CIMT, mirror therapy, FES: what the evidence supports and what it does not

1. Case. A 52-year-old woman, 5 months post-stroke. Right UE: active wrist extension 15°, finger extension 12° at the MCPs. FMA-UE 38/66. She uses the right arm intermittently for stabilization, rarely for primary task.

2. CPG section. AHA/ASA 2016 endorses CIMT (modified or original) as Class I, Level A for selected patients with mild-to-moderate UE motor impairment and adequate wrist/finger extension. EXCITE trial (Wolf SL et al. *JAMA*. 2006;296:2095–2104; long-term Wolf SL et al. *Lancet Neurol*. 2008;7:33–40) showed sustained improvements in arm motor function for at least 1–2 years. Mirror therapy: Cochrane review (Thieme H et al. *Cochrane*. 2018;CD008449, n = 1,685; 62 studies) — low-quality evidence for motor function improvement (SMD 0.47, 95% CI 0.27–0.67), moderate-quality evidence for ADL (SMD 0.48, 95% CI 0.30–0.65; 622 participants, 19 studies), low-quality evidence for pain reduction (SMD −0.89, 95% CI −1.67 to −0.11). FES for foot drop: equivalent to AFO for walking speed in stroke (Howlett OA et al. *Arch Phys Med Rehabil*. 2015;96:934–943); when added to physiotherapy, low-quality evidence for gait-speed gains (da Cunha MJ et al. *Ann Phys Rehabil Med*. 2020).

3. Reasoning walkthrough. She meets EXCITE inclusion (≥10° wrist and ≥10° finger extension; minimal balance/cognitive limitation). Discuss CIMT versus modified CIMT — daily-life impact of mitt wear matters. Mirror therapy is a reasonable adjunct, especially when active movement is limited; the evidence supports motor function and ADL gains. FES is most defensible for foot drop in walking patients who do not tolerate or prefer an AFO; do not present it as superior to AFO for walking speed.

4. Outcome measure. FMA-UE, Wolf Motor Function Test (WMFT), Motor Activity Log (MAL). MAL MCID ≈ 0.5 on the 6-point scale; WMFT MDC stroke ≈ 1.5–2 s per item (Lin KC et al. *Neurorehabil Neural Repair*. 2009;23:429–434).