Management of the Arm and Hand

Stroke frequently affects the function of the arm and a large number of stroke survivors with arm weakness at stroke onset do not regain normal function. Bilateral arm function is critical for almost every daily activity. A number of techniques have been developed for those individuals who have some minimal arm movement.

The rehabilitation techniques that can be used are expanding and speak to the need for increased access to therapy time to carry out these techniques.

To achieve timely and appropriate assessment and management of arm and hand function the organization requires:

• Initial standardized arm and hand function assessment performed by clinicians experienced in stroke and stroke rehabilitation.
• Timely access to specialized, interprofessional stroke rehabilitation services.
• Timely access to appropriate type and intensity of rehabilitation for stroke survivors.
• Access to appropriate equipment
• Long-term rehabilitation services widely available in nursing and continuing care facilities, and in outpatient and community programs.

1. Change (improvement) in functional status scores using a standardized assessment tool from admission to an inpatient rehabilitation program to discharge.
2. Change in arm and hand functional status scores using a standardized assessment tool from admission to an inpatient 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. Average hours per day (minimum of three) of direct task-specific therapy provided by the interprofessional stroke team.
6. Average days per week (minimum of five) of direct task specific therapy provided by the interprofessional stroke team.

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
• The FIM ® Instrument data can be found in the National Rehabilitation Reporting System database at the Canadian Institute of Health Information for contributing organizations.

• FIM ® Instrument
• Chedoke-McMaster Stroke Assessment ³⁶⁹
• Chedoke-McMaster Arm and Hand Activity Inventory ³⁷⁰
• Chedoke-McMaster Spasticity sub-scale
• Modified Ashworth Scale ³⁷¹
• Box and Block Test ³⁷²
• Nine Hole Peg Test ³⁷³

There is strong evidence that treatment of the upper extremity and hand post-stroke using effective interventions can impact on motor recovery and functional outcomes beyond the improvement that has been seen with conventional therapies.

Functional Electrical Stimulation (FES):  A high quality study found FES in addition to conventional therapy more effective than conventional therapy alone in the early period post-stroke for improving hand function and dexterity.³⁷⁷ However these improvements were not maintained in the long-term (at 32 week follow-up). The findings related to functional independence are conflicting. While two studies of FES found no improvement in functional independence with FES.^{377, 378} a more recent study found significant differences in favour of FES in conjunction with occupational therapy versus occupational therapy alone.³⁷⁹ For patients late after stroke (>6 months) there is strong evidence that FES with conventional therapy is more effective than conventional therapy alone for improving hand function and dexterity ^380-384, and range of motion.^{385, 386}

Strength training is effective in improving upper limb function as shown in a meta-analyses.³⁷⁴ Strength training improves upper-limb function in individuals with stroke: a meta-analysis. Strength training should not be avoided in those with spasticity as spasticity has not been shown to be a contraindication to the use of strengthening exercises.³⁸⁷

Task-oriented-training along with strengthening is superior to neurodevelopmental treatment (NDT) treatment and other conventional therapies. 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.³⁸⁸ This is in contrast to therapy defined as repetitive training, where 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. This may explain, in part, why a meta-analyses on repetitive task training post-stroke found no significant difference in upper limb outcomes for repetitive task use versus other therapies.³⁸⁹The authors do add a cautionary note regarding the variability in the treatments and the relatively few studies on which to base findings.

Constraint-induced movement therapy – CIMT (constraint of the unaffected arm for at least 90 percent of waking hours, and at least six hours a day of intense UE training of the affected arm) improves upper limb for selected patients who demonstrate some degree of active wrist and arm movement and minimal sensory or cognitive deficits.  Intensive Constraint induced therapy should not be used for individuals in the first month post stroke until further research is completed based on a high quality RCT that compared the effectiveness of two intensities of CIMT versus traditional UE therapy acute stroke. ^{375, 390} Those receiving high-intensity CIMT had significantly less improvement in motor function at 14 and 90 days compared to the other two groups. In the subacute phase one high quality RCT has found CIMT more effective for improving UE grip strength than traditional therapy late after stroke.³⁹¹

Modified constraint-induced movement therapy – mCIMT (constraint of the unaffected arm with a padded mitt or arm sling for a minimum of six hours a day with two hours of therapy for usually a minimum of 14 days). In acute stroke there is conflicting evidence from three high quality RCTs regarding whether mCIMT is more effective than conventional therapy for improving motor function ^{390, 392, 393} and it has not been found to be more effective than traditional therapy for functional independence.^{390, 393}In the subacute phase post-stroke two high quality studies have found mCIMT improves motor function over traditional therapy ^{394, 395} while one did not.³⁹⁶The use of mCIMT late after stroke has been studies extensively with strong evidence that mCIMT is more effective than traditional rehabilitation for improving UE motor function.^397-401

To increase the number of hours of therapeutic use of the upper limb, it is recommended that clinicians prescribe a Graded Repetitive Arm Supplementary Program (GRASP) one hour per day six days per week on hospital ward or at home to extend practice outside of direct therapy time.³⁷⁵ The GRASP program should include strengthening (small wrist weight, putty, hand gripper), range of motion (stretching, active exercises), and gross, fine motor skills (e.g., blocks, Lego, pegs), along with repetitive goal and task oriented activities designed to simulate partial or whole skill required in ADL (e.g. folding, buttoning, pouring, and lifting).

Similarly, the use of motor imagery has been shown in a high quality study to improve arm function as compared to traditional therapy alone and may be a valuable adjunct to other upper limb interventions, and as a precursor or adjunct to the use of mCIMT. ⁴⁰²Other interventions focused on improving upper limb function such as mirror therapy, virtual reality and robot-assisted therapy may be used in conjunction with the interventions listed in the recommendations as interventions that are showing promise as adjunctive strategies for upper limb treatment.

Given the strong evidence from three high quality randomized controlled trials that biofeedback does not improve upper limb outcomes over conventional therapy, its use is not recommended.^403-405

Finally, while clinicians often place an emphasis on the use of bilateral upper limb activity, evidence from a 2010 Cochrane Review suggests that bilateral upper limb training is not more effective for improving arm function than interventions focused only on the more affected limb. ⁴⁰⁶ Simultaneous bilateral training for improving arm function after stroke.

For additional information and more extensive reviews of the literature, please refer to:

StrokEngine:www.strokengine.ca/

Evidence Based Review of Stroke Rehabilitation www.ebrsr.ca