Sources
| A | Veerbeek et al, 2014b; French et al, 2016; Grattan et al, 2016; Wattchow et al, 2018; Chen et al, 2019; Zhang et al, 2021; da Silva et al,2020 |
| B | Kwakkel et al, 2015; Corbetta et al, 2015; Barzel et al, 2015; Yadav et al, 2016; Liu et al, 2017; Abdullahi, 2018 |
| C, D | Guideline Development Group consensus |
| E | Thieme et al, 2018; Yang et al, 2018; Zeng et al, 2018; Zhang et al, 2021 |
| F | Page and Peters, 2014; Di Rienzo et al, 2014; Barclay et al, 2020; Stockley et al, 2021; Poveda-Garcia et al, 2021 |
| G | Da-Silva et al, 2018; Guideline Development Group consensus |
| H | Dawson et al, 2021; Ahmed et al, 2022; Guideline Development Group consensus |
| I | Mehrholz et al, 2018; Takebayashi et al, 2020 |
Evidence to recommendations
Repetitive task practice
There is good quality evidence for interventions involving intensive, repetitive, task-oriented and task-specific training including constraint-induced movement therapy, mental practice, virtual reality and interactive video games (Pollock et al, 2014b). It remains unclear whether practising unilateral functional activities is more beneficial than bilateral practice, but this is likely to depend on a person’s level of impairment. The evidence base for virtual reality and interactive video gaming-based interventions for the arm (as an adjunct to usual care to increase overall therapy time) is developing, though studies are often of low quality and further research is needed before recommendations can be made regarding their use. [2023]
The ideal dose of repetitive task practice required to be beneficial remains unclear (Lang et al, 2009; French et al, 2016a) but is likely to be substantially higher than is currently being delivered (Schneider et al, 2016; Clark et al, 2021) and in the order of several hundred repetitions per day (McCabe et al, 2015; Daly et al, 2019; Ward et al, 2019; Hayward et al, 2021). This can lead to both short-term and sustained improvements in arm and hand function in people with both subacute and chronic stroke (French et al, 2016a; Wattchow et al, 2018) even in those with cognitive impairments such as neglect or inattention (Grattan et al, 2016). [2023]
Adding trunk restraint to task-oriented arm and hand training can further improve impairments and activity within the first six months after stroke by limiting compensatory movements (Zhang et al, 2022). There is some evidence that priming activities can enhance training effects, with moderate quality evidence for brain stimulation or sensory priming, and low quality evidence for motor priming to enhance improvements in impairments and activity (da Silva et al, 2020). Brain stimulation usually involves transcranial magnetic or direct current stimulation, sensory priming involves electrical or sensory stimulation and motor priming involves aerobic activity or bilateral activities (da Silva et al, 2020) but there is little information on the appropriate dose, timing or type of priming activity. [2023]
High quality systematic reviews and meta-analyses provide sufficient evidence to discourage routine use of Bobath therapy in place of repetitive training or practice of functional tasks (Veerbeek et al, 2014b; Wattchow et al, 2018). [2023]
Electrical stimulation
Four good quality systematic reviews with meta-analysis have shown that electrical stimulation to the wrist and hand can improve motor impairments and function (Yang et al, 2019; Tang et al, 2021; Kristensen et al, 2022; Loh et al, 2022). Tang et al (2021) included a network meta-analysis which indicated that functional electrical stimulation to the wrist and finger extensors during practice of functional tasks was more effective at improving upper limb function than passive neuromuscular electrical stimulation, especially when used to enable repetitive task practice (Yang et al, 2019). A suggested way to do this is by coupling stimulation of the weak arm with movements of the unaffected arm (referred to as contralaterally controlled functional electrical stimulation; Loh et al, 2022). The optimal dose and stimulation protocol are still unclear so clinical decisions should be made according to an individual person’s needs, goals and preferences. [2023]
Vagus nerve stimulation
High quality evidence from systematic reviews of six RCTs of vagus nerve stimulation (VNS; n=237; (Xie et al, 2021; Zhao et al, 2021; Ahmed et al, 2022)); including a phase III trial of implanted VNS in 108 people with chronic stroke (Dawson et al, 2021), showed VNS can enhance the effect of repetitive task practice on upper limb impairment, with a moderate effect size. All trials which reported on safety found VNS to be safe. However, many factors remain unclear, such as the optimal dose and stimulation parameters, integration of stimulation with repetitive task practice and identifying those who benefit most. Further research is needed to understand these factors, and the relative merits of implanted or transcutaneous stimulation. Furthermore, the dose of repetitive task training is likely to be important; it is unlikely that VNS would be effective without a high dose of repetitive task practice, which is currently rarely achieved in practice. VNS may be considered, when it can be provided without reducing the amount of practice completed, alongside other priming techniques according to patients’ presentation, goals and preferences. [2023]
Intensive upper limb programmes
Whilst findings from single-centre studies of specialist intensive upper limb programmes for selected patients appear promising (Daly et al, 2019; Ward et al, 2019), there was insufficient high quality evidence to make general recommendations regarding provision of such programmes. Providing the evidence-based, intensive upper limb treatments contained in the recommendations in this section at a sufficient dose should remain the priority, along with delivering generalisable RCTs of intensive upper limb programmes in chronic stroke. Providers and commissioners/service planners should ensure access for all people with stroke who could benefit from rehabilitation at the intensities recommended, including measures to ensure therapy can be replicated and maintained over the longer term at home. [2023]
Constraint-induced movement therapy
Constraint-induced movement therapy (CIMT) includes an extended daily period of constraint of the non-paretic arm, repetitive task training for the paretic arm (shaping and task practice) and a ‘transfer package’ to support implementation into everyday life. Evidence suggests the transfer package is of particular importance, ensuring that motor gains translate into functional tasks and improve outcomes. Outcomes generally relate to arm function and effects are mostly confined to the trained activities (Pollock et al, 2014a; Pollock et al, 2014b; Veerbeek et al, 2014b). Challenges in clinical delivery and adherence to original CIMT protocols have resulted in modified CIMT (mCIMT) being adopted, where the time during which the non-paretic arm is constrained is reduced and the training hours spread over a longer period of time. Other mCIMT protocols have explored different methods and locations of delivery, for example home, clinic or remote delivery. Both CIMT and mCIMT improve arm function and activities of daily living in people with mild-moderate weakness (that is at least 20 degrees of active wrist extension and 10 degrees of active finger extension in the affected hand) in people with acute and subacute stroke (Corbetta et al, 2015; Kwakkel et al, 2015; Liu et al, 2016). However, mCIMT protocols vary and the optimal way to modify CIMT is unclear (Barzel et al, 2015; Yadav et al, 2016; Abdullahi, 2018). [2023]
Future research should aim to identify the most effective mCIMT protocols to use in clinical practice for people with different degrees of weakness and disability (e.g. the duration and frequency of constraint). Research should also consider the acceptability of CIMT and mCIMT for people with stroke and consider the support required for its use. There is emerging evidence of successful alternative ways to administer CIMT/mCIMT for example through video games or telehealth (Smith & Tomita, 2020; Taub et al, 2021; Gauthier et al, 2022) that merit further investigation. [2023]
Mental practice
Mental practice is an adjunct to conventional therapy, which can lead to significant improvement in upper limb function in the acute, subacute and chronic phases after stroke (Barclay et al, 2020). There is some evidence that mental practice may be more effective in the first three months after stroke in people with the most severe arm weakness, but the required dose is unclear and further research is warranted (Barclay et al, 2020; Stockley et al, 2021). A small observational study has indicated that the ability to mentally visualise (i.e. imagine) movements should be assessed before prescribing mental practice (Poveda-Garcia et al, 2021). [2023]
Mirror therapy
Systematic reviews and meta-analyses provide moderate evidence that mirror therapy can improve arm function and activities of daily living for people after a stroke (Thieme et al, 2018; Yang et al, 2018; Zeng et al, 2018; Zhang et al, 2021). [2023]
Mirror therapy is only effective for improving arm function as an adjunct to therapy or compared to a placebo (Thieme et al, 2018). Mirror therapy is not superior to dose-matched, conventional rehabilitation that involves upper limb action observation, movement or functional training (Lin et al, 2019). More robust research is required, and future research should focus on defining the most effective treatment protocols and the patients for whom it is most beneficial (Morkisch et al, 2019). Systematic reviews also suggest that mirror therapy may be effective in the treatment of pain and neglect, but this was not a focus of the 2023 update. [2023]
Robotics
A Cochrane review (Mehrholz et al, 2018) concluded that electromechanical and robot-assisted arm training resulted in a slight improvement in activities of daily living, muscle strength and arm function. However, a variety of types of robot were used and the dose of training was under-reported making it unclear how robotics could be routinely adopted in practice. Further uncertainty comes from suggestions from other trials that the effects of robotic therapy on arm function are confined to secondary outcomes in people with subacute stroke when combined with conventional therapy (Takebayashi et al, 2022) or only if enhanced by the addition of functional electrical stimulation (Straudi et al, 2020). A further systematic review suggested robotic therapy maybe slightly superior to therapist-led training (Chen et al, 2020) while other studies indicate that including robotic therapy in a conventional therapy session could achieve similar improvements to conventional therapist-led treatment but with less staffing resource (Aprile et al, 2020; Budhota et al, 2021). Further research is needed to find ways to translate the improvements in upper limb impairment seen with robot-assisted training into meaningful benefits in upper limb function and activities of daily living (Rodgers et al, 2019a). In the meantime, teams may consider or continue supplementing face-to-face therapy with robot-assisted arm training and be reassured regarding its safety, and seek opportunities for their patients to participate in research studies. Future research should include non-inferiority or equivalence trials, as it may be that equivalent clinical outcomes can be achieved using less resource. The target population should be people with severe arm weakness and less potential for spontaneous recovery (Wu et al, 2021). An economic evaluation concluded that robot-assisted therapy was not cost-effective, and also recommended further research (Fernandez-Garcia et al, 2021). [2023]
