Impaired upper limb function is a common complication encountered after stroke. Approximately 50-80% of individuals with stroke will experience loss of upper extremities function, which may persist after a year.
The approach to neurorehabilitation of the upper limb requires multimodal interventions, performed in a high-intensity and task specific manner.
Management and recovery often take place over several months or years and must be considered in the context of other impairments including presence of spasticity, apraxia, neglect, impaired tactile sensation, pain and other concurrent stroke complications.
1.1. Patients should engage in training that is meaningful, engaging, repetitive, progressively adapted, task-specific and goal-oriented to enhance motor control and restore sensorimotor function [Evidence Level: Early-Level A; Late-Level A].
1.2. Training should encourage the use of patients’ affected limbs during functional tasks and be designed to simulate partial or whole skills required in activities of daily living (e.g. folding, buttoning, pouring, and lifting) [Evidence Level: Early-Level A; Late-Level A].
2.1. Range of motion exercises (passive and active assisted) that includes placement of the upper limb in a variety of appropriate and safe positions within the patient’s visual field should be provided. [Evidence Level C].
2.2. Suitable patients should be encouraged to engage in mental practice/ mental imagery to enhance upper-limb, sensorimotor recovery [Evidence Level: EarlyLevel A; Late-Level B]. Mental practice involves repetitive cognitive rehearsal of intended physical movements without actually attempting to move the limbs physically. This stimulates neuroplasticity to promote recovery as neuroimaging studies have demonstrated that overlapping brain areas which are activated in mental practice are similar to those activated in actual physical movement.
2.3. Mirror therapy should be considered as an adjunct to motor therapy for patients with very severe paresis. It may help to improve upper extremity motor function and ADLs. [Evidence Level: Early-Level A; Late-Level A].
2.4. Neuromuscular or Functional Electrical Stimulation targeted at the wrist and forearm muscles should be considered to reduce motor impairment and improve arm and hand function. [Evidence Level: Early-Level A; Late-Level A].
2.5. Conventional or modified constraint-induced movement therapy (CIMT) should be considered for a select group of patients who demonstrate at least 20 degrees of active wrist extension and 10 degrees of active finger extension, with minimal sensory deficits and appropriate cognitive level. [Evidence Level: EarlyLevel A; Late-Level A].
2.6. Effective CIMT should comprise of three main components: ‘Shaping’ via intensive graded practice, constraint-use of the non-paretic arm for a specific treatment duration, and transfer training package to learn the use of the paretic arm in a realworld environment.
2.7. Targeted practical time duration is between for 3-4 hours for modified CIMT (mCIMT), and 6 hours a day for 2 weeks for the conventional/ original CIMT protocol.
2.8. Strength training should be considered for persons with mild to moderate upper extremity impairment for improvement in grip strength [Evidence Level: Early-Level A; Late-Level A), as long as strength training does not aggravate tone or pain [Evidence Level A].
2.9. Virtual reality, including both immersive technologies (e.g. head mounted or robotic interfaces) and non-immersive technologies (e.g. gaming devices) can be used as adjunct tools to other rehabilitation therapies to provide additional opportunities for engagement, feedback, repetition, intensity and task-oriented training [Evidence Level: Early-Level A; Late-Level A].
2.10. Robotics (e.g. mechanically assisted arm training) may be used to improve upper limb function for stroke survivors with mild to severe arm weakness.
2.11. Non-invasive brain stimulation, including repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) could be considered as an adjunct to upper extremity therapy [Evidence Level A (rTMS); Evidence Level B (tDCS)].
2.12. Practise pearl – Kinesio tape can be used by trained practitioners to reduce shoulder subluxation, improve motor function of the upper limb and ADLs in patients with hemiplegic shoulder pain.