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Hand function and stroke

SM Hunter and P Crome

Reviews in Clinical Gerontology / Volume 12 / Issue 01 / February 2002, pp 68 - 81

DOI: 10.1017/S0959259802012194, Published online: 21 August 2002

Link to this article: http://journals.cambridge.org/abstract_S0959259802012194

How to cite this article:

SM Hunter and P Crome (2002). Hand function and stroke. Reviews in Clinical Gerontology, 12, pp 68-81
doi:10.1017/S0959259802012194

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Reviews in Clinical Gerontology 2002 12; 68–81

Hand function and stroke

SM Hunter and P Crome
School of Medicine, University of Keele, Staffordshire, UK

Introduction of upper limb paresis on admission is a more

1 appropriate predictor of the level of upper limb
Stroke is particularly prevalent in older people
recovery that can be expected.5,7 The presence of
and the effects of stroke can be profound.2,3 Not
early recovery of movement, specifically shoulder
only are the abilities to stand, balance and walk
shrug, synergistic hand movements14 and grip15
affected, but also the ability to use the upper limb
have been shown to be indicative of good poten-
and hand in its diversity of functions in everyday
tial for further recovery, with further improve-
life. Loss of independence of upper limb function
ments of motor function and dexterity within
contributes enormously to functional disability,
three months poststroke necessary for significant
affecting quality of life and independence in
upper limb recovery.16 Although advancing age is
‘basic’ (washing, grooming, feeding, dressing,
generally considered to limit functional recovery
etc.) and ‘instrumental’ activities (shopping,
following stroke, Nakayama et al.17 reported that
home/financial management, etc.) of daily living.2
advancing age was not an independent factor
A larger proportion of stroke patients with initial
associated with neurological recovery. However,
severe upper limb paresis are discharged to insti-
older stroke patients were found to have less abil-
tutionalized care (63%) than are discharged home
ity to compensate for lost movement following
(37%).4
stroke. Subsequently, their general level of func-
Approximately 60–70% of all stroke patients
tional upper limb recovery (assessed by subsec-
will have upper limb paresis on admission to hos-
tions of the Barthel Index, allowing use of either
pital,5-7 with approximately half of those (33% of
upper limb to achieve the activity) was less than
all strokes) having ‘severe’ paresis, the other half
that found in younger patients.
having ‘mild’ paresis (classified by the
Scandinavian Stroke Care sub-scores for arm and
hand). Of those surviving stroke long-term, 50- The hand
70% will continue to experience loss of function
The hand has many functions, primarily sensation
and disuse in the hemiplegic upper limb 2–4 years
and prehension, with secondary functions of
poststroke,7-9 in spite of some 25%9 having rela-
expression, gesture, communication, visceral
tively normal movement scores (>50 out of 54–
(food to mouth), protection/defence/offence,
Fugl Meyer Motor Assessment arm section).
hygiene, balance/stabilization, contribution to
Most recovery of upper limb function has been
body image, and thermoregulation,18,19 all playing
reported to occur during the first three months
an essential role in our everyday lives. Motor and
following stroke.7,10,11 Yet there is substantial evi-
sensory functions of the hand cannot be dissoci-
dence that recovery continues at a slower rate
ated, making the hand an exceptional organ, with
over a much longer, unspecified period (months or
the ability to both seek and provide information.
years).7-9,12,13 Although initial stroke severity is
Other organs of sensation are static, remaining
generally thought to be a predictive factor for
dependent on the arrival of a stimulus. Placed at
overall recovery, it has been reported that the
the end of the arm (which acts as a long, mobile,
recovery of arm function is independent of the
yet stable vector), the hand can be moved
overall level of stroke severity.7 Instead, the degree
throughout a large area of space because of shoul-
der joint, shoulder girdle and trunk mobility.
Address for correspondence: SM Hunter, Department of
Efficient and appropriate placement of the hand
Physiotherapy Studies, University of Keele, Staffordshire for function is dependent on the dynamic stabil-
ST5 5BG, UK. ity of the proximal joints of the upper limb, shoul-

der girdle and trunk. Elbow joint movements posi-
tion the hand close to or away from the body, and
combined forearm and wrist movements place the
hand in the required position to grasp.18 The hand
and the arm are often considered to function as
one whole unit.20
The control of voluntary and skilled hand
movement, and the relationship between sensation
and voluntary movement, have been comprehen-
sively described.21,22 Neural mechanisms involved
specifically in hand and finger movement control
consist of direct neural connections from cortex
to spinal cord, known as cortico-motoneurones,
ensuring quick responses and intricate patterns of
movement (dexterity) in the hand.
Primary hand functions
Sensation
External stimuli result in superficial or exterocep-
tive sensation, informing about the intensity, qual-
ity and specificity of a sensation, contributing to
the role of protection, and prompting actions of
defence, such as withdrawal from a sharp object.
Internal stimuli result in deep or interoceptive sen-
sation, informing about limb position and move-
ment (proprioception and kinaesthesia), with
cutaneous mechanoreceptors in the hand playing
an essential role and contributing to the regula-
tion of motor control.18,23
The integration of sensory and motor functions
of the hand enables active exploration and manip-
ulation of objects through touch (active touch).
The correct interpretation of different sensations
received from the skin, muscles and joints allows
accurate recognition of the three-dimensional fea-
tures of an object (haptic perception). Sensations
received through the hand and fingers are
enhanced by visually acquired information.
Haptic perception is thus dependent on intact
peripheral and central sensory mechanisms, and
correct and appropriate central interpretation of
the stimulus. It requires the interaction of several
different systems, particularly sensory, motor and
cognitive/ perceptual systems and is an extremely
complex, yet intrinsic, part of many activities of
daily living.24 Haptic perception plays an impor-
tant role in grip formation.
Hand function and stroke 69
Prehension
The kinematics of prehension have been described
by Jeannerod.25,26 Prehension includes two identi-
fiable phases – transport (reach) and grasp
(manipulation). During reach, anticipatory pos-
tural adjustments of the legs and trunk precede
the selective movements of the upper limb and
shoulder girdle,27 which transport the hand to the
required position to grasp. The hand opens in
preparation for grasp, its aperture and posture
being pre-set according to the visually perceived
size and shape of the object and the chosen grip
configuration, appropriate to the object properties
and the task. The grasp phase involves the hand
making contact with the object and closing
around it to form a grip. The automatic response
of grip force to changes in load force, whether
expected or unexpected, is essential for success in
everyday manual tasks.28
If the object is to be lifted, a force (grip force)
is exerted by the parts of the hand in contact with
the object, scaled according to the load force (act-
ing tangential to the contact surfaces) and subse-
quent ‘behaviour’ of the load. The programming
of grip force control has been extensively investi-
gated and reported by Roland Johansson and col-
leagues27,29-32 and likened to the control of posture
and balance in upright stance. Each is controlled
by automatic, subconscious neural processes, with
an anticipatory or feed forward element of con-
trol to prepare for predictive events, and both also
depend on sensory signals to enable automatic
adjustments and corrective or compensatory
action, where unanticipated events threaten sta-
bility.27 Object characteristics (such as surface tex-
ture and friction, size/shape, and weight),
acquired through touch and vision, influence the
motor programme parameters required to control
grip force.27,32 Previous experiences of lifting
objects with similar characteristics are stored in
sensorimotor memory (internal models)32 and
contribute to the initial pre-setting of grip force,
matching object weight and surface friction.27,31
Surfaces with greater frictional properties, such as
sandpaper, require less grip force than more silky
or shiny surfaces, which offer less friction and are
more likely to slip.27 Moment-to-moment somato-
sensory information from the fingertips is pro-
vided by cutaneous mechanoreceptors, which
drives the automatic corrective action. In addi-
tion, intact motor cortex, cerebellum and primary
70 SM Hunter and P Crome
somatosensory cortex, are all involved in the
regulation of predictive and automatic grip
responses.27
Effects of stroke
Both sensory loss and motor impairment con-
tribute significantly to the loss of function in the
hand, particularly where their integration is essen-
tial. The loss of the primary hand functions of
sensation and prehension significantly impair
activities of daily living and limit independence.
Loss of sensation
Levels of sensory impairment and dysfunction are
recorded less frequently than motor impairment.
Yet it has been reported that 60–74% of all stroke
patients suffer sensory loss in the hemiplegic
upper limb and hand.9,33 Somatosensory loss can
be manifest in different ways. These include
delayed perception, uncertainty of responses,
changes in sensory thresholds, fatigue, increase or
decrease in time for sensory adaptation to occur,
altered nature of the sensation, and situations
where interrupted touch feels like continuous
touch or where the sensation persists when the
stimulus has been removed.33
Proprioception has been reported as the most
frequently lost sensation long-term, occurring in
52% of patients, followed by loss of vibratory
sense in 44%, loss of light touch in 37%, and loss
of pinprick sensation in 35%.9 However, reliable
sensory testing is difficult,34 sensation being inex-
tricably related to perception and so is affected by
‘attention, understanding, concentration, goodwill
and a host of other ‘subjective’ factors’.35 Thus,
perceptual dysfunction is sometimes mistaken as
somatosensory impairment.33 Intrinsic sensations
of proprioception, kinaesthesis and two-point dis-
crimination have been highlighted as potentially
the most important for hand function, each
requiring the higher level cortical functions of per-
ception, interpretation and integration.7,36,37
Somatosensory loss can potentially occur fol-
lowing cortical or subcortical damage, and fol-
lowing disruption to most of the major cerebral
arteries.33 Damage to the sensory system at dif-
ferent locations between the cortex and the brain-
stem results in different patterns of sensory loss
in the hand. Brainstem strokes can be character-
ized by the loss of pain and temperature sensa-
tions in the contralesional limb; strokes occurring
at the level of the thalamus frequently result in
general sensory loss, but particularly position
sense (proprioception). However, the sensory
effects of lesions occurring at subcortical and cor-
tical levels are more complex.
Damage to the sensory cortex characteristically
results in problems of spatial relations, involving
localization of sensation, two-point discrimination
and detection of movement and movement direc-
tion. In addition, loss of the ability to appreciate
or interpret the intensity and quality of a stimu-
lus occurs, as well as loss of the ability to appre-
ciate the features of objects, such as shape, texture
and size.35 Somatosensory impairments following
parietal lobe lesions have been reported to be sim-
ilar to those following posterior column dysfunc-
tion,26,38 with discriminative function and
movement position and detection being particu-
larly disturbed. These become particularly appar-
ent when visual input is additionally excluded.39
The full nature of general somatosensory loss after
stroke has been detailed by Carey.33 Three main
problems occurring as a result of sensory loss have
been highlighted: (1) loss of detection of sensory
information (2) disturbed performance of motor
tasks that require somatosensory information and
(3) influence on rehabilitation outcome.
Loss of motor function
Irregular neural damage and incomplete structural
lesions mean that the precise long-term nature of
motor impairment following stroke cannot be
accurately forecast. The hand is accorded widely
distributed representation in the brain, specifically
including the frontal and parietal cortices, the
basal ganglia, thalamus and cerebellum.40 Hence,
a lesion in any cortical or subcortical structures,
as well as the ascending and descending pathways
of the corticospinal system, has the potential to
affect the control of finely-tuned, skilled move-
ments and dextrous function of the hand.
However, recovery in the upper limb is potentially
greater if the damage is purely cortical than purely
subcortical, where devastating damage to motor
pathways can result from very small lesions.41
Primate studies have shown that the damaged cor-
tex can reorganize and undergo plastic changes
following specific training programmes, and the
control of lost hand movements can be recov-
ered.42-45 Redundancy of cortical tissue and motor

representation may enhance the potential for reor-
ganization and plastic adaptation, enabling re-
establishment of neural mechanisms.
Experimental division of cortico-motoneurones
in primates results in permanent motor loss in the
fingers and hand, but with no additional perma-
nent loss of postural control.22,46 Damage to the
posterior limb of the internal capsule is particu-
larly associated with poor recovery of selective
movement in the arm.41 The potential for recov-
ery of hand function after stroke thus appears to
be related to the preservation of central motor
conduction via the corticospinal tracts, and in
particular to the amplitude of motor-evoked
potentials (MEPs).47
Parietal cortical lesions seriously disturb not
only sensory but also motor functions in the hand,
including active touch, exploration and manipu-
lation skills, prehension and grip control, intensi-
fied by the exclusion of visual feedback
control.39,48 The nature of the motor disturbances
can be summarized as (1) poor explorative man-
ual movements, (2) slow and clumsy object
manipulation, (3) inability to perform precision
grip under visual control, (4) inability to maintain
constant grip force control, (5) failure to flex fin-
gers in time to catch an object.48
Stroke patients with parietal lobe dysfunction
demonstrate disturbances of all aspects of the
transport and grasp phases of prehension, includ-
ing overshooting the target, increased duration of
reach, and incomplete, inaccurate or absent grip
formation.26,38,48 The ability to ‘shape’ the fingers
in preparation for fingertip grip is frequently lost,
the whole palmar surface being used, instead, to
grasp.26 In the absence of sufficient tactile hand
sensation, extremely large grip/load force ratios
occur in order to maintain adequate grip force.49
These disturbances result, however, not from a
loss of sensory stimulus inflow but from distur-
bances of sensorimotor integration, where the
‘conception and generation’ of movement pat-
terns, which enable the hand to collect and receive
somatosensory information, are predominantly
affected.38 Thus, sensory information is not
received and the perception of sensation becomes
further disturbed. Prolonged sensory loss and sig-
nificantly reduced sensory stimulation of the hand
results in its disuse.13 This, in addition to the ini-
tial motor impairment, frequently results in
patients habitually neglecting to use any move-
ment that may be available in the early stages.
Hand function and stroke 71
Repeated non-use of the hand over time results in
a decrease in size of cortical representation of the
hand in both sensory and motor cortices, and sub-
sequent further loss of movement. The result is
the ‘learned non-use phenomenon’.50–52
Hand dysfunction has also been reported in the
arm ipsilateral to the stroke lesion. In a summary
of the presence and types of sensory loss in the
‘unaffected’ arm (ipsilateral to the lesion), Carey33
reported that 12–26% of patients were affected in
this way. Stroke patients have been found to
demonstrate significantly slower performance on
tests of function using the unaffected upper limb,
compared to established norms.53 Sunderland and
colleagues54,55 reported short-term loss of dexter-
ity in the ipsilesional hand and arm, and related
this particularly to cognitive dysfunction.
Therapy for hand function after stroke
Therapy for the upper limb after stroke is gener-
ally seen as challenging and demanding on time
and human resources, and intervention has been
described as ‘inappropriate and insufficient’.20
Recovery of upper limb function is frequently dis-
regarded in order to pursue more achievable goals
associated with functional mobility, balance and
stability.20,56 However, the hand may be further
neglected by clinicians waiting inadvertently until
proximal control is gained before embarking on
active retraining of sensorimotor hand function.
General therapeutic principles can be directed
at prevention of biomechanical changes in mus-
cle, stiffness and spasticity, and at retraining or
facilitating specific functional activity. Splinting,
careful movement and handling, attention to pos-
tural correction and positioning of the limb, pas-
sive and active movements/mobilization, and
education of the patient are common general
interventions.57
In addition to general therapeutic principles,
therapists use many different specific interventions
and strategies, with a wide range of these occur-
ring in any one treatment session. Most of these
interventions have not been scientifically evalu-
ated,58 and most have not even been described in
any literature. They are passed on as practical
skills. However, some interventions and specific
training programmes have been described and
evaluated and their main features are summarized
in Table 1.
 72
Table 1. Summary of intervention studies

Study Study type Subjects Time since Intervention Principal findings

SM Hunter and P Crome

(Country) stroke

Ostendorf and Single-case 1 18 months Intervention phase involved restraint of intact upper limb 1) General decrease in time taken to complete various
Wolf62 experimental in shoulder sling throughout the whole day for 1 week functional tasks
(USA) A-B-A design 1 2) Self-reported increase in total behaviours per day
during intervention phase
Dannenbaum and Single case report 1 1.5 years Cutaneous electrical stimulation to fingertips, twice Clinically significant improvements in hand function
Dykes59 weekly for 15 minutes each session for approx. 3 weeks. during activities of daily living (ADL) and sensory
(USA) Then daily, rough, cutaneous stimulation (Velcro) to tips functions - proprioception, pain, touch, pressure, point
of fingers and thumb for approx. 2 months, with active localization after 15 months of training
task retraining twice/week for approx. 9 months.
Wolf et al.63 Before/after 21 >1year Intervention phase involved restraint of intact limb in a Significant improvements (p < 0.05) in function (reduced
(USA) intervention study sling during waking hours, removed for 30 mins each day times or increased force) during 2nd week of intervention,
for exercise, over 2 weeks and at 1 year follow-up
Kraft et al.64 Controlled 22 6–72 months 1) EMG-triggered electrical stimulation (EMG-stim) of 1) All experimental group improved Fugl-Meyer scores
(USA) experimental design wrist extensor muscles, finger and elbow extensors, significantly more than controls (p < 0.01) and maintained
forearm supinators and pronators, shoulder elevators or them over 9 months (p < 0.005)
abductors for 1 hour, 3 times/week for 3 months (n = 6) 2) Greater improvement in FM scores pre - post
2) Bias/balance stimulation (B/B stim) - self-administered treatment with EMG stim than with PNF (p < 0.05)
electrical stim combined with voluntary effort to wrist 3) Improved grip strength in all experimental subjects
extensor muscles for 30 mins, 5 times/week for 3 months (p < 0.01)
(n = 4)
3) PNF for approx. 1 hour, 3 times/week, for 36 sessions
over 3 months (n = 3)
Sunderland et al.65 Stratified 132 3 weeks Experimental group received enhanced therapy (ET) 1) Greater recovery of arm function (Extended Motricity
(UK) randomized involving more hands-on therapy time, self-directed Index (EMI)) within 1st month for ET group compared to
controlled design exercise programmes, aspects of ‘conventional’ therapy, controls (p < 0.01) for all patient sub-groups
EMG biofeedback, computer games, active involvement 2) Better arm function for ET group in ‘mild’ subgroups at
of patient and family 6 months (EMI, Motor Club Assessment, 9-hole peg test)
Sunderland et al.66 1-year follow-up 97 1 year compare to controls (p < 0.05)
(UK) 3) Trend for ‘severe’ patients to perform better with
conventional therapy (control group)
4) Differences not present at 1 year follow-up
Carey et al.61 Single case quasi- 8 5–26.5 weeks 1) Retraining of finger-tip texture discrimination during 1) Improved texture discrimination
(Australia) experimental (A-B) intervention phase 2) Improved joint position detection
and controlled 2) Retraining of detection of wrist position sense 3) Improved functional performance
experimental (A-B-
C) design
Yekutiel and Controlled trial 20 2–18 years 1) Experimental group - supervised/assisted active tactile 1) Improved sensory function - localization,
Guttman13 exploration of objects reinforced by vision and unaffected proprioception, two-point discrimination, haptic perception
(Israel) hand for 45 mins, 3 times/week for 6 weeks 2) Improved functional performance reported
spontaneously in 2 patients, although not formally tested
(Israel) hand for 45 m ns, 3 t mes/week for 6 weeks 2) Improved funct onal performance reported
spontaneously in 2 patients, although not formally tested

Table 1. Continued

Study Study type Subjects Time since Intervention Principal findings

(Country) stroke

Taub et al.12 Randomized 9 1.2–18 years 1) Experimental group – unaffected arm restrained in 1) Increase performance times on tests of motor ability in
(USA) controlled different splint for 90% of waking hours, for 14 days, with 6 hours experimental group (p < 0.06)
groups design task retraining on each weekday 2) Improved quality of movement and functional ability in
exp. Group (p < 0.003) using Emory Test (grip strength)
and Arm Motor Activity Test (AMAT)
3) Increase in everyday activities (Motor Activity Log)
(p < 0.01)
4) Increased range of passive movement
Hummelsheim et al.67 Stratified controlled 40 45 days – 3 years 1) Cutaneous/proprioceptive stimulation (CPS) over the 1) Increase in muscle response amplitude (measured
(Germany) trial wrist extensor muscle of affected arm with transcranial magnetic stimulation (TMS)) with all
2) Weight-bearing through affected elbow and forearm interventions, reaching significance following VA
3)Activation of affected shoulder girdle elevation (p < 0.005) in all subjects
4) Maximum isometric activation of non-affected 2) Decrease in TMS response in all patient groups with
hand/fingers with resistance all interventions, but greatest following VA (p < 0.005)
5) Voluntary activation (VA) of wrist extensors of affected 3) Significant facilitatory effect (p < 0.008) following CPS
arm only in severe strokes
4) Prolonged response latency with CPS in healthy
volunteers
Butefisch et al.68 Multiple baseline 27 3–19 weeks 1) Group 1 – training programme of resisted grip, rapid 1) Significant increases in motor function (Rivermead Motor
(Germany) across-individuals wrist extension against low resistance, repeated resisted Assessment) - arm section between end of baseline and end
design finger flexion and hand extension, 15 mins twice daily for of baseline and intervention phases for Group 1
4 weeks, in addition to usual therapy (p < 0.05) and Group 2 (p < 0.001)
2) Group 2 – TENS over wrist extensor muscles for 15 2) Significant increases in grip strength (Group 1
mins, twice daily for 2 weeks, then training programme as p < 0.006, Group 2 p < 0.002), peak isometric force (Group
for Group 1 1 p < 0.05, Group 2 p < 0.007) and peak acceleration

Hand function and stroke

(Group 1 p < 0.05, Group 2 p < 0.004) after 1 week of
training
Hummelsheim et al.69 Multiple baseline 12 3 weeks – 4 1) Baseline phase (A) – ‘normal’ therapy for 1–3 weeks 1) Significant increase (p < 0.008) in function (RMA) during
(Germany across-individuals months 2) Intervention phase (B) - 20 mins electrical stimulation retraining phase C
(A-B-C) design to wrist extensor (15 mins) and flexor (5 mins) muscles, 2) Significant increase in movement parameters (grip
twice daily for 2 weeks in addition to ‘normal’ therapy strength p < 0.001; peak force of isometric hand extension
3) Retraining phase (C) (described above by Butefisch p < 0.01; peak acceleration during isotonic hand extension
et al. 1995) - 20 mins twice daily f or 2 weeks (p < 0.02) for stimulation vs. retraining phase

Pandyan et al.70 Fixed order design 11 4 week – 13 1) Intervention (ON) phase involved 30 min sessions of 1) Temporary/short term (<2 weeks) improvements in
(UK) (OFF-ON-OFF) years electrical stimulation (ES) of wrist extensors daily for 2 wrist posture and range of passive extension following
weeks in addition to ‘normal’ rehabilitation intervention

73
2) OFF phase consisted of ‘normal’ rehabilitation only
 74
Table 1. Continued

SM Hunter and P Crome

Study Study type Subjects Time since Intervention Principal findings
(Country) stroke

Feys et al.71 Single-blind 108 2–5 weeks 1) Experimental group - subjects seated in rocking chair, 1) Experimental group showed greater improvement in
(Belgium) stratified arm in inflatable splint resting in gutter, with shoulder at Brunnstrom-Fugl-Meyer scores at 6 months (p = 0.004)
randomized 80 degrees of flexion and slight abduction, elbow and 12 months (p = 0.03) but n/s difference in Action
controlled extended, wrist dorsiflexed, and active ‘push’ with Research Arm Test and Barthel Index compared to
multicentre design affected arm and leg to perform rocking motion controls
2) Control group – positioned in rocking chair with arm on
lap, no additional stimulation, short wave therapy applied
to affected shoulder
3) Both groups – 30 mins, 5 days/week for weeks in
addition to usual rehabilitation
Sonde et al.72 Randomized 44 1 year 1) Experimental group received low frequency TENS in 1) Improvement in motor function (Fugl-Meyer Motor
(Sweden) controlled trial addition to ‘normal’ daily rehabilitation for 3 months Performance Scale) in all patients (p < 0.05) from baseline to
end of intervention phase
2) Decrease in motor function (Fugl-Meyer) from end of
Sonde et al.73 3-year follow-up 28 4 years treatment to follow-up at 3 years (p < 0.05) in less severely
(Sweden) affected subgroup
Powell et al.74 Randomized 60 1 month 1) Treatment group received 3 half-hour sessions of 1) Significant increases in isometric strength of wrist
(UK) controlled parallel electrical stimulation (ES) to wrist & finger extensor extensors in treatment group compared to controls at end
group (with bring muscles daily for 8 weeks in addition to ‘standard’ in- 2) Significant improvement in grasp (p = 0.013) and grip
assessment) patient therapy (Bobath & Movement Science (p = 0.02) scores (Action Research Arm Test) at 8 weeks
approaches combined) of treatment (p = 0.004) and at 32 weeks (p = 0.014)
after ES compared to controls
Kwakkel et al.75 Single-blind 101 2 weeks 1) Control group – immobilization of affected arm and leg 1) Leg-training group had significantly higher Barthel
(Netherlands) randomized with inflatable pressure splint for 30 mins, 5 days/week Index and Functional Ambulation scores at 20 weeks
controlled trial 2) Arm training group – 30 mins, 5 days/week for 20 compared to control group (p < 0.05) and at 6 weeks
weeks compared to arm-training group (p < 0.05)
3) Leg training group – 30 mins, 5 days/week for 20 2) Leg-training group had significantly higher Action
weeks Research Arm Test (ARAT) scores from week 6
4)All groups received 15 mins daily leg rehab, 15 mins compared to controls (p < 0.01)
daily arm rehab, plus 1.5 hours/week ADL training 3) Arm-training group had significantly higher ARAT
scores from week 12 compared to controls (p < 0.01)
Van der Lee et al.76 Single blind 66 1– 20 years 1) Group 1 – forced use treatment 6 hours/day, 5 1) Significant differences in effectiveness in favour of
(Netherlands) randomized days/week for 2 weeks with ‘healthy’ arm immobilised in forced use group compared with control group for
control trial resting splint and closed sling dexterity (Action Research Arm Test) and amount of use
2) Group 2 – bimanual training based on Neuro (Motor Activity Log) 1 week after last treatment session
Developmental Treatment (NDT) for 6 hours/day, 5
days/week for 2 weeks
Table 1. Continued

Study Study type Subjects Time since Intervention Principal findings

(Country) stroke

Kunkel et al.77 Intervention study 2 3–15 years 1) Intervention involved restraint of unaffected upper limb 1) Significant improvement in use and quality of
(Germany) in resting splint and sling for 90% waking hours, for 14 movement of affected arm (p < 0.02) after training
days. Additional behavioural training (shaping) of the 2) Increase in scores of quality of movement, mean
affected upper limb for 6 hours/day on 10 weekdays over performance times and functional ability at post-test and
2 weeks. Each shaping task repeated 10 times in a block follow-up (p < 0.05)
of trials repeated throughout the day
Miltner et al.78 Replication study 15 0.5–17 years 1) Intervention involved:
(Germany) (see Taub et al. a) restriction of movement of unaffected upper limb in a 1) Significant improvement in scores on Motor Activity
1993)
splint or sling for 90% of waking hours for 12 days, and Log (indication of use of limb during activities of daily
b) training of the hemiplegic arm (shaping) for 7 living) from 1st contact to 6 month follow-up – Amount of
hours/day on 8 weekdays in 12 days use (AOU) p < 0.0001, quality of movement (QOM)
p < 0.0001
2) Significant improvements in Wolf Motor Function Test
scores from baseline to 6 months follow-up – Functional
Activity (FA) p < 0.004, QOM p < 0.0001
Cauraugh et al.79 Randomized clinical 11 >1 year 1) Experimental group (n = 7) – passive range of 1) Significant improvement in manual dexterity (Box and
(USA) study in field setting movement (PROM) of hemiplegic arm plus gentle stretch Block Test) (p < 0.05) and force generation (sustained
with modified cross- to wrist and finger flexors followed by 2 sessions of 30 contraction) (p < 0.04) for experimental group compared to
over design movement trials involving EMG-triggered electrical controls
stimulation (EMG-stim) of wrist and finger extensor
muscles 3 days/week for 2 weeks (12 sessions = 360
stim trials)
2) Control group (n = 4) – PROM and gentle stretch as
above, followed by attempted voluntary wrist extension, 2

Hand function and stroke

sessions of 30 trials, 3 days/week for 2 weeks. On
completion of 12 sessions, subjects received EMG-stim
as above

75
76 SM Hunter and P Crome
Retraining sensation
Sensory impairment following stroke generally
receives less attention by therapists than motor,
despite its well-documented adverse effect on
functional outcome. Dannenbaum and col-
leagues59,60 reported promising responses from
patients with cortical lesions to a structured pro-
gramme of sensory retraining linked with func-
tional activity. Significant improvements in
sensation and function were reported from a sin-
gle case with left parietal stroke and significant
right-sided sensory loss, 17 months poststroke,
who undertook the programme twice weekly for
13 months. However, this was only a descriptive
account and lacked experimental control.
Improvements in finger texture discrimination
and detection of joint position sense following
specific sensory retraining, based on theories of
perceptual learning, have been reported by Carey
et al.61 Although there were some variations in
sensory recovery between subjects, all subjects
reported improved functional performance, and
this study suggested that this approach to sensory
retraining had potential to be effective across a
broad range of stroke patients.
Significant improvements in sensory function
following a programme of sensory retraining
through active touch and haptic perception fol-
lowing long-term stroke (2–18 years), were
reported by Yekutiel and Guttman.13 Patients with
right brain damage showed significantly poorer
gains in haptic perception/object recognition than
those with left brain damage. Two patients spon-
taneously reported an improvement in functional
use of their hand, although functional task
retraining did not form part of the retraining pro-
gramme. This study recommended that meaning-
ful sensory retraining should commence early
after stroke to improve use of the hand, and a
more detailed and comprehensive account of the
programme of sensory retraining has since been
produced.80
Retraining of movement and functional activity
Therapists frequently apply sensory stimulation to
enhance muscle activity. Therapeutic handling and
facilitation of movement (also known as ‘guiding’)
is a commonly-used but highly skilled activity,
involving the input of specific cutaneous sensory
and proprioceptive information from therapist to
patient to achieve a motor output.81,82
Hummelsheim et al.67 reported the effects of five
different therapeutic facilitation techniques on the
responses of wrist extensor muscles using tran-
scranial magnetic stimulation (TMS) in stroke
patients. Whilst all interventions increased the
muscle response amplitude in all subjects, this was
significant (p < 0.005) following direct activation
of the target muscle. Muscle response latency was
also decreased by all interventions in all patients
with the greatest reduction occurring after direct
activation (p < 0.005). Cutaneous/proprioceptive
stimulation from the therapist showed a signifi-
cant facilitatory effect only in severely impaired
patients (p < 0.008).
Direct activation of muscles involves the corti-
comotoneuronal pathways, directly facilitating
excitation of the spinal motor neurones. In the
absence of a direct cortico-motoneuronal connec-
tion, as a result of an interruption within the sys-
tem, cutaneous stimulation has the effect of
providing an excitatory influence on the spinal
motor neurones,67 thus facilitating activity.
Proprioceptive sensation appears to be most
appropriate and effective sensory stimulus for
facilitation of muscle activity. Sensory stimulation
using transcutaneous nerve stimulation (TENS) to
increase sensory awareness of the paretic arm 6-
12 months after stroke has not been found to
improve long-term motor function or functional
activity.73 Cutaneous palmar stimulation consist-
ing of pressure and stretch has been shown to
improve voluntary finger flexion in a number of
stroke patients.83 Although no explanation was
offered for this at the time, cutaneous mechanore-
ceptors in the hand, which are stimulated by skin
deformation as a result of pressure, touch and
stretch, are now known to contribute greatly to
proprioception and kinaesthetic awareness.23,84
Additional forms of electrical stimulation have
been investigated with reports of short-term
improvements in muscle strength, grasp and grip,
and reduction of muscle contracture following
passive electrical stimulation of forearm muscles
in selected stroke patients, which were not main-
tained on cessation of the treatment.70,74 The
effects may be attributed to improvements in limb
sensation by increasing afferent input, but a direct
influence on functional ability has not been sub-
stantiated.69
A more active treatment, involving the appli-
cation of electrical stimulation triggered by

electromyography (EMG-triggered electrical stim-
ulation) to the forearm extensor muscles in
patients with chronic stroke, significantly
improved sustained muscle contraction for wrist
stabilization, with a subsequent improvement in
grasp of small objects.79 Initial small, voluntary
muscle activity, detected by EMG, triggers the
external electrical stimulation, which further stim-
ulates the muscle, increasing the contraction and
proprioceptive feedback from muscle receptors.
Motor activity is increased through the process of
functional equivalence (‘the ability of the motor
system in achieving a movement goal through
multiple routes’)79 and is a result of integration of
sensorimotor information.
Active retraining of paretic muscles involved in
hand function and the repeated practice of iso-
lated movements are effective therapeutic strate-
gies for regaining control, motor learning and skill
acquisition.68,85,86 This is particularly so where
patients are less severely affected by stroke.65,66,87
Recovery is ‘training specific’75 and therapeutic
activities need to be selected according to the aims
of treatment. Retraining only the proximal upper
limb activity and stability does not improve dis-
tal, specific, hand functions of grip or grasp.71
Sunderland et al.65 considered the effects of
content and intensity of therapy. Significant
improvements in strength, range of movement and
manual dexterity were reported following a con-
trolled trial of an enhanced therapy regime with
less severe stroke patients. However, the differ-
ences between groups were no longer significant
at one-year follow-up.66 The enhanced therapy
included more hands-on therapist contact time,
self-directed exercise programmes, aspects of con-
ventional ‘Bobath therapy’, EMG biofeedback,
computer games, and active involvement of the
patient and their family. Objective feedback on
performance and the practice of increasingly chal-
lenging tasks were specific features of the pro-
gramme suggested by the authors to have been the
most important elements for success. However,
patients with severe stroke were found to benefit
more in the long-term from ‘conventional’ ther-
apy. In all patients, the major effects occurred in
the first month of treatment, suggesting that early
intensive therapy for the arm and hand is essen-
tial to maximize long-term functional outcome.
‘Constraint-Induced (CI) therapy’ or ‘forced
use’ is a therapeutic strategy, encompassing
aspects of motor learning theory and movement
Hand function and stroke 77
science, described by Taub and colleagues.12,52 It
involves a programme of intensive training of the
affected upper limb in specific functional activity,
with the additional use of a constraint (sling or
splint), applied to the less affected limb, as a
means of providing motivation to use the hemi-
plegic arm and hand. Intensive task retraining is
generally undertaken for six hours per day over
2–3 weeks, with constraint applied to the unaf-
fected upper limb for 90% of waking hours.
Everyday tasks such as writing, playing dominoes,
using cutlery at meal times, and playing ball, are
included. The application and effects have been
widely reported including significant long-term
(more than two years) improvements in task
performance times, quality of movement, func-
tional independence and daily living activi-
ties.12,50–52,62,63,76,77 Neuroimaging and transcranial
magnetic stimulation (TMS) have provided
evidence of long-term neuroplastic changes and
cortical reorganization following an intense
period of functional retraining,88,89 suggesting that
the ‘learned non-use phenomenon’ can be
reversed.63,90
Constraint-induced therapy has been found to
be most effective for chronic stroke patients with
initial modest impairment91 and in the absence of
sensory and perceptual deficits.76 Studies have
included only patients with some degree of active
wrist extension. There is little evidence that this
approach is as effective with more severe strokes
with no initial active voluntary movement.12
Although mean improvements in quality of move-
ment or skilled movement has been shown to be
large in some patients, the movement in the
majority of patients following constraint-induced
therapy has been reported to be ‘clumsy’ (E Taub,
personal communication Oct 2001).
Conclusion
The recovery of hand function after stroke
remains problematic and unsatisfactory, with a
large proportion of patients perceiving their hemi-
plegic hand to be non-functional months, even
years, after stroke, in spite of relatively good
reduction in the initial impairment. The evidence
suggests that most patients are underachieving
and levels of recovery could be better if therapy
was more specific to individual problems in spe-
cific patients at different times during recovery.
Early intensive treatment programmes have
78 SM Hunter and P Crome
shown improved levels of recovery, with the rate
of recovery being greatest in the early period,
coinciding with the period of spontaneous recov-
ery. However, in spite of evidence that recovery
can continue beyond this point, therapy tends to
be discontinued after six months.
The importance of the hand as a driving force
for the arm, and its influence on recovery of the
whole upper limb, must not be overlooked.
Likewise, the effect of meaningful sensory stimu-
lation and sensory retraining programmes on the
potential for improving functional activity war-
rants further investigation. Intensive retraining
programmes with repeated practice of tasks have
been shown to be most appropriate for less
severely affected stroke patients, who can maxi-
mize their already recovering movement. More
severely affected stroke patients, and patients with
cognitive and perceptual deficits appear to require
a different programme of therapy with more
emphasis on sensory stimulation and its interpre-
tation.
The importance of sensory and perceptual loss
after stroke and its effect on hand function and
relearning of hand motor skills is frequently over-
looked and underestimated.80 There is evidence
that sensory impairment can be substantially
improved through retraining programmes and this
can in turn enhance the potential motor recovery.
Therapists thus need to address the problems of
sensory impairment alongside motor impairment,
with an overall resultant improvement in sensori-
motor integrative functions in the hand, and a
reduction in the levels of disability and depen-
dency in stroke patients.
Current evidence is incomplete. Further
research is essential to inform therapists about the
accurate choice of the most effective interventions
for particular patients, at the most appropriate
intensity and duration, at clearly identified stages
of recovery in order to deliver the most effective
therapy.91
Acknowledgment
The authors would like to acknowledge Research
into Ageing and the Bernard Isaacs Memorial
Trust for their support.
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