The Effects of Bilateral Arm Training on Motor Control and Functional Performance in Chronic Stroke: A Randomized Controlled Study

Abstract

Background. Most studies of bilateral arm training (BAT) did not employ a randomized controlled trial design and involved very limited functional training tasks. Objective . Compare the effects of BAT with control intervention (CI) on motor control and motor performance of the upper extremity and also functional gains in patients with chronic stroke. Methods. This 2-group randomized controlled trial with pretreatment and posttreatment measures enrolled 33 stroke patients (mean age = 53.85 years) 6 to 67 months after onset of a first stroke. They received either a BAT program concentrating on both upper extremities moving simultaneously in functional tasks by symmetric patterns or CI (control treatment) for 2 hours on weekdays for 3 weeks. Outcome measures included kinematic analyses assessing motor control strategies for unilateral and bimanual reaching and clinical measures involving the Fugl-Meyer Assessment (FMA) of motor-impairment severity and the Functional Independence Measure (FIM) and the Motor Activity Log (MAL) evaluating functional ability. Results. After treatment, the BAT group showed better temporal and spatial efficiency during unilateral and bilateral tasks and less online error correction only during the bilateral task than the control group. The BAT group showed a significantly greater improvement in the FMA than the control group but not in the FIM and MAL. Conclusions. Relative to CI, BAT improved the spatiotemporal control of the affected arm in both bilateral and unilateral tasks, decreased online corrections to perform bilateral tasks, and reduced motor impairment. These findings support the use of BAT to improve motor control and motor function of the affected upper limb in stroke patients.

Keywords

cerebrovascular accident motor activity kinematics rehabilitation randomized controlled trial upper extremity

References

Schaechter JD Motor rehabilitation and brain plasticity after hemiparetic stroke. Prog Neurobiol. 2004;73:61-72.

Pomeroy V. , Tallis R. Neurological rehabilitation: a science struggling to come of age. Physiother Res Int. 2002;7:76-89.

Mudie MH , Matyas TA Responses of the densely hemiplegic upper extremity to bilateral training . Neurorehabil Neural Repair. 2001;15:129-140.

Platz T. , Winter T. , Muller N. , Pinkowski C. , Eickhof C. , Maurita KH Arm ability training for stroke and traumatic brain injury patients with mild arm paresis: a single-blind, randomized, controlled trial. Arch Phys Med Rehabil. 2001;82:961-968.

Luft A. , McCombe Waller S. , et al. Repetitive bilateral arm training and motor cortex activation in chronic stroke. A randomized controlled trial. JAMA. 2004;292:1853-1861.

Hesse S. , Werner C. , Pohl M. , Rueckriem S. , Mehrholz J. , Lingnau ML Computerized arm training improves the motor control of the severely affected arm after stroke. A single-blinded randomized trial in two centers . Stroke. 2005;36:1960-1966.

Summers JJ , Kagerer FA , Garry MI , Hiraga CY , Loftus A. , Cauraugh JH Bilateral and unilateral movement training on upper limb function in chronic stroke patients: a TMS study. J Neurol Sci. 2007;252:76-82.

Morris JH , van Wijck F. , Joice S. , Ogston SA , Cole I. , MacWalter RS A comparison of bilateral and unilateral upper-limb task training in early poststroke rehabilitation: a randomized controlled trial. Arch Phys Med Rehabil. 2008;89:1237-1245.

Mudie MH , Matyas TA Upper extremity retraining following stroke: effects of bilateral practice . J Neurol Rehabil. 1996;10:167-184.

10.

Mudie MH , Matyas TA Can simultaneous bilateral movement involve the undamaged hemisphere in reconstruction of neural networks damaged by stroke? Disabil Rehabil. 2000;22:23-37.

11.

Lewis GN , Byblow WD Neurophysiological and behavioral adaptations to a bilateral training intervention in individuals following stroke. Clin Rehabil . 2004;18:48-59.

12.

Whitall J. , McCombe Waller S. , Silver KHC , Macko RF Repetitive bilateral arm training with rhythmic auditory cueing improves motor function in chronic hemiparetic stroke. Stroke. 2000;31:2390-2395.

13.

Richards LG , Senesac CR , Davis SB , Woodbury ML , Nadeau SE Bilateral arm training with rhythmic auditory cueing in chronic stroke: not always efficacious . Neurorehabil Neural Repair. 2008;22:180-184.

14.

McCombe Waller S. , Liu W. , Whitall J. Temporal and spatial control following bilateral versus unilateral training. Hum Mov Sci. 2008 ;27:749-758.

15.

Stinear JW , Byblow WD Rhythmic bilateral movement training modulates corticomotor excitability and enhances upper limb motricity poststroke: a pilot study. J Clin Neurophysiol. 2004;21:124-131.

16.

Lum PS , Burgar CG , van der Loos M. , Shor PC , Majmundar M. , Yap R. MIME robotic device for upper-limb neurorehabilitation in subacute stroke subjects: a follow-up study. J Rehabil Res Dev. 2006;43:631-642.

17.

Chang JJ , Tung WL , Wu WL , Huang MH , Su FC Effects of robot-aided bilateral force-induced isokinematic arm training combined with conventional rehabilitation on arm motor function in patients with chronic stroke. Arch Phys Med Rehabil. 2007;88:1332-1338.

18.

McCombe Waller S. , Whitall J.

Bilateral arm training: why and who benefits?

NeuroRehabilitation. 2008;23:29-41.

19.

Platz T. , Bock S. , Prass K. Reduced skillfulness of arm motor behaviour among motor stroke patients with good clinical recovery: does it indicate reduced automaticity? Can it be improved by unilateral or bilateral training? A kinematic motion analysis study. Neuropsychologia. 2001;39:687-698.

20.

Carr JH , Shepherd RB Reaching and manipulation. In: Carr JH , Shepherd RB , eds. Stroke Rehabilitation: Guidelines for Exercise and Training to Optimize Motor Skill. Edinburgh, UK: Butterworth Heinemann; 2003:159-191.

21.

Brunnstrom S. Movement Therapy in Hemiplegia. New York, NY: Harper & Row; 1970.

22.

Bohannon RW , Smith MB Interrater reliability of a Modified Ashworth Scale of muscle spasticity. Phys Ther. 1987 ;67: 206-207.

23.

Rosenthal R. , Rosnow RL Essentials of Behavioral Research: Methods and Data Analysis. 2nd ed. New York, NY: McGraw-Hill; 1991.

24.

Portney LG , Watkins MP Foundations of Clinical Research: Application to Practice. 3rd ed. Upper Saddle River, NJ: Prentice Hall Health; 2009.

25.

Wu CY , Chen CL , Tang SF , Lin KC , Huang YY Kinematic and clinical analyses of upper-extremity movements after constraint-induced movement therapy in patients with stroke: a randomized controlled trial. Arch Phys Med Rehabil. 2007;88:964-670.

26.

Michaelsen SM , Levin MF Short-term effects of practice with trunk restraint on reaching movements in patients with chronic stroke . Stroke. 2004;35:1914-1919.

27.

Michaelsen SM , Dannenbaum R. , Levin MF Task-specific training with trunk restraint on arm recovery in stroke: randomized control trial. Stroke . 2006;37:186-192.

28.

Tunik E. , Poizner H. , Levin MF , et al. Arm-trunk coordination in the absence of proprioception. Exp Brain Res. 2003;153: 343-355.

29.

Fugl-Meyer AR , Jaasko L. , Leyman I. , Olsson S. , Steglind S. The post-strike hemiplegia patient. I. A method for evaluation of physical performance. Scand J Rehabil Med. 1975;7:13-31.

30.

Duncan PW , Propst M. , Nelson SG Reliability of the Fugl-Meyer assessment of sensorimotor recovery following cerebrovascular accident. Phys Ther. 1983;63:1601-1610.

31.

DiFabio RP , Badke RB Relationship of sensory organization to balance function in patients with hemiplegia. Phys Ther. 1990;70:542-548.

32.

Hamilton BB , Granger CV , Sherwin FS , Zielezny M. , Tashman JS A uniform national data system for medical rehabilitation. In: Fuhrer MJ , ed. Rehabilitation Outcomes: Analysis and Measurements. Baltimore, MD: Brookes; 1987:137-147.

33.

Chau N. , Daler S. , Andre JM , Patris A. Inter-rater agreement of two functional independence scales: the Functional Independence Measure (FIM) and a subjective uniform continuous scale. Disabil Rehabil. 1994;16:63-71.

34.

Hamilton BB , Laughlin JA , Fiedler RC , Granger CV Interrater reliability of the 7-level Functional Independence Measure (FIM). Scand J Rehabil Med. 1994;26:115-119.

35.

Gosman-Hedstrom G. , Svensson E. Parallel reliability of the Functional Independence Measure and the Barthel ADL index. Disabil Rehabil . 2000;22:702-715.

36.

Sterr A. , Elbert T. , Berthold I. , Kolbel S. , Rockstroh B. , Taub E. Longer versus shorter daily constraint-induced movement therapy of chronic hemiparesis: an exploratory study. Arch Phys Med Rehabil . 2002;83:1374-1377.

37.

Uswatte G. , Taub E. , Morris D. , Light K. , Thompson PA The Motor Activity Log-28: assessing daily use of the hemiparetic arm after stroke. Neurology. 2006;67:1189-1194.

38.

van der Lee JH , Beckerman H. , Knol DL , de Vet HCW , Bouter LM Clinimetric properties of the Motor Activity Log for the assessment of arm use in hemiparetic patients . Stroke. 2004;35:1410-1414.

39.

Lin KC , Wu CY , Wei TH , Lee CY , Liu JS Effects of modified constraint-induced movement therapy on reach-to-grasp movements and functional performance after chronic stroke: a randomized controlled study. Clin Rehabil. 2007;21:1075-1086.

40.

Wu CY , Lin KC , Chen HC , Chen IH , Hong WH Effects of modified constraint-induced movement therapy on movement kinematics and daily function in patients with stroke: a kinematic study of motor control mechanisms. Neurorehabil Neural Repair. 2007 ;21:460-466.

41.

Georgopoulos AP On reaching. Annu Rev Neurosci . 1986;9: 147-170.

42.

Kamper DG , McKenna AN , Kahn LE , Reinkensmeyer DJ Alterations in reaching after stroke and their relationship to movement direction and impairment severity. Arch Phys Med Rehabil. 2002;83:702-707.

43.

Haaland KY , Prestopnik J. , Lee RR , Adair J. Hemispheric asymmetries for kinematic and positional aspects of reaching . Brain. 2004;127:1145-1158.

44.

Elliott D. , Helsen, WF , Chua R. A century later: Woodworth’s (1899) two-component model of goal-directed aiming. Psychol Bull. 2001;127:342-357.

45.

Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Erlbaum; 1988.

46.

Cauraugh JH , Summers JJ Neural plasticity and bilateral movements: a rehabilitation approach for chronic stroke. Prog Neurobiol . 2005;75:309-320.

47.

Stewart KC , Cauraugh JH , Summers JJ Bilateral movement training and stroke rehabilitation: a systematic review and meta-analysis. J Neurol Sci. 2006 ;244:89-95.

48.

Adam JJ The effects of objectives and constraints on motor control strategy in reciprocal aiming movements. J Mot Behav. 1992;24:173-185.

49.

Smith RO , Morrow ME , Heitman JK , Rardin WJ , Powelson JL , Von T. The effects of introducing the Klein-Bell ADL Scale in a rehabilitation service . Am J Occup Ther. 1986;40: 420-424.

50.

McDowd JM , Filion DL , Pohl PS , Richards LG , Stiers W. Attentional abilities and functional outcomes following stroke. J Gerontol B Psychol Sci Soc Sci. 2003;58:P45-P53.

51.

Uswatte G. , Giuliani G. , Winstein C. , Zeringue A. , Hobbs L. , Wolf SL Validity of accelerometry for monitoring real-world arm activity in patients with subacute stroke: evidence from the extremity constraint-induced therapy evaluation trial. Arch Phys Med Rehabil. 2006 ;87:1340-1345.

52.

Choquette S. , Hamel M. , Boissy P. Accelerometer-based wireless body area network to estimate intensity of therapy in post-acute rehabilitation. J Neuroeng Rehabil. 2008 ;5:20.

53.

Mehrholz J. , Wagner K. , Rutte K. , Meissner D. , Pohl M. Predictive validity and responsiveness of the functional ambulation category in hemiparetic patients after stroke. Arch Phys Med Rehabil. 2007 ;88:1314-1319.