Stroke flexor synergy of the hand: physiotherapy protocol

1. Assessment at baseline and every 2-4 weeks

• Active movement: shoulder flexion, elbow extension, forearm supination, wrist extension, finger and thumb extension.
• Passive range: especially elbow extension, forearm supination, wrist/finger extension. Note whether restriction changes with slow positioning, which helps distinguish spasticity from contracture.
• Tone: Modified Ashworth Scale or Modified Tardieu Scale, ideally recording the joint angle of catch.
• Function: Action Research Arm Test, Fugl-Meyer upper-extremity score, Box and Block Test, or a simple goal-based measure.
• Hand use: ability to reach, open the hand, grasp, release, stabilize an object, dress, wash, eat, or use a phone.
• Pain, edema, shoulder subluxation, skin integrity, sensory neglect, apraxia, and triggers that worsen tone such as pain, infection, constipation, poor positioning, or anxiety.

2. Treatment session template

A. Preparation and positioning

1. Optimize proximal alignment
   • Sitting with feet supported, pelvis neutral, scapula supported but free to move.
   • Arm supported on table, lap tray, or mobile arm support as needed.
   • Aim for shoulder in comfortable flexion or slight abduction, elbow gradually toward extension, forearm neutral to supination, and wrist near neutral to slight extension.
2. Slow sustained movement
   • Slow active-assisted elbow extension, forearm supination, wrist extension, finger and thumb opening.
   • Use prolonged comfortable positioning, not aggressive stretching.
   • Integrate scapular upward rotation and trunk extension during reach.
3. Avoid reinforcing the synergy
   • Do not repeatedly ask for maximal effort if it causes shoulder elevation, elbow flexion, and a clenched fist.
   • Reduce task difficulty, speed, resistance, or range until selective movement returns.

B. Train movement out of the synergy

• Table slides forward with the forearm supported, emphasizing elbow extension.
• Reaching to targets at shoulder height or below, then returning with relaxed hand.
• Forearm supination practice with elbow supported at 90 degrees, progressing to reach-and-turn tasks.
• Wrist extension with the forearm supported on a table.
• “Open hand before reach” and “open hand before release” cueing.
• Weight-bearing through an open palm only if the wrist and fingers can be placed comfortably and there is no shoulder pain.
• Bilateral tasks: holding a towel, rolling a ball, carrying a light tray, folding cloth, opening containers with the affected hand as stabilizer.

• Use external goals: “touch the cone,” “push the cup,” “release the block,” rather than “extend your wrist.”
• Start with enough assistance to achieve a near-normal movement.
• Reduce assistance gradually.
• Give feedback on one error at a time, for example elbow position or wrist extension.
• Progress from large objects and supported reach to smaller objects, varied locations, and real-life tasks.

C. Functional hand training

1. Reach with controlled shoulder and elbow movement.
2. Open the hand before contact.
3. Shape hand around the object.
4. Grasp with the minimum force necessary.
5. Transport while keeping wrist as close to neutral/extension as possible.
6. Release deliberately, with visual attention to finger opening.

• Slide cup or cloth on table.
• Stabilize a container with affected hand.
• Pick up and release foam blocks.
• Move coins, pegs, or large buttons.
• Reach for a bottle, open hand, grasp, place it down, and release.
• Grooming, dressing, food preparation, phone use, and household tasks.

3. Electrical stimulation

• Target: commonly extensor carpi radialis with finger extensors, individualized after examination.
• Pair each stimulation-assisted opening with reach, grasp preparation, or release.
• Begin in a supported position to limit compensatory shoulder and elbow flexion.
• Progress to functional reach-and-release activities.

4. Splinting and orthoses

• Maintaining a comfortable wrist and finger position.
• Protecting skin or preventing worsening shortening where active opening is absent.
• Supporting hygiene, nail care, or pain management.
• A short-duration positioning program after focal spasticity treatment.

• Fit and monitor by trained staff.
• Check skin, pain, edema, numbness, and increased tone.
• Continue active hand practice. A splint does not replace training.
• Avoid prolonged use if it worsens pain, pressure injury, or flexor activity.

5. Constraint-induced movement therapy

6. When tone is a barrier: coordinate with the spasticity team

Example home program: 20-30 minutes daily

• 5 minutes: supported arm position, slow elbow extension, supination, wrist/finger opening.
• 10 minutes: 30-50 supported reach-and-open-hand repetitions.
• 10 minutes: grasp-release practice with 1-3 objects, emphasizing opening before grasp and full release.
• 5 minutes: affected hand as stabilizer during a real daily task.

Avoid

• Forceful stretching of a painful or stiff hand.
• Repeated squeezing devices or high-resistance gripping early, as this may reinforce flexor dominance.
• Passive modalities without subsequent active, functional practice.
• Treating the hand in isolation when poor scapular control, trunk asymmetry, sensory loss, or neglect is the main limiter.
• Using a resting splint as the sole intervention.

Recent-evidence note