Improving Drop Foot After Stroke

Today’s post is a masterclass on improving foot drop after stroke. In it, we’ll discuss the following:

•  Introduction
• What is foot drop? Why do we have a foot drop after a stroke?
• What is the first strategy after stroke when dealing with foot drop?
• Passive Activities
• Active Activities
• Examples of Passive and Active Strategies
• Best Practice for Foot Drop
• The Ultimate Strategy for Foot Drop
• Advanced Neuroplastic Strategies After Foot Drop

Introduction

Many of you (perhaps up to 25%-40%) will deal with foot drop, especially after a middle cerebral artery stroke.

The middle cerebral artery supplies an area of the brain in charge of leg motor control. It also supplies parts of the somatosensory map that deal with information coming back from the body as well as control over the body.

While cerebellar strokes can have an influence on ankle and foot function, it’s usually after a middle cerebral artery stroke that you see a foot drop. And in some anterior circulation strokes, you canalso have an affected leg. But, that’s more in the planning of motor activities, not execution and direct motor control.

What is foot drop? Why do we have a specific foot drop after stroke?

Normally the anterior control (shin muscles) and the calf muscles are in balance. When you need to lift your foot before heel strike, the anterior muscles are active. You lift your foot and clear the ground. You’re ready for heel strike when you swing your leg forward (see gait explanation). Otherwise, you scuff the ground and can trip.

After stroke, the anterior muscles get weaker and the posterior muscles, the calf muscles and those on the underside of the foot, get more active. This results in so called foot posturing, meaning you cannot clear your foot of the ground as well as before the stroke. That’s what causes the foot to drop, not necessarily weakness, although that also happens.

With paresis, or weakness in your muscles, the anterior muscles lose out since there is less muscle bulk on the front and more calf muscle bulk to push off from the ground. You lose control, lose the anterior tibialis muscles, get flaccidity, and the muscles become weaker from disuse. Then the foot drops.

What is the first strategy after stroke when dealing with a foot drop?

You need to brace the ankle to make it safe while you start moving, because you lose control. There’s an increased chance of falling, which leads to more complications.

So, you’ll need a brace called an ankle-foot orthosis. It supports your ankle and lifts your foot. It often has a shaft and attachment to the leg higher up. Your foot is kept up by a plate in your shoe. You also can have foot braces that just support the ankle but also support an upward position of the foot.

This is the first strategy: Make sure that you get ambulatory, that you start moving and walking again, to ensure your condition improves.

You’re training your leg muscles, but that is not enough.

Bracing is the first strategy but should not be maintained. Why? When you do not actively use your ankle or foot, it gets lazy with a brace. Even if it’s difficult to get the controls back after your stroke, you must force the muscles to do their proper work—lifting the foot.  (I explain more about the muscles involved in the Anatomy of a Foot Drop training video.)

You’ll get a very stiff ankle that cannot lift anymore and does not support this movement in the ankle joint. You also lose the feedback to your brain. Your brain needs this feedback to create new pathways, engaging the areas around the infarcted area, in order to change function and help lift the foot again.

You need training periods with the brace as well as without.

Take the story of Linda, one of the co-founders of brain.rehab. While on holiday, to the horror of her family, she decided to lose her brace. She describes this in chapter 19 of her upcoming book as well. She thought, if I’m going to wear my brace all the time, I’ll lose function. I have to get rid of it and force myself.

The moment you’re forced to keep yourself upright without the safety of the brace, you must come up with strategies. You direct the neuroplasticity more when you are out of the safety of a brace or ankle-foot support to lift your foot and give stability.

Now, I’m not suggesting you do it just like Linda. I’ve also explained the dangers of the ankle-foot orthosis and that this must be done gradually.

Instead, make a well-thought-out decision: Am I going to use the brace? I have to walk a longer period. I know I will get weaker after 100 meters or a kilometer. If I don’t wear my support, my foot will buckle or I will trip. Be smart about it!

In the beginning, do both. Wear your brace and have periods without, practicing your balance and challenging yourself to drive neuroplasticity.

And, driving neuroplasticity is the only way to regain function through directed, well-constructed neuroplasticity. So, getting rid of the brace is likely the best step forward (see also the hidden dangers of an ankle brace explanation). Then actively start exercising. If the foot is very fixed and you cannot do it actively, do passive activities.

Passive Activities

You have a stroke and get fixed in a certain position. Your foot becomes twisted and starts to rotate inward because the anterior tibialis doesn’t lift the foot or correct the inward rotation. So, your foot drops in.

As humans, our muscles are special—our anterior muscles have rotated outward. The back muscles of our legs are really front muscles, like the biceps and pectoralis muscles. The hamstrings and gastrocnemius are on the back of our legs and this rotation enabled us to get upright. So, these are front muscles that want to flex us; they do not help us to stand upright.

These anterior muscles assist gravity to make us buckle and are important for propulsion and lifting. But they become more active while the muscles that keep us upright, that stretch our legs out and enable us to lift and swing our leg forward, get weaker. This results in a more gravity-assisted posture, not proper human posture.

Additionally, along with your spastic arm, there is a typical swing motion of the leg to overcome the inability to lift and move your leg forward. You use your back muscles to swing your leg forward instead of the proper extension of the leg. These back muscles are also weaker after the stroke.

When you are very fixed, spastic and without control of your leg to lift up, do passive exercises.

Passive exercise involves putting a sling around your foot, like a towel or elastic band, and passively lifting your foot with the band. This way, you assist the motion up. Do it outward and inward and hold it in position. You can also put your foot down and press on it, assisting the upward motion of your foot.

Because the foot is dropped in, you assist the foot to lift and rotate outward and up. Hold this position to promote mobility in the ankle joint and make your brain aware that you can still lift your leg.

Linda, who got rid of her brace on holiday, got movement back in three weeks. The reality is, it usually takes one to three months to get activity back. It’s not easy to retrain foot drop, although the control after a stroke of the leg is usually a bit better than when the arm is affected as well.

So, there’s certainly hope. And with a lot of work, you can retrain foot drop!

Active Activities

Active retraining starts with thinking about what you will do with your foot.

Sit down and think, I’m going to lift my foot, toes, big toe, little toes, forefoot, backfoot . . . And lift everything up. Rotate the foot a little bit out and lift up. You’re trying to lift the foot (unassisted) up and out of the inner rotation. Repeat 20 to 30 times, five or six times throughout the day. Then increase.

In the short video above you see Linda exercising her affected left foot while wearing a weighted sock (custom made by her mother). Click on the image to see Linda exercising her foot.

 To really get your foot lifted, start walking without the cane or brace. Do it in a safe environment with something to hold on to or the support of someone else. This way, you have a gradual transition to losing the brace.

A combination of active exercises (where you make the motion), losing the brace, and actively thinking through what you will do is a better strategy than passive activities alone.

If you cannot do active motions, start with the passive strategies and then move on.

Examples of Passive and Active Strategies

Throughout all these activities, you should be thinking and actively assisting with your mind. You will have to train the neuroplasticity in the networks and pathways and force the neuronal networks to change function and assist in this foot elevation alongside the physical exercises.

Passive strategies include using a sling, like a strap, towel, or tea towel, to move the foot and ankle. Make a sling and hold it with one hand, lifting the foot. Rotate the foot outward if it’s dropped inward. Lift it up, hold it, then relax.

Repetition is key! Do this five or six times a day. At first, 20 or 30 repetitions feels like a lot. But after a while, you should do hundreds of repetitions a day.

 Then you will see the changes I talked about in Linda’s case. You’ll see them after a month, after three months—but you will have to keep working on this. Later, you’ll start walking exercises).

In the years to come, you will have to actively train the neuronal networks and work toward purposeful, fluid motion. This is opposed to the compensatory motion, the swing you use to compensate for lost function. Instead, you’ll make the proper leg extension forward, heel strike, and lift, so you clear the ground.  

Over time, you’ll build up strength and lose your foot drop. You can even get rid of the brace after a couple of months. Use support when it is needed, for example, when the terrain is difficult or a challenging distance. Be wise about it!

Best Practice for Foot Drop

The best practice by far seems to be a combine active therapy with electrical stimulation, for example, a TENS electrical stimulation unit.

We explain how electrical muscle stimulation (EMS) works in future blog posts and training videos since we will also use it to regain wrist and finger function. A combination of electrical muscle stimulation and active exercise has even been shown in scientific studies to be the most effective in getting rid of a foot drop after stroke. So, it’s a great activity!

The stickers are placed on the anterior tibialis, the anterior muscle on the shin, and a small bit of current goes through them into your muscle.

Use it during your foot exercises to enhance the whole motion. You get a stronger signal back to the somatosensory cortex, where you become aware of the move, which spills over into the motor areas where you lost function. You activate networks that are still there. These activated neuronal areas get stimulated to change the function to help lift your foot.

So, go from bracing to passive activities to active ones. Then start combining the active strategies for the ultimate strategy.

The Ultimate Strategy for Foot Drop

The ultimate strategy combines active activities for a whole-body strategy.

What do we mean by that? Before you use the leg, you need the proper neurological base.

You need core stability because this stabilizes leg and arm movements, and even speech.

 Also, your vestibular integration must be correct. When your body awareness in space is off, you won’t have the proper motion for lifting your foot and propulsion. This is because your brain is not aware as you start to make the wrong movement. It’s also why it’s so important to choose a hemisphere-specific approach to retrain the foot motion.

 So, don’t just focus on the foot. That’s one of the biggest mistakes.

 You need whole-body strategies. While you focus on the foot, make absolutely sure that the foundation, the fundamental neurological development, is there.

Advanced Neuroplastic Strategies After

Foot Drop

 Start by doing the primary developmental motor exercises to create a better neuromotor basis for using your foot. Then look at:

• vestibular (balance) integration
• core stability
• field of vision
• hearing
• proprioception and feeling in your body

 Without these, you make unstable movements, so all must be in place. Some possible therapies include:

Infrared Light        

Warm up a leg, for example, while using infrared light. Infrared has been proven to stimulate body cells capacity to regenerate and penetrates much deeper than most other light sources.

Efference Copy Mechanisms

Start consciously practicing with feedforward, feedback and efference copy mechanisms. This is where you not only think more consciously through the motion (feedforward) before you act and feel conscious what the result is (feedback), you will also stimulate efference copy mechanisms by doing so. Efference copy is thought to reflect the predicted sensation of self-produced motor acts. It is the back and forward talk through circuits between the frontal cortex and cerebellum many times (up to 40 times) before a motoric act even takes place (within a split second)

Mirror Therapy

The good leg is projected onto a mirror over the nonfunctioning leg while you watch. Your brain is fooled into believing you’re using the good leg and that the affected foot is making the right movements. So, the body picture in the brain can change with mirror therapy (mirror therapy will be discussed in full detail in future brain.rehab training).

 You need all these full-body strategies to ensure an absolute, purposeful action in the foot lift. In other posts, we’ll talk in detail about the progression in all these exercises.

Of course, there are never golden promises that can be made but, when you engage in all these previously discussed activities together with the active exercises to overcome foot drop, you make a lot more progress in a lot less time.