After a stroke, it’s challenging enough to navigate the medical system to find what services you need, let alone the right treatment approach for you.
You've probably heard a lot of recommendations on how to recover hand function after stroke, and everyone seems to give different advice. That's why we sifted through the research for you. We'll explain the top 5 evidence-based methods for hand rehabilitation, why they work, and who they work for.
The top 5 evidence-based treatments for improving hand function after stroke:
- Constraint‐induced movement therapy (CIMT)
- Mental practice
- Mirror therapy
- Virtual reality
- High dose repetitive task practice
Constraint-Induced Movement Therapy
What it is:
Constraint-Induced Movement Therapy (CIMT) is a neuro-rehabilitation method where the non-affected hand is constrained or restricted in order to force the brain to use the affected hand, thereby increasing neuroplasticity.
There are two key components: constraint and shaping.
Constraint refers to the way in which the hand is restricted. Therapists have used casts, splints, and mitts to restrict the use of the non-affected hand. None of them have been shown to be more effective than the other.
Shaping involves repetitive movements or activities at the patient’s ability level which become progressively harder. Therapists use shaping techniques to avoid overwhelming the motor system.
Why it works:
Our brain automatically completes a task in the easiest way possible. Our brain is more interested in completing a task than in how it is accomplished.
After a stroke, it’s easier for our brain to do tasks one-handed. This leads to “learned non-use”.
When we constrain our non-affected hand, suddenly our stronger hand becomes the weaker, less functional hand and we’re forced to use our affected hand. Our affected hand might not have much movement, but to our brain any movement is better than no movement, and the brain is highly motivated to figure out how to accomplish a task.
This is where the "shaping" piece is so important. If you are presented with rehab tasks that overwhelm the motor system or are higher level than your affected hand can functionally do, you'll be more likely to knock the table over than to participate in picking up pennies from the table.
If you knock the table over with your affected hand, your occupational therapist might actually be excited about it; but in practical life finding that balance of not being too easy and not being so hard that you give up is an important lesson for every human being, not just those after stroke.
Who it’s for:
This approach is used for people who have at least 10 degrees of active wrist and finger extension, as well as 10 degrees of thumb abduction (the ability of the thumb to move out of the palm).
It’s been shown to be effective even years after stroke. Lower intensity CIMT is better than higher intensity in the very early stages after stroke.
Mental Practice
What it is:
Mental practice, sometimes called motor imagery or mental imagery, is a training method for improving your hand and arm function without moving a muscle!
Mental practice is typically done by listening to pre-recorded audio that describes in detail the motor movement of a specific task. The listener imagines their hand and arm moving in a “typical” way, and the instructor provides cues to extend their arm or open their fingers, as well as the entire sensory experience of the task.
While it’s true that you can do mental practice on its own, it's best combined with physical practice immediately following.
Why it works:
Brain scans show that similar parts of the brain are activated whether movement is actual, observed or imagined.
It’s a separate area of the brain that’s responsible for actually triggering the muscle movement, but it goes to show that there’s a lot more required of the brain to complete a task than just sending a signal to the muscle.
Who it’s for:
Mental practice has been shown to improve arm movement and functional use in patients after stroke of all levels of abilities and as a treatment approach for people months or years after stroke!
Mirror Therapy
What it is:
Mirror therapy is another voodoo-seeming approach that has a lot of scientific evidence to back it up. It essentially tricks your brain into thinking your affected hand is moving.
You position a mirror to reflect your non-affected hand, while hiding your affected hand. Any movement of your non-affected hand will be reflected in the mirror and make it seem as though you are actually moving your affected hand.
Why it works:
The approach is centered around mirror neurons, which fire in your brain when you see your arm move. Typically, we think about motor neurons being sent from the brain to the muscle, but we don’t realize that mirror neurons are connected to the motor neurons.
After a stroke you lose the ability to access your motor neurons, but not your mirror neurons. By accessing your mirror neurons through seeing your movement (even if the movement is fake), you are tapping into the network between the neurons.
It’s like trying to reconnect with an old friend on Facebook by finding the friends they’re connected with. It might not be the most direct approach in a real life situation, but in stroke rehab that friend of a friend might be your strongest connection.
Who it’s for:
Mirror therapy can be used for people with no movement of the hand or smaller movements of the hand and shoulder, but not functional movement of the hand.
If you have functional movement of your hand, meaning individual finger movement and wrist movement, you have surpassed the benefit that mirror therapy can provide.
It can be used early after stroke, as well as in the chronic stages of stroke.
Virtual Reality
What it is:
Virtual reality uses a computer interface to simulate a real life objects and events. It's become an increasingly more prevalent rehabilitation technique to provide motivation and engagement in therapy.
There are two types:
- Immersive: goggles are placed over the eyes and the patient is visually in a different environment than their actual physical one
- Non-immersive: sensors are placed on the body and track the movement of the body and the movements are shown on a screen
Why it works:
Virtual reality works best when paired with traditional therapy. It's theorized to provide more motivation and engagement for the intensity of therapeutic exercise needed for neuroplasticity. It's been shown to beneficial in high doses, meaning more than 20 hours.
Another possible factor of why virtual reality works are the same mechanisms that make mirror therapy effective (tapping into the mirror neurons) could be similar.
Virtual reality also creates a biofeedback loop: your brain sends a signal to the muscle, the brain receives a signal back in the form of visual or auditory input. Basically, you get rewarded for your effort.
Who it’s for:
Virtual reality can be used with people who have mild to severe impairments, and from early after stroke to years out.
When deciding what's right for you, it's important to look at the adjustability of the device to meet you where you're at and also to increase in difficulty as you improve.
If you have minimal movements, you'll want a virtual reality tool specifically for stroke rehabilitation. If you have more movement, it's possible to use gaming systems not specifically designed for rehab, but make sure you have the support to optimize it for rehab.
High Dose Repetitive Task Practice
What it is:
Repetitive Task Practice is when you practice a task or a part of a task over and over. Task-specific training is a type of repetitive task practice, and refers to the task we complete that is relevant to our daily life.
"Reach to grasp, transport and release" is a type of task-specific training because it is one of the common motor requirements for many functional daily tasks.
The keys for repetitive task practice:
- Task must be meaningful
- Participant must be an active problem-solver
- Real life objects are used
- Difficulty level is not too high and not too low
- Repetition is key
Why it works:
Repetitive Task Practice is based on motor learning theory. Our brains are driven by function. We're able to achieve neuroplasticity with development of skills, as our brain processes the demands of the task, which have motor and cognitive components.
It's often used with other treatments, such as virtual reality, to increase the 15 hour dosage that has been shown to be beneficial.
Who it’s for:
Task-specific practice is generally used and is studied in people who have some functional ability of their hand. It's been shown to be beneficial throughout the rehabilitation process.
Even though the research has been focused on "functional ability" of the hand by practicing reach, grasp, transport, release; there's potential for recovery by using the same principles of task-specific practice: real life objects, functional tasks, and problem-solving even without the ability to grasp.
Functionally, we can use our affected upper extremity as a stabilizer, an assist, or for manipulation. There are lots of ways to get that side involved to prevent "learned non-use" and to improve your problem-solving skills.
Now what?
There are two key factors to any hand recovery method: support and meaning.
Neofect aims to support and inspire you to live your best life with virtual reality tools that can be used as part of a constraint-induced movement therapy program or with repetitive task practice.
Our companion app to create healthy habits for stroke recovery: Rehabit and our YouTube Channel: Find What Works are based on the principles of repetitive task practice and aim to give you the tools to live your best life.
Now the only question is, what are you waiting for?
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. DOI: 10.1002/14651858.CD010820.pub2.
Call us (888) 623-8984 or email us at info@neofect.com to rehab smarter with Neofect today.
Clarice Torrey, OTR/LClarice is an occupational therapist, product designer, and health writer based out of San Francisco, CA. Clarice works for RAD Camp as a Community and Product Manager.
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