Therapeutic Goal: Improved arm and hand skill for independence
- Exercise and functional training should be directed towards enhancing motor control for restoring sensorimotor and functional abilities. [Evidence Levels: Early – Level A; Late – Level A].
- Engage in repetitive and intense use of novel tasks that challenge the patient to acquire necessary motor skills to use the involved limb during functional tasks and activities [Evidence Levels: Early – Level A; Late – Level A].
- The Upper extremity program should include strength training to improve impairment and function after stroke for upper extremity. Spasticity is not a contra-indication to strength training374 [Evidence Levels: Early - Level A; Late - Level A].
- Therapists should provide a graded repetitive arm supplementary program for patients to increase activity on ward and at home. This program should include strengthening of the arm and hand (small wrist weight, putty, hand gripper), range of motion (stretching, active exercises), and gross, fine motor skills (e.g., blocks, Lego, pegs), repetitive goal and task-oriented activities designed to simulate partial or whole skill required in activities of daily living (e.g. folding, buttoning, pouring, and lifting). The GRASP protocol suggests one hour per day, six days per week 375[Evidence Levels: Early-Level A; Late-Level C].
- Following appropriate cognitive and physical assessment, mental imagery should be used to enhance sensory-motor recovery in the upper limb [Evidence Levels: Early-Level A; Late-Level B].
- Functional Electrical Stimulation (FES) should be used for the wrist and forearm to reduce motor impairment and improve functional motor recovery [Evidence Levels: Early-Level A; Late-Level A].
- Intensive Constraint Induced Movement Therapy (CIMT) should not be used for individuals in the first month post stroke until further research is completed [Evidence Levels: Early-Level A; Late-N/A].
- Consider the use of intensive CIMT for a select group of patients who demonstrate at least 20 degrees of wrist extension and 10 degrees of finger extension, with minimal sensory or cognitive deficits. Intensive training should involve restraint of the unaffected arm for at least 90 percent of waking hours, and at least six hours a day of intense upper extremity training of the affected arm for two weeks [Evidence Level: Between 3 and 6 months-Level A; Late- Level A].
- Consider the use of modified CIMT for a select group of patients who demonstrate at least 20 degrees of wrist extension and 10 degrees of finger extension, with minimal sensory or cognitive deficits. Modified CIMT consists of 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 fourteen days [Evidence Levels: Early- Level A; Late- Level A]
- EMG biofeedback systems should not be used on a routine basis. (adapted from RCP) [Evidence Levels: Early- Level A; Late- Level A].
- For patients whose arm and hand are predicted to be less than stage three as measured by the Chedoke-McMaster Stroke Assessment,376 enhance sensory-motor recovery of the upper limb by using sensory motor stimulation [Evidence Levels: Early- Level B; Late- Level B].
This consists of passive and active-assisted range of movement that also includes placement of the upper limb in a variety of positions within the patient’s visual field (Adapted from HSF-AH 1.2a) [Evidence Levels: Early-Level C; Late Level C].
- There is insufficient evidence to recommend for or against neurodevelopmental treatment in comparison to other treatment approaches for motor retraining following an acute stroke [Evidence Levels: Early-Level B; Late Level B].
- Use adaptive devices for safety and function if other methods of performing specific tasks are not available or cannot be learned [Evidence Levels: Early- Level C; Late Level C].
- Assess the need for special equipment on an individual basis. Once provided, equipment should be re-evaluated on a regular basis. [Evidence Levels: Early-Level C; Late-Level C].
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.
- Change (improvement) in functional status scores using a standardized assessment tool from admission to an inpatient rehabilitation program to discharge.
- Change in arm and hand functional status scores using a standardized assessment tool from admission to an inpatient rehabilitation program to discharge.
- Median length of time from stroke admission in an acute care hospital to assessment of rehabilitation potential by a rehabilitation healthcare professional.
- Median length of time spent on a stroke unit during inpatient rehabilitation
- Average hours per day (minimum of three) of direct task-specific therapy provided by the interprofessional stroke team.
- Average days per week (minimum of five) of direct task specific therapy provided by the interprofessional stroke team.
- 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.
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, 393In 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:
Evidence Based Review of Stroke Rehabilitation www.ebrsr.ca