make washing, dressing and sitting painful for years. The usual culprits after a stroke are the shoulder, elbow, wrist and fingers, and the ankle.

Prevention is mostly routine: moving each joint through its full range once or twice daily, alternating positions, standing with support when possible so the ankle is stretched by body weight, and wearing any splint for the agreed hours. It is boring work, which is why it gets skipped. We teach it to the family so it happens every day, not just on physiotherapy days. Example movements are on our page of exercises for paralysis rehabilitation.

When there is no movement yet

Some families come to us weeks after a stroke with no visible movement in the arm or leg, frightened that nothing will change. We cannot tell anyone with certainty how much will return. What we can say is that the absence of movement now is not proof that none will come, and that the work done in this period protects the limb so that, if movement returns, it has somewhere to go.

In this period we use assisted movement where the person tries while we help, mirror and imagery practice, electrical stimulation to produce a contraction the person can feel and try to join, and plenty of trunk and strong-side work so they become as independent as possible regardless. Hemiparesis treatment in physiotherapy is as much about function with what is there as it is about chasing what is missing.

Stroke paralysis physiotherapy at home or at the clinic

Paralysed patients early after discharge are usually best seen at home, where we can also train whoever helps with transfers. Our home physiotherapy service for stroke covers Indirapuram, Ghaziabad, Raj Nagar Extension and Noida, and there is a dedicated page for paralysis physiotherapy at home in Noida. Once travel is manageable, our Indirapuram clinic adds supported walking and strengthening equipment. For an overview of all our stroke services, see the stroke care hub; if paralysis has another cause such as spinal injury, see our general paralysis physiotherapy page.

Frequently asked questions