Use of the non-paretic arm reflects a habitual behaviour in chronic stroke

A proportion of stroke survivors use their paretic arm less than might be expected based on their level of impairment. The resulting underuse of the paretic arm has a negative impact on participation in neurorehabilitation and functional independence. However, non-use remains poorly understood. One possibility is that prioritising the non-paretic arm reflects a habit, despite residual functional capacity in the paretic arm.

30 chronic stroke survivors (Mean Fugl Meyer Upper Limb Score: 28.9 ± 11.3) participated in a simplified version of the forced response paradigm, which reliably identifies the presence of a habit. Participants were asked to choose which arm to use to maximise points scored during a reaching task. During half of the trials, the presumed habit of using the non-paretic arm yielded more points, whereas in the other half using the non-paretic arm incurred a loss of points. Participants completed two versions of this task, once with unlimited response time available and once without.

Participants scored fewer points in the limited response condition compared to the unlimited response conditions. This difference was driven by a selective increase in the use of the non-paretic arm in trials where the paretic arm yielded more points. The results were not mediated by former hand dominance.

Our results demonstrate that not using the non-paretic arm may reflect a habit response that is more readily triggered in demanding (e.g. time-limited) situations. This may explain why successful neurorehabilitation does not always result in a more functionally useful arm. Our results pave the way for targeted interventions such as habit breaking techniques to be included in clinical practise.