Last updated on July 12, 2021
Before reading this post, read the previous one: Six basic rules to recover movements after stroke. The following infographic summarises its contents;
And, also skim through this post – brain’s recovery attempts after a stroke: Journeys to the brain -10 before going further.
This post reviews the best available evidence that provides answers to the following questions;
- Which side? the affected side or the both sides?
- What activities?
- How much and how long?
- How to promote continuity?
- Other supportive activities?
1. Which side? the affected side or both sides?
Exercises for the affected arm are more effective than doing it for both arms; that is what the 2014 Cochrane systematic review found2. In other words training programs should encourage use of the affected side – this is what the 2019 Canadian Stroke Best Practice Guidelines’ strong recommendation1.
Why we should promote use of affedted limbs?
Research shows use of the affected limb sends electric signals to the affected side of the brain. As a result, the surviving neurons release a special protein; the reserchers call it “Brain -Derived Neurotrophic Factor” (BDNF). This protein promotes the growth of new dendrites and synapses3.
Warning! If we do not promote use of the affected body parts, the brain recognizes it as non-functioning. So,
either use it or lose it!
“Either use it ot lose it”
2. What activities?
The activities should be meaningful, engaging, task-specific. What are those? Those are;
- Lifting a cup
- Combing hair
We need to make the chosen activities challenging and progressive. That means the difficulty of doing these activities should be increased with time.
Experts caution against a common pitfall while carrying out those exercises – the trunk should not be used to compensate during the training sessions.
In addition to these, muscle strengthening exercises are also necessary. however, these exercises should not be the main goal3.
3. How many repetitions per session and for how long?
Researchers still are searching for a definite answer to this question. However, as of present, based on animal research about 250-300 successful repetitions seem necessary per session4.
4. How to promote continuity
Virtual reality and video gaming
The success of the re-training sessions depends on continuity. This is very difficult because of fatigue and frustration due to the absence of quick results.
One way to address the challenge is to incorporate gaming practices such as video gaming. Virtual reality is another. Evidence shows these strategies promote engagement3.
The 2015 Cochrane review found beneficial effects of virtual reality and video gaming in improving arm function. The benefit was greatest for those with a low-moderate impairment and within less than six months post-stroke5.
Carers’ role in exercises
Research has shown one gains better results when stroke caregivers assist in rehab exercises. The good news is that the outcome of home-based programs is similar to the usual outpatient hospital program6.
5. Add these supportive activities too to regain arm movement after stroke
Training sessions should include the following supportive activities also.
- Range of motion (ROM) exercises (passive and active-assisted)
- Mental practice or mental imagery
- Functional electrical stimulation for the wrist and forearm muscles
- Constraint-induced movement therapy; this is 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 – this is as an adjunct for those with very severe paresis
No adequate evidence to support the following methods
According to a Cochrane review published in 2015, no sufficient evidence exists to support the following methods to improve arm function after stroke.
- Music therapy
- Repetitive trans cranial magnetic stimulation
- Electrical stimulation
Useful resources to regain arm movement after stroke
- Viatherapy app: This is an international free app that healthcare workers can use. The app assists to choose activities that best suited for the stroke survivor’s arm/hand requirements.
This app from Canadian and US experts translates standard guidelines into a decision-making algorithm. It guides occupational therapists and physiotherapists for personalized care.
- This video clip presented by an Occupational Therapist, Mitchel Edwards describes useful exercises to improve upper limb weakness. However, keep in mind that this is for informational purposes only and you need to obtain your health care professional’s guidance.
- The latest book on stroke prevention and treatment published in December 2020 re-emphasizes the need of implementing the following interventions to improve upper limb weakness;
- The Ontario Stroke Network provides a useful guideline for community-based exercise providers; here is the link.
- Canadian Stroke Best Practice Guidelines (2019): 5.1. Management of Upper Extremity Following Stroke
- Alex Pollock, Sybil E Farmer, Marian C Brady, Peter Langhorne, Gillian E Mead, Jan Mehrholz, Frederike van Wijck, Cochrane Stroke GroupCochrane Database Syst Rev. 2014 Nov; 2014(11): CD010820. Published online 2014 Nov 12. doi: 10.1002/14651858.CD010820.pub2PMCID: PMC6469541
- Cameron S. Mang, Kristin L. Campbell, Colin J.D. Ross, Lara A. Boyd, Promoting Neuroplasticity for Motor Rehabilitation After Stroke: Considering the Effects of Aerobic Exercise and Genetic Variation on Brain-Derived Neurotrophic Factor, Physical Therapy, Volume 93, Issue 12, 1 December 2013, Pages 1707–1716, https://doi.org/10.2522/ptj.20130053
- AHA/ASA guidelines for Adult stroke Rehabilitation & Recovery June 2016 – Upper Extremity Activity Recommendations
- Stroke Rehabilitation ClinicalHandbook, 2020: Page13 http://www.ebrsr.com/sites/default/files/EBRSR%20Handbook%20Chapter%204_Upper%20Extremity%20Post%20Stroke_ML.pdf
- Laver KE, George S, Thomas S, Deutsch JE, Crotty M. Virtual reality for stroke rehabilitation. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD008349. accessed on August 16, 2021.
- Coupar F, Pollock A, Legg LA, Sackley C, van Vliet P. Home-based therapy programs for upper limb functional recovery following stroke. Cochrane Database Syst Rev. 2012;5:CD006755. doi: 10.1002/14651858.CD006755.pub2.