Stroke Rehabilitation Assessment

Why the first visit is mostly measuring

Families often expect the first physiotherapy session to be exercise from minute one. It usually isn't. The first visit after a stroke is longer than the ones that follow, and a good part of it goes into asking, watching and testing. That can feel slow when everyone is anxious to see movement. But two people with the same scan report can need completely different work: one has a strong leg and a hand that won't open, the other can use the hand but falls sideways the moment they sit unsupported.

Without a careful baseline, there is no honest way to say later whether therapy is working. "He seems better" is a feeling. "He stood up from the dining chair without using his hands, which he couldn't do three weeks ago" is a measurement. The assessment is what makes the second kind of sentence possible. If you want the bigger picture of how recovery tends to unfold first, our overview of what to expect in stroke recovery is a good place to start.

The history we take before any hands-on testing

The discharge summary does a lot of work here. We look at the type of stroke (a clot or a bleed), which side of the brain was affected, the date, what the scans showed, and any procedures done in hospital. A bleed managed conservatively and a clot treated early can behave quite differently in the weeks after.

Then come the questions only the family can answer. What could this person do the week before the stroke? Did they walk to the market, climb to the terrace, manage their own bath? A 78-year-old who already used a stick for knee arthritis has a different realistic target from a 52-year-old who rode a scooter to work. We also ask about blood pressure and sugar readings, heart problems, previous falls, pain anywhere, sleep, and how the person is eating and swallowing. The list of current medicines matters too, not because we advise on it, but because some medicines cause dizziness on standing, and we need to know before we stand someone up.

Finally, the house. Which floor, whether there is a lift, how high the bed is, whether the bathroom has a step at the door. These details decide what is safe to practise and where.

Tone, strength and sensation

Muscle tone is the resting tension in a muscle. After a stroke it can be low (the arm hangs heavy and floppy, the shoulder starts to drop out of its socket) or high (the elbow bends and resists when you try to straighten it, the fingers curl into a fist). Often it changes over the first weeks, starting low and rising. We check tone by moving each joint at different speeds and feeling for the catch. It matters because the approach to a floppy arm and a stiff arm is close to opposite.

Strength is tested muscle group by muscle group, comparing the affected side with the other. Sometimes there is a flicker in the thigh muscle that can't yet lift the leg, and finding that flicker is useful, because it is something to build on. We also look at whether movements come in isolation or only in a pattern, for example the whole arm pulling up and in when the person only meant to bend the elbow.

Sensation gets less attention than it deserves. A person who can't feel where their foot is will drag it or place it badly even with decent strength. So we test light touch, the sense of joint position with eyes closed, and sometimes temperature. If the hand has poor feeling, that changes the safety advice for the kitchen and the bath. Our separate guide on numbness and altered feeling after a stroke covers this in more depth.

Balance, walking and the jobs of daily life

Here we watch real tasks rather than isolated muscles. Can the person roll to the stronger side, sit up from lying, sit on the edge of the bed without holding on? Can they stand from a chair, and how many tries does it take? When they walk, does the foot clear the floor, does the knee snap back, does the trunk lean? We note how much help is needed for each, from two people lifting to someone just standing close by.

Balance is checked sitting and standing, with eyes open and closed, and while reaching. Many falls after a stroke happen during turning or reaching for something on a shelf, not during straight walking, so we test those deliberately. For people already walking, the detail in our guide to walking and balance after stroke explains what we are looking for in the gait.

We also look beyond the legs: shoulder pain, swallowing difficulty, speech, attention, and memory. A physiotherapist does not diagnose cognitive problems, but if someone forgets the instruction halfway through a movement, or ignores everything on their left side, the plan has to account for it. Our page on thinking and memory changes after a stroke covers what families notice at home.

The scales used in stroke assessment physiotherapy, in plain terms

Standard scales let us compare the same person over time, and let the neurologist or any other therapist read our notes without guessing. Which ones we use depends on the person; nobody gets all of them in one visit.

• Muscle strength grades (0 to 5): 0 is no visible contraction, 3 is moving the limb against gravity, 5 is normal strength. Simple, quick, and good for spotting change in early weeks.
• Modified Ashworth Scale: grades how much a muscle resists being stretched. It is how we record whether spasticity is increasing or settling.
• Brunnstrom stages: describe how movement returns, from flaccid, through movement in fixed patterns, to separate controlled movement. Useful for explaining progress to families.
• Fugl-Meyer Assessment: a detailed score of movement, coordination and sensation, often used for the arm and hand.
• Berg Balance Scale: 14 everyday balance tasks (standing up, turning around, picking something off the floor), each scored 0 to 4.
• Timed Up and Go and the 10 metre walk: how long it takes to stand, walk and sit, and walking speed over a measured distance.
• Barthel Index or a similar daily living score: how much help is needed for feeding, bathing, dressing, toileting and moving around.

A score on its own means little. What matters is how it changes and whether the change shows up in daily life. If a family wants to keep their own record between visits, the stroke recovery progress calculator gives a simple way to track it.

From numbers to individual goals

By the end of the assessment we should be able to name the two or three things holding this person back most. It might be weak hip muscles on the affected side, poor sitting balance and fear of falling. It might be a stiff ankle and a foot that drops. Those findings, set against what the person and family want, become the goals. How those goals are set, split into short and long term, and reviewed is explained in our guide to building a stroke rehabilitation plan.

We also tell the family plainly what we don't yet know. Early after a stroke, the picture changes week to week, and it would be dishonest to promise a timeline on day one.

Why reassessment matters as much as the first visit

Monitoring outcomes is not paperwork. Tone can rise in the third or fourth week and suddenly make walking harder. A shoulder that was fine can become painful. Someone who looked safe with a walker can start catching their toes as they get tired. Regular reassessment catches these before they turn into a fall or a frozen shoulder.

In practice, we recheck a few key measures every couple of weeks in the early phase, then less often once things are steadier, and in full whenever something changes: a hospital admission, a new fall, a new medicine that makes the person drowsy. Progress notes are shared with the treating doctor so the whole team works from the same information. If progress seems to stall, the reassessment is what tells us whether it is a true recovery plateau or a problem we can fix.

How to prepare for the assessment

Whether the visit is at home through our home physiotherapy for stroke patients or at the clinic, a little preparation saves time and gives a more accurate picture.

• Keep the discharge summary, scan reports and the current prescription in one folder.
• Write down what the person could do before the stroke, in simple terms (walked alone outside, used stairs, bathed independently).
• Note recent blood pressure and sugar readings if you have been checking them.
• Dress the person in loose clothes that let the shoulder, knee and ankle be seen.
• Have the main family member or attendant present, since they will be doing much of the daily practice.
• Make a short list of the things that worry you most, such as night toilet trips or a painful shoulder.

If the person is still mostly in bed, we will start there; nobody needs to be got up and dressed in a chair beforehand. For the full range of what we offer after the assessment, see our stroke rehabilitation service.

Frequently asked questions