Upper limb recovery after stroke: arm and hand rehabilitation

The hand needs fine, finely timed control, and the brain areas that supply it are easily damaged by a stroke. Weakness may be accompanied by altered tone, stiffness, loss of sensation, poor coordination and, sometimes, neglect of the affected side. The NHS says recovery depends on how much the stroke has affected the person and on the rehabilitation plan, and that exercises and therapy are often hard but help people make progress.

Physiotherapists and occupational therapists usually share the work. NICE says people with trunk or limb weakness, sensory disturbance or balance difficulty should receive physiotherapy from therapists with relevant stroke skills, and that treatment should continue until the person can maintain or progress function either independently or with help from others, such as rehabilitation assistants, family members or fitness instructors.

Repetitive task training is the backbone of arm rehabilitation. The person practises purposeful movements, such as reaching to a shelf, picking up and releasing objects, pointing and manipulating items, over many repetitions. For the legs the same principle applies to sit-to-stand transfers, walking and stairs.

NICE also suggests considering strength training for muscle weakness, which can be built up through body-weight activities, weights or resistance machines, and encouraging general physical activity. When fitness programmes begin, people are told that shoulder pain is a common problem and to seek advice if it occurs.

Constraint-induced movement therapy, often shortened to CIMT, limits use of the unaffected hand for part of the day, commonly with a mitt, while the person does intensive practice with the weaker hand. The aim is to overcome learned non-use, where people stop trying to use the affected hand because it is easier to rely on the other.

NICE advises considering it for people who can already extend the wrist by 20 degrees and the fingers by 10 degrees. It warns teams to be aware of potential adverse events, including falls, low mood and fatigue, so selection and supervision are important. It is not suitable for everyone, particularly where balance is poor or the person finds the programme discouraging.

In mirror therapy the person watches the reflection of the unaffected limb moving, so that the brain receives a visual impression of normal movement in the weak limb. NICE suggests considering mirror therapy for weakness in the arms or legs as an adjunct to a rehabilitation programme. If provided, it should begin within the first 6 months after stroke, in sessions of about 30 minutes held at least 5 times a week over 4 weeks, supervised initially and for longer if needed.

The guidance is more cautious about equipment. Wrist and hand splints should not be offered routinely, but can be considered for people at risk, for example where the hand is immobile because of weakness or high tone, to maintain joint range, aid hygiene, improve comfort or assist function. They must be fitted by trained professionals with a review plan, and the person and family are taught how to apply them and check the skin.

Electrical stimulation to the arm or hand is not recommended routinely, but a trial can be considered within a comprehensive programme for people who show muscle contraction but cannot move the arm against resistance. It should be guided by a qualified professional and continued only if strength and function are improving. NICE advises against robot-assisted arm training in an upper limb programme.

Occupational therapists encourage people with arm weakness to use both arms in everyday activities, which turns ordinary tasks into practice. Compensatory methods such as one-handed dressing and adapted equipment are taught alongside, so that independence does not wait for full recovery. Telerehabilitation is also supported: the NHS notes that rehabilitation can be done in person or online, and that teams should provide the equipment and technical support needed at home.

The NHS recommends a review of progress after about six months, and NICE says health and social care needs should be reviewed at six months and then annually. People can usually self-refer for further help through their GP or the stroke rehabilitation service contact if needs change.

A heavy, weak arm can strain the shoulder. NICE asks teams to give people and carers information on preventing pain or trauma to the shoulder in those at risk, for example with weakness and spasticity. Safe handling, supported positioning and avoiding pulling on the arm during transfers are basic measures. Pain that does develop is covered on our guide to shoulder pain after stroke.