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Year : 2018  |  Volume : 7  |  Issue : 4  |  Page : 217-221

Stroke upper extremity rehabilitation: Effect of bilateral arm training

1 Department of Occupational Therapy, National Institute for Locomotor Disabilities, Kolkata, West Bengal, India
2 Department of Psychiatry, IMS and SUM Hospital, Siksha O Anusandhan University, Bhubaneswar, Odisha, India

Date of Web Publication15-Oct-2018

Correspondence Address:
Ms. Damayanti Sethy
Department of Occupational Therapy, National Institute for Locomotor Disabilities, BT Road, Bonhoogly, Kolkata - 700 090, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijhas.IJHAS_125_17

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OBJECTIVES: The main objective of this study is to investigate the effect of bilateral arm training on upper extremity motor and functional recovery in stroke hemiparesis.
METHODOLOGY: Twenty-eight patients with chronic stroke, attending the Department of Occupational Therapy, National Institute for the locomotor disabilities, Kolkata, West Bengal, India, participated in a single-blinded randomized pretest and posttest control group experimental study. Patients were randomized over two intervention groups; experimental group received bilateral arm training (n = 14) and the control group received an equally intensive conventional treatment program (n = 14). Each group received intensive training for 1 h/day, 5 days/week, and for 6 weeks. Pretreatment and posttreatment measurements were taken for upper extremity motor ability, functional ability, and functional use of the upper extremity using Fugl-Meyer Assessment of Physical performance (FMA-upper extremity section), Action Research Arm Test, and Motor Activity Log, respectively.
RESULTS: Bilateral arm training (P = 0.01) group showed statistically significant improvement in upper extremity functioning on Action Research Arm Test score in comparison to the conventional therapy group (P = 0.33). The bilateral arm training group also had greater improvements in FMA and Motor Activity Log score compared to conventional therapy group.
CONCLUSION: Bilateral arm training can be used as a better treatment choice for improving upper extremity function in comparison to conventional therapy.

Keywords: Bilateral arm training, conventional therapy, rehabilitation, stroke, upper extremity

How to cite this article:
Sethy D, Sahoo S, Kujur ES, Bajpai P. Stroke upper extremity rehabilitation: Effect of bilateral arm training. Int J Health Allied Sci 2018;7:217-21

How to cite this URL:
Sethy D, Sahoo S, Kujur ES, Bajpai P. Stroke upper extremity rehabilitation: Effect of bilateral arm training. Int J Health Allied Sci [serial online] 2018 [cited 2023 Oct 4];7:217-21. Available from: https://www.ijhas.in/text.asp?2018/7/4/217/243261

  Introduction Top

Stroke is the third leading cause of death and the leading cause of adult disability.[1] Upper limb hemiparesis is a common impairment underlying disability after cerebrovascular accident. Dysfunction from upper extremity hemiparesis impairs performance of many daily activities such as dressing, bathing, self-care, and writing, thus reducing functional independence. In fact, only 5% of adults regain full arm function after stroke and 20% regain no functional use.[2] Restoration of full function to the stroke-affected upper extremity is a major problem in rehabilitation. Hence, alternative strategies are needed to reduce the long-term disabilities and functional impairment resulting from upper extremity hemiparesis.[1]

Various conventional treatment techniques are used for upper extremity management in patients with stroke using the principles of Bobath neurodevelopmental Therapy, Brunnstrom movement therapy, Rood's techniques, and Proprioceptive Neuromuscular Facilitation developed by Knott and Voss.[3] The efficacy of these approaches with regard to transfer of treatment effect in life situation is questionable.[4] Only one-third of all stroke patients regain some dexterity within 6 months using conventional treatment programs.[5]

In light of the above fact, some recent studies based on the principle of neuroplasticity have produced promising results in improving upper extremity functioning in patients with chronic stroke. Bilateral arm training has been shown to have beneficial effects on upper extremity function in patients with chronic stroke.[1] In bilateral arm training, the principle of forced use and task specificity was retained, without constraining the nonparetic arm and both the arms are trained. Although neural mechanisms remain unclear, it has been speculated that bilateral practice may facilitate coactivation and interhemispheric activation and thus a possible change in the contralesional cortical network.[6]

The above facts suggest that training may also induce beneficial changes in the contralesional brain area, rather than only in the ipsilesional brain area.[6] This raises a question whether bilateral training is better for improving upper extremity function in patients with chronic stroke in comparison to conventional treatment program.

In this study, an attempt has been made to investigate the effectiveness of bilateral arm training on motor and functional recovery in patients with chronic stroke and to compare it with conventional therapy that is based on Bobath's techniques.

  Methodology Top


This study was a single-blind, pre test and post test control group design. Twenty-eight patients consisting of 19 men and 9 women with chronic hemiparesis due to middle cerebral artery stroke were recruited from outpatient Occupational Therapy Department and Indoor Rehabilitation Ward of National Institute for the Locomotor Disabilities, Kolkata. Informed consent was obtained from all the patients before inclusion in the study. Inclusion to the study were confirmed if the participants fulfilled the following study criteria of at least 6 months since a unilateral stroke, ability to follow simple instructions and two-step commands (Mini-mental state score >22), ability to actively extend at least 10* at metacarpophalangeal joint and interphalangeal joints and 20* at the wrist joint, and aged between 18 and 75 years. Exclusion criteria were uncontrolled hypertension (190/110 mmHg), significant orthopedic and pain conditions, and excessive spasticity, defined as a score of 3 or more on Modified Ashworth Scale (MAS). The patients were randomly allocated to BAT group and conventional therapy group by writing the group names with a number on paper slips. All the patients were asked to draw one paper slip and according to the numbers assigned to each group, patients were allocated to the respective groups.

Outcome measures

  • Fugl-Meyer measurement of physical performance-Upper Extremity Section (FMA): FMA is a 66-point, upper extremity section of FMA, which assesses several impairment dimensions using a 3-point ordinal scale (0, cannot perform; 1, can perform partially; 2, can perform fully). The FMA has impressive test–retest reliability (total range: 0.98–0.99; subtests range: 0.87–1.), interrater reliability, and construct validity[7]
  • Action Research Arm test (ARAT): ARAT is an observational scale used to measure upper extremity function. The ARA test is a 19 item test divided into 4 categories (grasp, grip, pinch, and gross movement), with each item graded on a 4-point ordinal scale (0, can perform no part of the test; 1, perform test partially; 2, completes test but takes abnormally long time or has great difficulty; and 3, performs test normally) for a total possible score of 57. The test is hierarchical in that, if the patient can perform each category, he or she will be able to perform the other items within the category and thus, they need not be tested. The ARA has high interrater reliability (r = 0.99) and test–retest reliability (r = 0.98), and it has high validity[8]
  • Motor Activity Log (MAL): The MAL is a semi-structured interview, where the patient and their caregivers independently rate how much and how well the patient has used the affected arm for 30 activities of daily living in the past week. Patients and caregivers use a 6-point amount of use (AOU) scale to rate how much they are using their affected arm and 6-point scale to rate quality of use to rate how well the arm is being used. A higher score indicates better performance. The MAL has established good test–retest reliability, internal consistency, stability and responsiveness, and convergent validity.[9]


The stroke patients who fit the inclusion criteria were allotted to BAT and conventional therapy groups after getting the informed consent. The study was approved by the local Ethics committee of the Institute. A general history including score on Mini-Mental State Examination (MMSE), MAS was taken from the patient, after which FMA and ARA, and MAL were administered by an occupational therapist independent of the group assignment. MMSE was used only for the screening purpose. Patients in both the groups received therapy for 1 h/day, 5 days/week for 6 weeks.

Bilateral arm training

Patients were seated comfortably in a chair in front of a table. Bilateral arm trainer was fixated on a table and was designed using wooden material. The trainer has got an overhead rack for placement of blocks and pegs. The rack was fitted to two parallel wooden bar. Both the bars were fixed to both sides of the table and the rack was fitted horizontally over the parallel bars. Velcro hooks were attached to both the upper and under surface of the overhead rack where the patient can place the blocks and pegs. The height of the overhead rack was adjustable. Nuts and screws were fitted in the side parallel bar in order to change the height of the rack. Blocks and pegs were also attached with Velcro loops.

Each session involves repetitive practice of bilateral tasks for 1 h. The tasks are-

  • Block placement-10 min – The patient has to pick up one block from the container and transport it to the overhead rack and place it above it. The same will be done bilaterally for 15 repetitions
  • Peg targeting-10 min – The patient has to grasp the pegs using both the hands and transport it to the targets on the rack where Velcro is attached
  • Peg inversion-10 min – two pegs have to be picked up using both the hands, rotated using supination and then placed over the under surface of the rack
  • Transferring object from one container to another-10 min.

Rest periods of 5 min each at four intervals between the tasks were given to each patient to reduce the effect of conditioning. Same tasks were maintained for each patient over the duration of the study. Practice was done using bilateral upper extremity simultaneously. The common movements in the bilateral task training are shoulder flexion/protraction and elbow extension and shoulder extension/retraction and elbow flexion. This action mimics the behavior of reaching for an object and bringing it to oneself.

Conventional occupational therapy

Conventional occupational therapy included techniques based on Bobath approach. Weight bearing for upper limb, reflex inhibiting patterns, trunk rotation, and scapular protraction were used to reduce spasticity. All the participants were then engaged in performing functional activities.

Intervention in both the groups, post treatment evaluation was done by using all the outcome measures.

Statistical analysis

SPSS version 17.0 (SPSS Inc., Chicago, IL)was used for all the statistical analysis. One-way ANOVA was used to compare the pretest and posttest measures on the dependent variables.

  Results Top

Homogeneity of the subsets was tested for all the outcome measures used in the study. The characteristics of the patients are presented in [Table 1]. Baseline patient characteristics were comparable across the groups (P = 0.988).
Table 1: Characteristics of the patient population

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The ARA test scores showed significant improvement on posttest (P = 0.01). Posthoc analysis revealed that the posttest score was significantly higher than the pretest score in BAT group. The conventional group had nominal improvement on ARA scores (P = 0.33). The Fugl–Meyer upper extremity motor performance section Test scores showed significant improvements in the bilateral arm training group (P = 0.001). Patients in BAT group had greater gains than conventional therapy patients (P = 0.693).

The MAL test scores showed significant improvement on posttest (P = 0.00). Post hoc analysis revealed that the posttest score of AOU (P = 0.001) and quality of movement (QOM) (P = 0.000) are significantly higher than the pretest score both in BAT and conventional therapy group. Although there was no significant improvement in the amount of use in conventional occupational therapy group, there was a significant improvement in the quality of movement in this group (P = 0.001). This shows that conventional occupational therapy is effective in improving the movement quality of upper extremity in chronic stroke patients. The descriptive and inferential statistics are given in [Table 2].
Table 2: Descriptive and inferential statistics for the outcome measures

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  Discussion Top

The result of the study provides experimental data addressing the changes that occurred in both motor and functional performance and quality of movement in patients with stroke following participation in a 6-week bilateral arm raining and conventional therapy program. The motor activity log scores showed greater improvements in quality of movement and amount of use in BAT as well as in conventional therapy group.

In this study, we found 6 weeks of BAT showed improvement in measures of motor impairment and functional use in patients with chronic upper extremity hemiparesis. This suggests that forced use in a repetitive manner bilaterally can improve motor ability and functional use of upper extremity in chronic hemiparetic stroke patients. This result is consistent with the findings of Whittal et al., 2000 and Luft et al., 2004.[1],[6] In our study, the BAT group showed better performance in the proximal part score of FMA than conventional therapy group. The repetitive reaching type movements comprising shoulder flexion, protraction, elbow extension, and shoulder extension/retraction; elbow flexion might have resulted in the improvement of proximal part motor ability, thereby improving the proximal part score of FMA in bilateral arm training group relative to conventional therapy group. The effectiveness of the bilateral arm training can be found in the behavior and neurophysiology literature. Practicing bilateral simultaneous movements may result in a facilitation effect from nonparetic arm. For example, when the bimanual movements are initiated simultaneously, the arms act as a unit that supersedes individual arm action, indicating that both arms are strongly linked as a coordinated unit in the brain (the entrainment effect). Studies by Kelso et al., 1979 on interlimb coordination during simultaneous performance of bimanual tasks suggest that when both limbs are performing identical actions, the same movement organization occurs in both hemispheres.[10] In fact, there may be a single command or central mechanisms applied to both limbs. When the two hands perform identical tasks, there is a tight phasic relationship observed in which one limb entrains the other, causing them to function together as a unit. Another important aspect of bilateral arm training is repetition which is a well-known motor learning principle and recent animal studies have demonstrated that forced use involving a motor task rather than forced use alone may best promote the central nervous system plasticity.[11]

In this study, patients in BAT group showed better improvement on FMA, ARA test, and MAL scores than conventional therapy. This result is consistent with that of previous studies.[12]

  Summary and Conclusion Top

The result of the study demonstrated that bilateral arm training is an effective therapy for upper extremity hemiparesis in chronic stroke patients in comparison to conventional therapy. Bilateral arm training is more effective in improving proximal upper extremity functions in chronic hemiparetic stroke patients. There were certain limitations in conducting the study. The study had a small sample size and no follow-up was done to see the maintenance effect of bilateral arm training. The equipment used for bilateral arm training in the study was locally made without any electrical connection giving auditory or visual feedback for movement. The entire patient in the BAT group used their own speed for the movements. Further studies are necessary to assess the long-term effects of bilateral arm training. Since training were given only to chronic patients; future studies on acute and subacute stroke population can be conducted. New designs of bilateral arm training involving the wrist and hand can be incorporated and studied on different stroke population.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Whitall J, McCombe Waller S, Silver KH, Macko RF. Repetitive bilateral arm training with rhythmic auditory cueing improves motor function in chronic hemiparetic stroke. Stroke 2000;31:2390-5.  Back to cited text no. 1
Bonifer NM, Anderson KM, Arciniegas DB. Constraint-induced movement therapy after stroke: Efficacy for patients with minimal upper-extremity motor ability. Arch Phys Med Rehabil 2005;86:1867-73.  Back to cited text no. 2
Radomski MV, Trombly Latham CA. Occupational Therapy for Physical Dysfunction. 6th ed. Baltimore, MD [etc.]: Wolters Kluwer/Lippincott Williams & Wilkins, 2008.  Back to cited text no. 3
Taub E, Uswatte G, Pidikiti R. Constraint-induced movement therapy: A new family of techniques with broad application to physical rehabilitation – A clinical review. J Rehabil Res Dev 1999;36:237-51.  Back to cited text no. 4
Dobkin BH. Clinical practice. Rehabilitation after stroke. N Engl J Med 2005;352:1677-84.  Back to cited text no. 5
Luft AR, McCombe-Waller S, Whitall J, Forrester LW, Macko R, Sorkin JD, et al. Repetitive bilateral arm training and motor cortex activation in chronic stroke: A randomized controlled trial. JAMA 2004;292:1853-61.  Back to cited text no. 6
Fugl-Meyer AR, Jääskö L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient 1. A method for evaluation of physical performance. Scand J Rehabil Med 1975;7:13-31.  Back to cited text no. 7
van der Lee JH, Beckerman H, Lankhorst GJ, Bouter LM. The responsiveness of the action research arm test and the fugl-meyer assessment scale in chronic stroke patients. J Rehabil Med 2001;33:110-3.  Back to cited text no. 8
van der Lee JH, Wagenaar RC, Lankhorst GJ, Vogelaar TW, Devillé WL, Bouter LM, et al. Forced use of the upper extremity in chronic stroke patients: Results from a single-blind randomized clinical trial. Stroke 1999;30:2369-75.  Back to cited text no. 9
Kelso JA, Putnam CA, Goodman D. On the space-time structure of human interlimb co-ordination. Q J Exp Psychol A 1983;35:347-75.  Back to cited text no. 10
Carr J, Shepherd R. Neurological Rehabilitation: Optimizing Motor Performance. Churchill Livingstone: Butter Worth-Heineman 1998. p. 241-64.  Back to cited text no. 11
Levine P, Page SJ. Modified constraint-induced therapy: A promising restorative outpatient therapy. Top Stroke Rehabil 2004;11:1-0.  Back to cited text no. 12


  [Table 1], [Table 2]


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