Approximately 70% of people experience loss of arm function after a stroke, and this persists for about 40%. This section includes interventions intended to deliver repetitive and functionally relevant practice to improve arm function. Guideline users should also refer to other relevant sections that cover the following: weakness (Section 4.17 Motor impairment), sensation (Section 4.47 Sensation), shoulder subluxation and pain (Section 4.23.3 Shoulder subluxation and pain), activities of daily living (Section 4.8 Independence in daily living). [2023]
Patterns of arm recovery are varied and are largely dependent on the initial degree of weakness and patency of the corticospinal tract (Stinear et al, 2017a), particularly preservation or return of finger extension and shoulder abduction. This has led to the development of tools to predict arm recovery in clinical practice: for example the SAFE and PREP2 tools (Nijland et al, 2010; Stinear et al, 2017b) and the Viatherapy app, an app to guide evidence-based rehabilitation (Wolf et al, 2016). Prognostic tools may be useful to help identify who is most likely to benefit from intensive upper limb interventions and who requires a compensatory approach focusing on reduction of secondary complications such as shoulder subluxation, pain and spasticity. [2023]
Whilst research regarding interventions to promote motor recovery has progressed, continued focus is required to ensure these are implemented into practice. Intensity of practice of movements and tasks during therapy must be coupled with efforts to translate movements into everyday activities. Current practice in the UK indicates too few rehabilitation sessions are dedicated to the upper limb and within sessions too few repetitions are achieved (Stockley et al, 2019). A co-ordinated multidisciplinary approach should be taken to maximise upper limb rehabilitation as well as ensuring that people are supported to practise outside of therapist-delivered sessions. [2023]
Management and recovery of the hemiplegic upper limb often takes place over months or years and must be considered in the context of other impairments including sensation, sensory or visual neglect, learnt non-use, spasticity and balance. Whilst promoting motor recovery (particularly early after stroke) is of the utmost importance, enabling the person to be independent in daily life activities, such as eating and drinking, is essential, and compensatory strategies should be used where appropriate. [2023]
Repetitive task practice
Recovery of the upper limb is best achieved through training that involves repetition of functional tasks and targeted exercises that follow motor learning principles. Components of functional tasks may be practised but should then be incorporated into practice of the whole functional task. Training should be supplemented with aids and equipment as necessary to enable safe, intensive and functionally relevant practice. [2023]
Electrical stimulation
Electrical stimulation has been used as an adjunctive treatment for the upper limb for many years. The most common form is therapeutic or cyclical electrical stimulation (also known as neuromuscular electrical stimulation [NMES]) to the wrist and finger extensors, which stimulates the muscles to contract in order to improve weakness and reduce motor impairment. [2023]
Vagus nerve stimulation
Vagus nerve stimulation (VNS) aims to enhance the effects of repetitive task training by stimulating the vagus nerve during the movement(s) being practised. It is therefore limited to use in people with mild-moderate upper limb weakness (typically, a Fugl-Meyer Upper limb Assessment score of 20-50/100). The stimulation is applied either by an implanted device directly attached to the vagus nerve, or indirectly by transcutaneous nerve stimulation over the vagus nerve in the left side of the neck or the sensory area of the nerve on the external part of the ear. The exact mechanism of action is unknown but it is associated with increased neuroplasticity (Hays et al, 2013; Engineer et al, 2019). [2023]
Constraint-induced movement therapy
The original constraint-induced movement therapy (CIMT) protocol incorporates three components of rehabilitation consisting of (1) intensive graded practice of the paretic arm for 6 hours a day for 2 weeks (shaping), (2) constraining the non-paretic arm with a mitt to promote use of the weak arm for 90% of waking hours, (3) a transfer training package to learn to use the paretic arm in a real-world environment completing functional tasks (Wolf et al, 2006; Taub et al, 2013). Original protocols for CIMT were found to be effective in improving arm function for people following a subacute stroke but only when all three components were used, and ‘forced use’ is not effective alone (Kwakkel et al, 2015). The time resource needed for CIMT has made this approach challenging to adopt in clinical practice. [2023]
In subsequent years various protocols have been developed aiming for 3-4 hours of CIMT, core components of which are consistent with the original intervention. These are now more commonly adopted in clinical practice, delivered by a combination of qualified therapists, rehabilitation assistants and self-practice, supported remotely as appropriate. Using the paretic arm in functional daily tasks remains a key feature of all modified CIMT (mCIMT) programmes and should be aligned to individualised goals. [2023]
Mental practice
Mental practice is a training method that involves repetitive cognitive rehearsal of physical movements in the absence of physical, voluntary attempts. From a practical perspective, mental practice constitutes a feasible alternative to other rehabilitation approaches to produce the movement because it does not require physical movement, can be performed without direct supervision, and requires minimal expense and equipment (Page & Peters, 2014). Mental practice may promote neuroplasticity, as neuroimaging studies have shown that similar overlapping brain areas are activated in mental practice and with physical movement (Di Rienzo et al., 2014). [2023]
Mirror therapy
Mirror therapy involves performing movements of the non-affected arm, whilst watching its mirror reflection hiding the affected arm. This creates a visual illusion of enhanced movement capability of the affected arm (Yang et al, 2018). The precise mechanisms of mirror therapy are not fully understood, but it is proposed that it promotes motor function of the upper limb via activation of the primary motor cortex or mirror neurones (Garry et al, 2005; Cattaneo & Rizzolatti, 2009). [2023]
Robotics
A robot is defined as a reprogrammable, multifunctional manipulator designed to move material, parts, or specialised devices through variable programmed motions to accomplish a task (Chang & Kim, 2013). Robot-mediated treatment uses devices to provide passive, active-assisted or resistive limb movement, and has the potential to offer extended periods of treatment and an opportunity to increase intensity through repetition. Some robots may be able to adapt treatment in response to performance. [2023]