Posted in Best practices rehab exercises

How to improve upper limb weakness

About 85 percent of those who experience a stroke will have some sort of weakness in one or both of their upper limbs. This post discusses recommended methods on how to improve upper limb weakness.

A stroke occurs as a result of an interruption to the blood supply to a part of the brain that controls body movements and sensory inputs from body parts. There are two types of strokes: ischemic and hemorrhagic. Although some of the damage is permanent, still some can be recovered with specific exercises.

Evidence shows that “high-intensity, repetitive, task-specific practice” clearly improves motor recovery after a stroke event. However, the practices to regain lost functions of arms are different from legs’. Let us look at how best practice guidelines translate this evidence into recommendations for practice.

The Canadian stroke best practice guidelines published in 2019 provides the following recommendations to improve the function of the upper limbs.

General principles

Both the principles cited below are recommended for all those who experienced a stroke event less and more than six months.

  • Create activities that are meaningful, engaging, repetitive, progressively adaptable, task, specific, goal-oriented.
  • Create activities of daily living, that encourage the use of the affected limb.

Specific treatment methods

We need to be knowledgeable and creative to use these methods because the selection of method/s depends on the function affected.

Strong evidence from a Cochrane review exists that exercise for the affected arm is more effective than both arms. The Canadian stroke best practice guidelines also do not recommend both arm training when one arm is affected.

Recommended exercise/treatment methods
  • Range of motion (ROM) exercises (passive and active-assisted)
  • Mental imagery
  • Functional electrical stimulation for the wrist and forearm muscles to reduce motor impairment and improve function
  • Constraint-induced movement therapy for those who at least 20 degrees of active wrist extension and 10 degrees of active finger extension, with minimal sensory deficits and normal cognition
  • Mirror therapy as an adjunct for those with very severe paresis

How do we know that these methods are effective?

A large number of research has demonstrated the effectiveness of the exercises. I will mention here one important study.

J. Leipert and colleagues mapped the cortical areas of the brain’s both sides of 13 individuals who were living with a stroke for more than six months. They found that the area of the affected side was significantly smaller than the area of the non-affected side. After subjecting them for 12-days of constraint-induced movement therapy, they re-mapped the same areas. Then, they found that those areas of the affected side were significantly enlarged. They published these findings in the Stroke journal in 2001.

Interventions with no evidence

It is also important for us to know the treatment methods with no sufficient evidence to date. According to a Cochrane review published in 2015, these are as follows;

  • Music therapy
  • Repetitive trans cranial magnetic stimulation
  • Medications
  • Electrical stimulation

A guideline resource for exercise providers

The Ontario Stroke Network provides a useful guideline for community-based exercise providers; here is the link.

Posted in Best practices rehab exercises

Glossary of Terms: Physical fitness and related terms

This glossary covers the terms used in the promotion of physical fitness. it includes the terms, physical activity, exercise, and types of exercises. The proper understanding of these terms and concepts are critically important in improving care for those living with a stroke.

Medical clearance

All guidelines recommend for anyone living with a stroke should consult a physician and undergo medical screening to decide the suitability of exercises and range of motions.

Physical fitness:

Physical fitness refers to a situation in which someone can do their expected physical activities – activities of daily living, leisure – without undue fatigue (Saunders et al. 2016). When physical fitness is declining, the range of physical activities including Activities of Daily Living (ADL) will become increasingly difficult and vice versa.

The concept entails a set of attributes. It includes the ability to carry out the activities of daily living with vigor and alertness, without undue fatigue, and with ample energy to enjoy leisure-time activities and to meet unforeseen emergencies (Carl J Caspersen and colleagues).

Physical fitness includes the following five components:

  • Heart and lung (cardiorespiratory) fitness: another name for this term is “endurance” which refers to the ability to do physical activities for an extended period than usual.
  • Muscle strength: this refers to the ability of a certain muscle or a muscle group to exert certain force such as pushing, pulling, or lifting.
  • Muscle power; refers to the ability to do single powerful action or a movement.
  • Balance; refers to the ability to maintain balance and posture while moving or stationary.
  • Range of motion (flexibility); this refers to the ability to do all movements around a joint.
  • Body composition; refers to the relative amount of fat or fat-free mass.

Physical activity:

Physical activity is defined as any bodily movement produced by skeletal muscles that result in energy expenditure (Carl J Caspersen and colleagues).

Physical activities can either be planned or unplanned. Exercise refers to planned physical activities.


Exercise refers to a sub-set of physical activity that involves planned, structured, and repetitive bodily movement that is done to maintain or improve one or more components of physical fitness (CDC US). These should be done with the purpose of improving physical fitness. For example, some may carry out their job-related or household physical activities with the aim of spending energy. Those activities are considered exercise (Carl J Caspersen and colleagues).

Light- moderate physical activities:

These activities include moderately-paced or leisurely walking or bicycling, slow swimming or dancing, and simple gardening (CDC).

Vigorous physical activities

These activities include fast walking, fast bicycling, jogging, strenuous swimming or sports, aerobic dance, or strenuous gardening (CDC)

Vigorous physical activities: These activities might include fast walking, fast bicycling, jogging, strenuous swimming or sports play, vigorous aerobic dance, or strenuous gardening. 

Strengthening activities:

These activities include strenuous muscular contractions such as weight lifting, resistance training, push-ups, sit-ups, etc (CDC).

Leisure-time physical activities; exercise, sports, or any other activity done during leisure time.

Types of physical fitness (exercise) training

(Saunders et al.(2016)
  • Heart-lung (cardio-respiratory) programs: to improve heart and lung fitness
  • Resistance training programs: to improve muscle strength and muscle power
  • Flexibility (stretching) training programs
  • Balance maintenance training programs
  • Mixed training programs: a combination of the above two types

Mode of training:

This refers to the methods employed for the type of training; for heart-lung training, it could be either walking, running, or cycling. It could be stationary too with or without an instrument/machine.

Dose of training:

The dose of training refers to the amount of training (the program length – number of weeks or months, duration of a session, and the intensity (amount of work or effort).

Exercise prescription:

This refers to a prescription that includes mode, type, and a dose of the exercise recommended.

Posted in Health professionals rehab exercises Resources

Exercise and rehab guidelines/ manuals


Canadian best practices guidelines

If you have more guidelines, manuals, and other resources related to exercises for stroke, please send us.

Clinicians’ handbook

US resources

E-learning resources

Posted in Best practices rehab exercises

Blend cardio with strength exercises

Are you doing only the muscle strength exercises? The evidence suggests you change it a little bit: blend cardio into it. Researchers have concluded that cardio with strength training exercises yields better walking ability, walking speed, and body balance (to a certain extent).

And, they also have concluded that muscle strength exercises alone do not improve walking ability.

The emphasis on cardio is a recent finding; traditionally, the rehab programs have been focused on gait training and balance.

This emphasis on cardio is because many who survive the stroke live with low levels of heart fitness; and, it could also be due to that those with low heart fitness are more likely to face a stroke.

What are the suitable cardio exercises?

Walking and cycling are the two commonest cardio exercises. The cardio strengthens the heart. That is why it is called cardio. However, prior to engaging in cardio, the physician should assess the heart fitness and the physiotherapist should recommend the types of cardio that need to follow. The Heart and Stroke Foundation has published an excellent patient guide. You can access this brochure through this link.

What are muscle fitness exercises ? (resistance or strength training)

Some common examples of muscle fitness include pushing, pulling with elastic bands, and lifting weights. In these types of exercises, we do not exert pressure on the heart as much as in walking and cycling.

Range of motions and body balance exercises

Invariably, when we engage in the above two types of exercises, we certainly involve our joints with different types of range of motions and exercises that improve body balance.

About the research

In 2015, David Saunders and his team reviewed 58 clinical trials that compared people with a stroke and engaged in special exercise sessions with a similar group of people who followed usual care. The total number of study participants involved in all these trials was 2797.

In this study, they classified physical fitness into three groups: heart fitness (endurance) training, muscle fitness (strength) training, and mixed training (a combination of the above two forms).

Always blend cardio with muscle strength training exercises

You can access the article through this link;

Do you have any comments, ideas, or suggestions about how to blend cardio with strength exercises? Please initiate a discussion about it.

A guideline resource for exercise providers

The Ontario Stroke Network provides a useful guideline for community-based exercise providers; here is the link.