Hand and Arm Therapy After A Stroke: How Effective is Repetition

The Main Problem with Arm and Hand Rehabilitation and Contemporary Solutions

Loss of strength, weak arm after stroke, excessive involuntary contraction of arm and hand muscles, coordination disorder, sensory and perception disorders are common side effects of stroke. Essentially, stroke doesn’t directly create musculoskeletal problems. The problem is the damage to the part of the brain where movement orders are generated. The loss of neural capability leads to movement disorders. However, the neural pathways can be reshaped -a mechanism called neuroplasticity- to “relearn” how to move appropriately. The methods for movement therapy of hand and arm are built around the concept of neuroplasticity.

The initial goal for hand therapy for stroke patients is to prevent unwanted additional problems (complications). Even if the problem is not caused by the hand or arm, issues such as dropped shoulder, stiffness and limitation in the hand joints, edema, and pain may occur if the proper therapy is neglected. Hand recovery after stroke is secondary to prevent unwanted additional problems. Additionally, compensatory methods are used in cases where a full recovery cannot be achieved.

The best exercises for the arm and hands after stroke include components such as range of motion and stretching exercises, neurophysiological therapy methods, electrical stimulation, sensory training, and occupational therapy. There is a lack of scientific evidence on how effective the currently applied methods are, primarily because stroke is a complex disease that can affect many parts of the body and the difficulty in identifying patients and treatments in different groups in an unbiased manner.

Although there have been thousands of studies with tens of thousands of participants, definitive results about arm and hand treatment after stroke are scarce. According to the most comprehensive reviews (some majors are summarized in (3)), there is moderately strong scientific evidence that the following treatment modalities are effective:

• Constraint-induced movement therapy
• Mental exercises (mental rehabilitation)
• Mirror therapy
• Therapies for sensory disorders
• Virtual reality
• Intensive repetitive task exercises

However, there is insufficient evidence to compare the treatments with each other. So we cannot say which method is most effective in restoring hand and arm functionality after stroke. On the other hand, it is seen that increasing the intensity of therapy provides more successful results. To improve the treatment of arm and hand after stroke, it is recommended that all hospitalized patients be integrated into scientific studies in some way.

How Intensive Should Arm/Hand Therapy Be?

The classical approach recommends sessions lasting at least 45 minutes a day, at least five days a week, for patients who can participate. However, there are studies indicating that this intensity is insufficient (4).

It has been shown that arm and hand therapy, begun 1-2 months after a stroke and lasting at least 2-3 hours per day for six weeks, gives clinically meaningful improvement, but lower-intensity rehabilitation provides far less benefit. Patients who receive therapy for more than 3 hours a day have a considerable advantage over those who receive therapy for less than 3 hours. As a result, the idea that paralyzed hand care should be given with a high level of intensity by a multidisciplinary team while hospitalized in the early stages of a stroke has gained traction. The rehabilitation team includes health professionals who specialize in many different areas such as physical therapy and rehabilitation specialist, rehabilitation nurse, physiotherapists, occupational therapists, speech therapists, and orthotics technicians.

Repetition is Essential, but How Many Reps?

Does it take dozens of repetitions to form new connections about movement in the brain? Hundreds? Or thousands? According to the results of animal experiments, the number of repetitions has to be at least in the hundreds. Most rehabilitation practices don’t come close to these numbers (5).

Methods for Increasing Rehabilitation Intensity

To increase the rehabilitation intensity, therapists developed the self-administered gradual repetitive arm support program GRASP therapy. It can be used in patients with various degrees of paralysis. Positive results have been observed when applied to hospitalized patients in the early post-stroke period.

Constraint-induced movement therapy is a way of increasing the intensity of therapy on functionally meaningful tasks. Patients wear a sling or gloves that restrict the use of their unaffected hands in daily activities. Although it seems simple, it is more effective than standard therapy (7). However, some patients may find it challenging to tolerate its application for 6 hours a day.

Using devices that provide gamified training ensures that specially planned movements are performed with high repetitions. According to the results of the research, these kinds of devices should not be considered as an alternative to one-on-one work with a therapist but as a complementary therapy modality.

Increasing Brain Plasticity

Neuro-plasticity induced by high repetition and high-intensity therapy is the basis for arm and hand therapy after stroke. The more the brain repeats a movement, the stronger the adaptation and learning. There are also studies to investigate methods to facilitate the plasticity mechanism. In order to increase the plasticity potential, a balance is required between the excitability and suppression of nerve cells in the brain. Stimulation and suppression are under the control of particular hormones and molecules in the brain, and there are drugs that can increase their effects. Magnetic or electrical brain stimulation is also used to facilitate plasticity.

Mental imagery, movement observation, mirror therapy, bilateral movement, sensory stimulation, and aerobic exercises can be used to prepare the brain for more specific exercises and workouts.

Drugs such as selective serotonin reuptake inhibitors and dopamine agonists are being investigated to enhance functional recovery after stroke. However, there is no routine clinical use of drugs for this purpose yet.

Conclusion

Our current medical findings suggest that arm and hand therapy after stroke should start as early as in the first week after stroke and that the best results will be achieved if it is applied with intensive therapy programs (more than 3 hours a day if possible) with high repetition by a multidimensional approach.

References

1. Persson HC. Upper extremity functioning during the first year after stroke. Goteborg Universitetsbibliotek. 2015; 15: 178-86
2. Nakayama H, Jørgensen HS, Raaschou HO, Olsen TS. Recovery of upper extremity function in stroke patients: the Copenhagen Stroke Study. Arch Phys Med Rehabil. 1994;75(4):394–8.
3. Pollock  A, Farmer SE, Brady  MC, Langhorne P, Mead  GE, Mehrholz J, van Wijck  F. Interventions for improving upper limb function after stroke. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD010820.
4. Han C, Wang Q, Meng P, Qi M. Effects of intensity of arm training on hemiplegic upper extremity motor recovery in stroke patients: a randomized controlled trial. Clin Rehabil. 2013;27(1):75–81.
5. MacLellan CL, Keough MB, Granter-Button S, Chernenko GA, Butt S, Corbett D. A critical threshold of rehabilitation involving brain-derived neurotrophic factor is required for poststroke recovery. Neurorehabil Neural Repair. 2011;25(8):740–8.
6. Harris JE, Eng JJ, Miller WC, Dawson AS. A self-administered Graded Repetitive Arm Supplementary Program (GRASP) improves arm function during inpatient stroke rehabilitation: a multi-site randomized controlled trial. 2009;40(6):2123–8.
7. Wolf SL, Winstein CJ, Miller JP, Taub E, Uswatte G, Morris D, et al. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. JAMA J Am Med Assoc. 2006;296(17):2095–104.