Stroke is one of the leading causes of acquired disability in adults worldwide. According to consistent epidemiological data, up to 80% of people who suffer a stroke present some degree of motor deficit in the upper limb during the acute phase (Langhorne et al., 2011). This figure, although reduced over time and with rehabilitation, remains considerable in the chronic phase: between 40% and 50% of survivors maintain significant functional limitations in the affected arm and hand at six months after the event (Kwakkel et al., 2003).
The functional impact of this deficit is profound. The hand and arm are involved in virtually all activities of daily living (ADLs): feeding, personal hygiene, dressing, writing, use of electronic devices and, in general, any task requiring grip, reach or object manipulation. Loss of upper limb function is directly associated with reduced independence, lower social participation and a negative impact on the quality of life of the patient and their family environment.
Therefore, functional recovery of the arm and hand represents one of the priority objectives in any post-stroke neurorehabilitation programme. In recent years, international clinical guidelines and scientific evidence have consolidated a set of interventions that, combined in an individualised manner, can contribute to optimising functional outcomes. These include robot-assisted rehabilitation, functional electrical stimulation (FES), mirror therapy and constraint-induced movement therapy (CIMT).
The European Stroke Organisation (ESO) updated its clinical practice guidelines for post-stroke rehabilitation in 2025, including specific recommendations on upper limb recovery. These guidelines are based on systematic literature reviews and the consensus of European neurology and rehabilitation experts.
Key points of the ESO 2025 recommendations for the upper limb include:
«Post-stroke upper limb rehabilitation should be early, intensive, repetitive and task-oriented, adapting interventions to the individual needs of the patient.» — Key principles of the ESO 2025 guidelines.
Robot-assisted rehabilitation for the upper limb has been the subject of extensive research over the past two decades. Robotic devices, such as the upper limb rehabilitation robot, allow patients to perform guided or assisted movements repetitively, with precise dosing and objective real-time feedback.
The Cochrane systematic review by Mehrholz et al. (2020), which included 45 randomised clinical trials with more than 1,600 participants, concluded that robot-assisted therapy for the upper limb, as a complement to conventional rehabilitation, may contribute to improving arm motor function and activities of daily living in people who have had a stroke. Results showed statistically significant, although clinically modest, effects on motor function scales (such as the Fugl-Meyer scale for the upper limb) and on arm muscle strength.
More recent reviews have expanded this evidence base. A meta-analysis by Veerbeek et al. (2017), published in Stroke, confirmed that robotic therapy offers added benefit over conventional therapy alone, particularly in patients with moderate to severe deficit. Data also suggest that the combination of robotics with other therapeutic modalities (such as FES or task-oriented therapy) may potentiate outcomes.
Functional electrical stimulation (FES) is a technique that uses low-intensity electrical impulses to produce muscle contractions in weakened or paretic muscles. In the context of post-stroke upper limb rehabilitation, FES is typically applied to the wrist and finger extensor muscles, facilitating hand opening and wrist extension during functional task execution.
Scientific evidence supports the use of FES as a complement to conventional rehabilitation. The Cochrane review by Nascimento et al. (2014) and subsequent updates have shown that FES may contribute to improving upper limb motor function, especially when combined with functional task practice. Effects appear to be more consistent in patients in the subacute phase with moderate deficit.
The combination of FES with robotic therapy constitutes a particularly interesting integrated approach. While the upper limb rehabilitation robot facilitates and guides movement of the shoulder, elbow and wrist, FES can act on the intrinsic muscles of the hand, addressing both proximal mobility and distal dexterity in a complementary way. Some preliminary studies suggest this combination may offer superior results to either technique applied in isolation (Hayward et al., 2010).
Mirror therapy is a neurorehabilitation intervention based on visual feedback. The patient places the affected upper limb behind a mirror and observes the reflection of the healthy limb while performing movements, creating a visual illusion of normal bilateral movement. This visual stimulus can activate motor neural networks in the injured hemisphere through the mirror neuron system and neuroplasticity mechanisms.
The Cochrane systematic review by Thieme et al. (2018), which included 62 clinical trials with more than 1,900 participants, concluded that mirror therapy, used as a complement to conventional rehabilitation, may contribute to improving upper limb motor function and reducing pain in people after a stroke. The quality of evidence was considered moderate to low, but results were consistent in the direction of effect.
Advantages of mirror therapy include its low cost, ease of application (it can also be performed as part of a supervised home programme) and safety. It can be applied in patients with severe deficit who cannot perform active movements with the affected limb, and is useful as a complementary tool within a multimodal rehabilitation programme.
In the context of a robotic neurorehabilitation centre, mirror therapy can be integrated as part of treatment sessions, alternating or combining it with work on the upper limb rehabilitation robot to address different aspects of motor recovery.
Constraint-Induced Movement Therapy (CIMT) is one of the interventions with the greatest scientific support in post-stroke upper limb rehabilitation. It is based on two fundamental principles: restriction of the healthy limb's use (usually with a glove or splint) and intensive, repetitive practice of functional tasks with the affected limb.
The EXCITE clinical trial (Wolf et al., 2006), a multicentre randomised study with 222 patients, demonstrated that CIMT produces significant improvements in upper limb motor function and movement quality, measured with the Motor Activity Log and the Wolf Motor Function Test. These benefits were maintained at 12-month follow-up.
However, CIMT in its original protocol is very demanding: it requires restriction of the healthy limb for 90% of waking hours and 6-hour daily treatment sessions for 2 weeks. Modified versions (mCIMT) with less intensive protocols have therefore been developed, maintaining part of the efficacy with better patient acceptance.
It is important to note that CIMT is indicated primarily for patients who retain a minimum of active extension in the wrist and fingers (generally at least 20° of wrist extension and 10° of finger extension), which limits its application to a specific subgroup of patients. For those with more severe deficit, other interventions such as robotics or FES may be more appropriate as a starting point.
At GNeuro, a robotic neurorehabilitation centre located in Ourense, an integrated approach is applied that combines the mentioned therapies according to each patient's clinical profile. The upper limb rehabilitation robot is a central tool of the upper limb rehabilitation programme, allowing intensive, repetitive and quantifiable training that is adjusted in real time to the patient's capabilities.
The upper limb rehabilitation process at GNeuro follows a structured protocol:
This multimodal approach aligns with the recommendations of the ESO 2025 guidelines, which emphasise the importance of combining different evidence-based interventions to optimise upper limb recovery. The availability of advanced robotic technology in a centre in Ourense means that patients from the province and health area can access these therapies without needing to travel to large cities.
Neuroplasticity —the brain's capacity to reorganise its neural connections in response to experience and learning— is the biological basis of recovery after stroke. Neuroscience research has shown that this reorganisation capacity is especially active during the first months after the injury (Murphy and Corbett, 2009), which justifies the recommendation to start rehabilitation early.
However, neuroplasticity is not limited to the acute and subacute phase. Functional neuroimaging studies have shown that cortical reorganisation can continue for years after stroke, provided there is an adequate therapeutic stimulus. This has important clinical implications: evidence suggests that patients in the chronic phase can also benefit from intensive rehabilitation programmes, especially when technologies allowing repetitive and intense stimulation such as robotics are used (Kwakkel et al., 2015).
The ESO 2025 guidelines acknowledge this reality and, while emphasising the importance of early intervention, do not establish a rigid time limit for rehabilitation. The decision to initiate or continue a treatment programme should be based on an individualised clinical assessment considering each patient's potential for improvement.
Is robotics useful for recovering arm mobility after a stroke?
Scientific evidence, including Cochrane reviews with more than 2,000 patients, suggests that robot-assisted rehabilitation may help improve motor function of the arm and muscle strength when used as a complement to conventional therapy. Results vary according to the severity of the deficit, the time of onset and the intensity of training. At GNeuro, the upper limb rehabilitation robot is integrated within a multimodal programme adapted to each patient.
When should upper limb rehabilitation begin after a stroke?
Clinical guidelines recommend starting rehabilitation early, ideally within the first weeks after the stroke, provided the patient's clinical situation allows it. The subacute phase (first 3–6 months) is considered a period of greater neuroplasticity, although functional improvement may continue beyond this period with appropriate treatment. Even patients in the chronic phase may experience improvements with intensive programmes.
What is the difference between robotic therapy and conventional physiotherapy for the arm?
Robotic therapy does not replace conventional physiotherapy, but complements it. The upper limb rehabilitation robot allows a high number of repetitions with assistance adapted to the patient's level, provides real-time feedback and enables objective quantification of progress. The combination of both approaches, according to available evidence, may offer better results than either of them alone.
Is it possible to improve arm function months or years after the stroke?
Scientific evidence suggests that brain neuroplasticity remains active beyond the first months after stroke. Although the window of greatest spontaneous recovery is in the first 3–6 months, studies with intensive rehabilitation programmes, including robotics, have shown functional improvements in patients in the chronic phase. An individualised clinical assessment can determine the potential for improvement in each case.
At GNeuro, a robotic neurorehabilitation centre in Ourense, we carry out a comprehensive clinical assessment to design a programme tailored to each patient's needs.
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