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Management of the Upper Extremity following Stroke

2016 UPDATE
February 2016

The Canadian Stroke Best Practice Recommendations for Stroke Rehabilitation, 5th Edition (2015) is published in the International Journal of Stroke (IJS) and available freely online. To access the specific recommendations for Management of the Upper Extremity following Stroke, and all other sections of the Stroke Rehabilitation recommendations, please click on this URL which will take you to the recommendations online in the IJS: http://journals.sagepub.com/doi/pdf/10.1177/1747493016643553

For the French version of these recommendations, open the appendix at this link :  http://wso.sagepub.com/content/suppl/2016/04/18/1747493016643553.DC1/Stroke_Rehabilitation_2015_IJS_Manuscript_FINAL_FRENCH.pdf

All other supporting information, including performance measures, implementation resources, evidence summaries and references, remain available through www.strokebestpractices.ca, and not through the IJS.  Please click on the appropriate sections on our website below for this additional content.

Rationale

Arm and hand function is frequently reduced following stroke, limiting stroke survivors’ ability to perform activities of daily living. Unfortunately, a large number of stroke survivors with initial arm weakness do not regain normal function; however, many therapeutic techniques have been developed for those individuals who have minimal arm movement.

 

 

System Implications

To achieve timely and appropriate assessment and management of upper extremity function the organization requires:

  • Initial standardized arm and hand function assessment performed by clinicians experienced in the field of stroke.
  • Timely access to specialized, interprofessional stroke rehabilitation services where therapies of appropriate type and intensity are provided.
  • Access to appropriate equipment (such as functional electrical stimulation).
  • Long-term rehabilitation services widely available in nursing and continuing care facilities, and in outpatient and community programs.
  • Robotics are an emerging and developing area and stroke rehabilitation programs should begin to build capacity to integrate robotic technology into stroke rehabilitation therapy to appropriate patients as the research evidence suggests, and in the future incorporate this therapy as part of comprehensive therapy where available.

 

Performance Measures

  1. Extent of change (improvement) in functional status scores using a standardized assessment tool from admission to an inpatient or community-based rehabilitation program to discharge.
  2. Extent of change in arm and hand functional status scores using a standardized assessment tool from admission to an inpatient or community-based rehabilitation program to discharge.
  3. Median length of time from stroke admission in an acute care hospital to assessment of rehabilitation potential by a rehabilitation healthcare professional.
  4. Median length of time spent on a stroke unit during inpatient rehabilitation
  5. Median hours per day of direct task-specific therapy provided by the interprofessional stroke team.
  6. Average days per week of direct task specific therapy provided by the interprofessional stroke.

Measurement Notes

  • A data entry process will need to be established to capture the information from the outcome tools such as the Chedoke-McMaster Stroke Assessment (e.g., ARAT or WMFT).
  • FIM® Instrument data is available in the National Rehabilitation Reporting System (NRS) database at the Canadian Institute of Health Information (CIHI) for participating organizations.
  • For Performance Measure 5, the direct therapy time is considered 1:1 time between therapist and patient and does not include group sessions or time spent on documentation.

 

Implementation Resources and Knowledge Transfer Tools

Health Care Provider Information

Patient Information

 

Summary of the Evidence

Evidence Table 5.1: Management of the Upper Extremity following Stroke

There are many therapeutic approaches and treatment modalities that can be used to improve hand and upper-limb function following stroke.

Task-Oriented Training

Task-oriented training involves practicing real-life tasks (such as answering a telephone), with the intention of acquiring or reacquiring a skill (defined by consistency, flexibility and efficiency). The tasks should be challenging and progressively adapted and should involve active participation. This approach differs from repetitive training, whereby a task is usually divided into component parts and then reassembled into an overall task once each component is learned. Repetitive training is usually considered a bottom-up approach, and is missing the end-goal of acquiring a skill. In a systematic review of motor recovery following stroke, Langhorne et al. (2009) identified 8 randomized controlled trials (RCTs) of repetitive task training, specific to the upper-limb, from a Cochrane review including trials of both upper and lower-limb therapy (French et al. 2007). In these trials, treatment duration varied widely from a total of 20 to 63 hours provided over a 2 week to 11 week period. Therapy was not associated with significant improvements in arm function (SMD=0.19, 95% CI -0.01 to 0.38) or hand function (SMD= 0.05, 95% CI -0.18 to 0.29). Perhaps the inclusion of trials that evaluated repetitive task training in addition to task-oriented training was, in part, responsible for the null result. Patten et al. (2013) conducted a cross-over RCT with 19 participants in the chronic phase of stroke (12.96 months). Participants were randomized into one of two groups: 1) functional task practice (FTP), or 2) HYBRID (combined FTP plus power training). Treatment was delivered in two, 4-wk blocks of twelve, 75min sessions interspersed with a 4-wk washout period. Wolf Motor Function Test-Functional Abilities Scale (WMFT-FAS) scores were significantly greater following HYBRID vs. FTP (p=0.049) regardless of the order of treatment. These improvements were retained 6-months post intervention (p=0.03). Shimodozone et al. (2012) evaluated 49 participants in the sub-acute phase of stroke in a RCT. Participants were randomized to one of two groups: 1) repetitive facilitative exercise (RFE), or 2) control-conventional rehabilitation program; both groups received 40 min sessions 5x/wk. for 4 weeks of their allocated treatment. Both groups performed 30 min/day of dexterity-related training immediately after each treatment session and continued their participation in a standard inpatient rehabilitation program (e.g., physical therapy, mobility, speech). Action Research Arm Test (ARAT), Fugl-Meyer Assessment (FMA) was assessed at baseline, and at week 2 and 4. After 4 weeks of treatment, significantly larger improvements on the ARAT (p=0.009) and FMA (p=0.019) was demonstrated by the RFE group compared to the control group. Han et al. (2012) carried out a RCT studying 32 participants, on average, 40 days post stroke. Participants were randomized into one of three groups. All groups received arm training (5x/wk. for 6 wks.) including correct positioning and caring of the arm, passive, assisted and active movements, strength training, and functional activities with varying intensities: 1) Group A-1 hr, 2) Group B-2 hr, or 3) Group C-3 hr. After two weeks, there were no significant between-group differences in FMA or ARAT scores (p>0.05). After four weeks of treatment, there were significant improvements in FMA scores in group C compared to groups A and B (p<0.05) but no significant differences in FMA scores between groups A and B (p>0.05). There were no significant differences in ARAT scores between all groups (p>0.05). After six weeks of treatment, the FMA and ARAT scores had increased significantly in each group (p<0.05 for all); FMA and ARAT scores improved more significantly in groups C and B than in group A (p<0.05) but no significant difference between groups B and C (p<0.05).

Constraint Induced Movement Therapy

Traditional constraint-induced movement therapy (CIMT) involves restraint of the unaffected arm for at least 90 percent of waking hours, and at least six hours a day of intense upper extremity (UE) training of the affected arm every day for two weeks. This form of therapy may be effective for a select group of patients who demonstrate some degree of active wrist and arm movement and have minimal sensory or cognitive deficits. Evidence from the VECTORS trial (Dromerick et al. 2009) suggests that traditional (intensive) CIMT should not be used for individuals in the first month post stroke. In this RCT, patients who were randomized to receive 3 hours of intensive therapy in addition to wearing a constraint for 6 hours/day had lower Action Research Arm Test (ARAT) scores at 3 months compared with patients who had received conventional occupational therapy or standard CIMT for 2 hours each day. In one large RCT (Wolf et al. 2009), which included 222 patients 3-9 months post stroke, patients in the CIMT group had significantly higher Wolf Motor Function Tests (WMFT) scores and Motor Activity Log (MAL) (Amount of Use and Quality of Movement sub scores) at 3 months, compared with patients in the control group who received usual care, which could range from no therapy to a formal structured therapy program.

Modified constraint-induced movement therapy (m-CIMT) is a more feasible therapy option when resources are limited. In the most common variation of traditional CIMT, the unaffected arm is restrained with a padded mitt or arm sling for five hours a day, and with half-hour blocks of 1:1therapy provided for up to 10 weeks (Page et al. 2013). The results from several good-quality RCTs suggest that patients who received mCIMT in the subacute or chronic phase of stroke experienced greater functional recovery compared with patients who received traditional occupational therapy. A Cochrane review (Sirtori et al. 2009) including the results from 19 trials reported a moderate improvement in arm function and a significant reduction in disability at the end of the treatment period, although treatment effects were not maintained at 3-6 months post treatment. The results from this review are difficult to interpret since trials of all forms of CIMT were included as were patients in all stages of stroke recovery. Singh et al. (2013) evaluated 40 participants in the sub-acute phase of stroke. Participants were randomized into one of two groups: 1) experimental - 2 hours of structured m-CIMT therapy 5x/wk. for 2 wk. plus use of a mitt to restrain affected arm 10h/day for 2 week, or 2) control - conventional rehabilitation time-matched to experimental group. For both groups, WMFT (p=0.003 and p<0.001, respectively) and FMA (p<0.001 for both) scores improved significantly between baseline and post intervention. No between-group statistics were reported, although the difference in scores between pre and post were greater on both the WMFT and FMA for the experimental group compared to the control group.

Evidence from a single trial evaluating the Graded Repetitive Arm Supplementary Program (GRASP) program suggests that this type of therapy can increase the number of hours of therapeutic upper limb use received by a patient (Harris et al. 2009). In this RCT, 103 patients recruited an average of 21 days following stroke with upper-extremity Fugl Meyer scores between 10 and 57, were randomized to participate in a 4 week (one hour/day x 6 days/week) home-based, self-administered program designed to improve ADL skills through strengthening, ROM and gross and fine motor exercises or to a non-therapeutic education control program. At the end of the treatment period, participants in the GRASP group had significantly higher Chedoke Arm & Hand Activity Inventory, ARAT and MAL scores compared with the control group. The improvement was maintained at 3 months.

Mental Practice

Similarly, the use of mental practice has been shown to improve arm function compared with traditional therapy alone. It may also be a valuable adjunct to other upper limb interventions and used as a precursor to mCIMT. A large treatment effect (SMD=1.37, 95% CI 0.60 to 2.15, p<0.0001) was reported in a Cochrane review, (Barclay-Goddard et al. 2011) which included the results from 6 RCTs. Length of treatment ranged from 3 to 10 weeks. Subgroup analysis based on stroke chronicity and dosage was not possible due to small numbers of trials. In a RCT by Timmermans et al. (2013), 42 participants (2-6 weeks post stroke) were randomized into one of two groups and trained 3x/day for 6 weeks: 1) conventional rehabilitation plus 10 min mental practice-based training for 10 min per session, or 2) usual therapy and additional bimanual upper extremity techniques based on neurodevelopmental principles for 10 min per session. There were no significant differences between groups over time on either the FMA or WMFT (p>0.05 for both).

Virtual Reality

Results from two systematic reviews suggest that patients with mild to moderate upper-limb impairment may benefit from treatment using commercially available non-immersive virtual reality devices. A Cochrane review (Laver et al. 2011) included the results from 19 RCTs and reported that arm function, assessed using the FMA, was significantly improved following treatment (mean difference=4.43, 95% CI 1.98 to 6.88, p<0.0001). Improvements in hand function approached statistical significance (MD=3.55 95% CI -0.20 to 7.3, p=0.063). In sub group analysis, based on time since stroke onset, treatment provided in both the acute and chronic phase of stroke was effective. Saposnik et al. (2011) reported similar findings in their review, which included the results from 12 studies. There was significant improvement in motor impairment, assessed using the FMA, but no improvement in performance on the Box & Block test (BBT) or the WMFT (manual function). In a recent RCT by Kiper et al. (2014), 44 participants within one year of a first-ever stroke were randomized into one of two groups: 1) reinforced feedback in virtual environment (RFVE) 1hr/day plus traditional rehabilitation (TR), or 2) TR only. Training occurred for 2 hr/day, 5x/wk, for 4 wk. Fugl-Meyer Upper Extremity Scale (F-M UE) and Functional Independence Measure (FIM®) were assessed at baseline and at 4 wk follow-up. F-M UE scores significantly increased in only the RFVE group (p<0.001) but not the TR group (p<0.053). FIM® was significantly increased in both the RFVE (p<0.001) and TR groups (p<0.006). Furthermore, Lee et al. (2014) conducted a RCT with 59 participants (<1 month post-stroke) and randomized individuals into one of three groups: 1) Group A-cathodal tDCS, 2) Group B-virtual reality (VR), or 3) Group C- tDCS plus VR. All participants received standard therapy. Manual Muscle Test (MMT), Manual Function Test (MFT), FMA, BBT, Korean-Modified Barthel Index (K-MBI); assessed at pre- and post-treatment. Changes in scores on the MFT and FMS were significantly different between the three groups (p=0.021, p=0.03 respectively). Improvement in Group C was significantly greater compared to Group A and B on MFT (Group C vs. Group A, p=0.016; Group C vs. Group B, p<0.01). Group B also had a significantly greater improvement in MFT score compared to Group A (p<0.01). FMS score improvement was significantly greater in Group C than Group A (p=0.013) and Group B (p<0.01). Further, Group A was significantly improved compared to Group B (p=0.035). In all three groups, significant increases were noted in the MMT (shoulder) and K-MBI. Only Group C showed a significant increase on the Box and Block Test (p-values not provided). A RCT by Sin et al. (2013) randomized 40 hemiplegic participants (>6 month post stroke) into one of two groups: 1) virtual reality (VR) training using the Xbox Kinect for 30 min followed by standard occupational therapy for 30 min, or 2) standard occupational therapy alone. Therapy occurred 3x/wk for 6 wks. Between groups, FMA and BBT scores differed significantly (p<0.05), with the VR group experiencing a greater improvement. Significant improvements were observed in the AROM of flexion, extension and abduction of the shoulder, flexion of the elbow, and flexion and extension of the wrist. Significant differences between the two groups were noted at follow up for the shoulder and flexion of the elbow (p<0.05).

Turolla et al. (2013) assigned 376 post-stroke patients to one of two of groups: 1) upper limb conventional (ULC) rehabilitation, or 2) reinforced feedback in the virtual environment (RFVE) group. Participants received 40 sessions of therapy 5x/wk for 4 wks. A significant improvement in the FM-UE scores were noted for both groups following treatment, a 4% increase in the ULC group (p<0.001), and a 10% increase in the RFVE group (p<0.001). FIM scores were significantly higher among the RFVE group compared to the ULC group post-treatment (p=0.007). An analysis based on Stroke to Rehabilitation Interval (SRI) sub-groups on the FM-UE scores showed significant improvements for the RFVE group compared to the ULC group on all three sub-groups (p<0.001). In a RCT, Yin et al. (2014) randomized 23 post-stroke patients to one of two groups: 1) 30 minutes of non-immersive virtual reality training for nine weekdays within two weeks (five days a week) and conventional therapy, or 2) only conventional therapy. FMA-UE was assessed at baseline, post intervention and 1-month post intervention. Participants’ feedback and adverse effects were recorded. All participants improved in FM-UE scores (mean change (SD) =11.65 (8.56), P<.001). These effects were sustained at one month after intervention (mean (SD) change from baseline=18.67 (13.26), P<.001). All other outcome measures showed similar patterns. There were no significant differences in improvement between both groups. The majority of the participants found VR training useful and enjoyable, with no serious adverse effects reported.

Mirror Therapy

Mirror therapy is a technique that uses visual feedback about motor performance as a means to enhance upper-limb function following stroke and to reduce pain. Evidence from a Cochrane review (Thieme et al. 2012), which included the results from 14 RCT, suggests a modest benefit associated with treatment. There were significant improvements in motor function, the primary outcome, both immediately following treatment (SMD=0.61; 95% CI 0.22 to 1.0, p= 0.002) and at 6 months (SMD=1.09; 95% CI 1.09 to 1.87, p= 0.0068). There were also improvements in performance of ADLs (SMD=0.33, 95% CI 0.05 to 0.60, p=0.02) and pain (SMD= -1.1, 95% CI -2.10 to -0.09, p=0.03).

In a recent RCT, Radajewska et al. (2013) randomized 60 right-handed participants (mean 9.25 wk post stroke) to mirror therapy (n=30) or a control group (n=30). Within each group, patients were divided into left- versus right-arm paresis subgroups. Both groups received standard rehabilitation. The treatment group received 15 minute sessions of mirror therapy 2x/day, 5d/wk for 3 wk. Functional Index ‘Repty’, Frenchay Arm Test, and MSS were assessed at baseline, post intervention and at 3-week follow-up. No significant differences were shown for the left or right groups on all outcome measures (p>0.05 for all). Wu et al. (2013), RCT, 44 community dwelling individuals, within 2 years post stroke, meeting the following criteria: first-ever unilateral stroke, FMA-UE score of 26-56, and MAS of <3. Patients were stratified based on FMA-UE scores 26-40 or 40-66. Patients then received either mirror therapy or traditional therapy (control group). Treatment was 1.5 hrs/d, 5d/wk, for 4 weeks. Specifically, the treatment group had 1hr mirror therapy and 0.5hr task-oriented practice. FMA-UE, Revised Nottingham Sensory Assessment (rNSA), Motor Activity Log (MAL), and ABILHAND questionnaire were assessed; mirror therapy group showed significantly greater improvement compared to the control group on FMA-UE (p=0.009). No significant between-group differences were found for the Motor Activity Log (p>0.05) and ABILHAND (p>0.05).

EMG-biofeedback

There is evidence that EMG-biofeedback is associated with modest improvements in arm function. In a review which included the results 4 small RCTs that compared a 3-12 week program of EMG-biofeedback treatment + physiotherapy with physiotherapy alone in the upper limb, there was a significant improvement in arm function (SMD=0.41, 95% CI 0.05 to 0.77, p<0.05) (Langhorne et al. 2009). Nevertheless, its use in routine clinical practice is the subject of ongoing debate.

Neuromuscular Electrical Stimulation

Meilink et al. (2008) examined the effectiveness of EMG-triggered neuromuscular electrical stimulation (NMES) applied to the extensor muscles of the forearm to improve hand function following stroke. This systematic review included the results of 8 studies (157 patients, >6 months post stroke). Compared with usual care, there was a non-statistically significant treatment effect for all outcomes assessed (FMA: SMD=0.10, 95% CI -0.43 to 0.64, p=0.35BBT: SMD=0.37, 95% CI -0.27 to 1.01, p=0.13; ARAT: SMD=0.0, 95% CI -0.56 to 0.57, p=0.5; and reaction time: SMD=0.41, 95% CI -0.20 to 1.03). The results of a small RCT authored by Page et al. (2012) suggest that 2 hours of daily therapy for 8 weeks using the commercially-available Bioness device reduced impairment from baseline levels for patients in the chronic stage of stroke; however, when compared with the results of patients in the control group who participated in a 30-minute per weekday home-exercise program, there was no difference in mean FMA scores between groups.

Boyaci et al. (2013) randomized 31 hemiplegic subjects (>4 wk post stroke) into three groups; 1) EMG triggered active NMES, 2) passive NMES, and 3) sham stimulation. Treatments occurred for 45 min/day, 5x/wk for 3 wk. FMA, self-care of FIM, MAL, and MAS were assessed pre- and post-intervention. Significant improvements were noted in the FMA-UE, MAL, self-care FIM, wrist extension, and grip strength among the active NMES and passive NMES treatments (p<0.05 for all); these improvements were significantly better in the active and passive NMES groups compared with the control group at the end of treatment (p<0.05 for both). There were no significant differences for any parameters between active NMES group and the passive NMES group. De Jong et al. (2013) randomized 46 subjects (2-8 weeks post stroke) into one of two groups. Both groups received conventional rehabilitation in accordance with Dutch guidelines. Subjects in the experimental group received arm stretch positioning (60 hr) plus NMES (51 hr) whereas the control group received sham stretching treatment and low-intensity TENS (51 hr). Passive ROM were assessed at baseline, mid-treatment, at the end of the treatment period (8 weeks) and at follow-up (20 weeks). There were no significant group effects or time-by-group interactions on any of the passive range of arm motions.

Functional Electrical Stimulation

Three recent studies have evaluated the effect of function electrical stimulation (FES) in improving upper limb function post stroke (Langhorne et al. 2009; Page et al. 2012; Kim et al. 2014). Most recently, Kim et al. (2014) conducted a RCT where 23 participants <6 months post-stroke were randomized into one of two groups. Both groups were given conventional rehabilitation therapy for 60 min/day, 5 days/wk for 4 wk. For 30 minutes/day, 5 days/wk for 4 wk, the experimental group also received FES with mirror therapy (MT+) while the control group received FES without mirror therapy (MT-). FMA, BMRS, MFT, BBT were assessed pre- and post-intervention. FMA scores for shoulders, lower arms, wrists, hands and upper limb coordination increased significantly in both groups (p<0.05). Both groups demonstrated a significant improvement in BMRS scores post intervention (p<0.05), but with hand recovery in the experimental group showing significantly greater increases than the control group (p<0.05). Both groups improved MFT scores significantly in shoulder and hand function (p<0.05); the experimental group showed a more significant improvement in hand function than the control group (p<0.05). BBT demonstrated significant improvement in both groups (p<0.05).

Transcranial Direct Current Stimulation

Transcranial direct-current stimulation (tDCS) has been shown to improve shoulder abduction (Khedr et al. 2013), spasticity (Wu et al. 2013), and upper extremity motor function (Lee et al. 2014). In a RCT, Khedr et al. (2013) randomized 40 subjects (mean 12.9 days post stroke) into one of three groups: 1) anodal tDCS over affected hemisphere, 2) cathode tDCS over unaffected hemisphere, or 3) sham stimulation. Treatment lasted 25 min for 6 consecutive days over the motor cortex hand area. Orgogozo’s MCA scale (OMCASS), Barthel Index (BI), Friedman test were assessed at baseline, post treatment, 1, 2, and 3 months post treatment. There was a significant time x group (real vs. sham) effect on the OMCASS (p=0.005) and BI (p=0.006). A significant time x group effect for anodal vs. sham was noted on OMCASS (p<0.001), BI (p=0.002) and marginally significant effect for cathodal vs. sham OMCASS (p=0.033) and BI (p=0.017). A significant improvement of strength was noticed in all groups post-treatment on the Friedman Test (p<0.0001). A greater improvement was found in the combined group than in the sham group for shoulder abduction, foot dorsiflexion, and hip flexion (p=0.005). In another RCT, Lee et al. (2014) randomized 59 subjects (<1 months post stroke) with impaired unilateral UE motor function. Subjects were randomized into one of three groups: 1) Group A-cathodal tDCS, 2) Group B-virtual reality (VR), or 3) Group C- tDCS plus VR. In addition to their specified group treatments, all participants received standard therapy. In total, 15 treatments were received over a 3-wk period. MMT, Manual Function Test (MFT), FMA, BBT, K-MBI were assessed at pre- and post-treatment. Changes in scores on the MFT and FMS were significantly different between the three groups (p=0.021, p=0.03 respectively). Improvement in Group C was significantly greater compared to Group A and B on MFT (Group C vs. Group A, p=0.016; Group C vs. Group B, p<0.01). Group B also had a significantly greater improvement in MFT score compared to Group A (p<0.01). FMS score improvement was significantly greater in Group C than Group A (p=0.013) and Group B (p<0.01). Further, Group A was significantly improved compared to Group B (p=0.035). In all three groups, significant increases were noted in the MMT (shoulder) and K-MBI. Only Group C showed a significant increase on the BBT (p-values were not provided). Wu et al. (2013) randomized 90 subjects (2-12 months post stroke) into one of two groups: 1) tDCS to the primary sensorimotor cortex of the affected hemisphere with cathodal stimulation, or 2) sham stimulation to the same area. Stimulation sessions lasted 20 minutes/day, 5 days/week, for 4 wk. Both groups also received physiotherapy for two 30 min sessions per day, for 4 wk. FMA of motor recovery, BI, and MAS were assessed pre-, post-treatment and 4-wk follow up. Compared to the sham group, the tDCS group showed greater improvements on FMA (p<0.001) and BI (p<0.05) post intervention. At the four week follow up, the tDCS group showed significantly greater improvement on FMA (p<0.001) and BI (p<0.01) than the sham group.

Transcutaneous Electrical Nerve Stimulation

In an RCT, Au-Yeung et al. (2014) 73 subjects (≤ 46 hr post-stroke) were randomized to one of three groups: 1) Group 1-Transcutaneous Electrical Nerve Stimulation (TENS), 2) Group 2-sham stimulation, or 3) Group 3-standard rehabilitation. Groups 1 and 2 also received standard rehabilitation therapy. Electrical Stimulation Treatment was received fir 60 min/day, 5 days/wk, for 4 wk. Hand grip, pinch strength, ARAT were assessed at pre-, 4, 12, and 24 wk post-treatment. The TENS group improved significantly more than the control group in hand grip (p=0.015) and pinch strength (p=0.007) compared to controls beginning at week 4; improvements were maintained at follow up (p≤ 0.006). No significant differences were found between the sham stimulation group and the control group for hand grip or pinch strength. There were no significant differences in ARAT scores between groups (p>0.05 for all).

Bilateral/Unilateral Arm Training

While clinicians often place an emphasis on the use of bilateral upper limb activity, evidence from a Cochrane Review (Coupar et al. 2010) and a systematic review (Van Delden et al. 2012) suggests that bilateral upper limb training is no more effective than unilateral training for improving arm function. There were no significant differences between treatment and control groups on any of the impairment of activity outcomes assessed in either study.

In a systematic review, including 13 RCTs, (Harris & Eng 2010) therapy programs including a strength training or resistance training component were associated with significant improvements in grip strength (SMD=0.95, 95% CI 0.05 to 1.85, p=0.04), but not performance of ADLs (SMD=0.26, 95% CI -0.10 to 0.63, p=0.16). There is currently no evidence that strength training increases spasticity or reduces range of movement. Furthermore, Dispa et al. (2013), conducted a crossover-RCT, with 10 Participants (6 months post-stroke) having the ability to lift and hold an object of 250 g between the thumb and the index finger for a few seconds. Participants were randomized into two groups: 1) started with the bilateral movement therapy, 2) started with the unilateral movement therapy. Therapy sessions occurred for 1hr 3x/wk for 4wk followed by another 4wk of the opposite treatment. Two-way repeated measure analysis of variance (RM-ANOVA) was assessed at inclusion (t0), baseline (t1), 4 weeks (t2), and 8 weeks (t3). RM-ANOVA comparison between t0 and t1 results did not show any significant difference. Results of the paretic hand at t1, t2, and t3 did not detect any difference between the bilateral and unilateral movement therapies (p>0.144 in all instances). A highly significant difference between both hands was detected for digital dexterity (p<0.001). The temporal grip-lift parameters tended to take longer; however, only the loading phase showed a significant difference between both hands (p=0.048). The grip-lift dynamics showed no significant difference between the paretic and the non-paretic hand (p>0.507 in all instances)

Repetitive Transcranial Magnetic Stimulation (rTMS)

Le et al. (2014) conducted a systematic review and meta-analysis of 8 RCTs (273 participants, >18 yr) published in English between 1990 and 2012 that examined the effect of rTMS on hand function and plasticity of the motor cortex; time since stroke onset ranged from 5 days to 10.7 years. The frequency of rTMS ranged from 1 Hz to 25 Hz. Stimulation sites of low-frequency rTMS included the primary motor cortex and premotor cortex whereas high-frequency rTMS occurred at M1. Seven studies examined rTMS compared to a control and in the remaining study it was compared to constraint induced movement therapy. Treatments duration ranged from 1 day to 10 days, with a frequency of 0.4-1 sec to 25 min. Finger coordination and hand function (at 3Hz) demonstrated a significant standard mean difference of 0.58 (p=0.01) and -0.82 (p=0.007), respectfully. No improvement was demonstrated for hand function at 10Hz (p=0.34) compared to control groups (Lee et al. 2014).

In a RCT, Ji et al. (2014) randomized 35 participants (mean 8.9 months post stroke) into one of three groups: 1) combined mirror therapy plus rTMS (MT+rTMS), 2) mirror therapy alone (MT), or 3) sham stimulation. All participants received physical therapy 30 min/day, 5 times/wk, for 6 wk. FMA and BBT scores of all groups significantly improved following treatment (p<0.05). Scores were significantly better for MT+rTMS compared to MT (p<0.05) and sham (p<0.05) groups. In another RCT, Wang et al. (2014) randomized 48 participants (2-6 wk post stroke) into one of three groups: 1) Group A received rTMS (10 sessions, 1 Hz) over the unaffected hemisphere and then intermittent theta burst stimulation (iTBS) over the affected area (3 sessions, 50Hz), 2) Group B received had the same protocol as Group A but in the reverse order, 3) Group C received sham stimulation in the same order as Group A. Treatment lasted 4 weeks and all participants received physiotherapy for one hour (task orientation). Group A demonstrated the largest improvement among all groups. Group A demonstrated improvements in MRC proximal (from 2.6±1.5 to 3.9±1.0, p<0.01), MRC distal (from 2.3±1.6 to 3.4±1.4, p<0.05), FMA (from 26.2±21.6 to 36.6±24.0, p<0.001), and WMFT (from 30.4±14.5 to 40.3±29.1, p<0.001). Group B demonstrated less improvement on motor skills than Group A with MRC proximal (from 2.6±1.3 to 3.8±1.5, p<0.01), MRC distal (from 2.4±1.3 to 3.7±1.3, p<0.01), FMA (from 28.4±24.1 to 34.7±28.3, p<0.01), and WMFT (from 30.9±15.7 to 36.5±23.5, p<0.05). FMA was particularly improved in Group A but not in other groups. Group C in comparison to the other groups showed the least improvement.

In a RCT, Kim et al. (2014) 31 participants post stroke were randomly assigned to either rTMS (10 sec, 10 Hz), or rTMS with sessions lasting 10 min, 5x/wk for 4 wk. Participants also received 30 min of task orientation training (maneuvering of objects along with increasing the number of repetitions and difficulty). MFT was assessed at baseline and 4 wk follow-up. There was a significant improvement in MFT at 4 weeks in the rTMS group (from 13.20±5.00 to 22.20±2.86, p<0.05). The sham rTMS also demonstrated an improvement in MFT but to a smaller degree at 4 weeks (from 14.20±2.82 to 16.90±2.13, p<0.05). Improvements in the rTMS group were significantly greater compared to the sham rTMS group (p<0.05).