- Email: [email protected]
Effectiveness of Bilateral Arm Training for Improving Extremity Function and Activities of Daily Living Performance in Hemiplegic Patients
Effectiveness of Bilateral Arm Training for Improving Extremity Function and Activities of Daily Living Performance in Hemiplegic Patients Min-Jae Lee,
OT, MSc,*
Jung-Hoon Lee, PT, PhD,† Hyun-Mo Koo, Sun-Min Lee, PT, PhD§
PT, PhD,‡
and
Background: Bilateral movement therapy, which encourages simultaneous use of the limbs on both the affected and nonaffected sides, is known to help in motor function recovery in hemiplegic patients. However, studies on the effectiveness of bilateral arm training for improving upper limb function and activities of daily living (ADL) performance in hemiplegic stroke patients are lacking. The present study investigated the effectiveness of bilateral arm training for improving upper limb function and ADL performance in hemiplegic stroke patients. Methods: The study included 30 hemiplegic stroke patients. The patients were randomly divided into an experimental group (n = 15) and a control group (n = 15). All patients received a uniform general occupational therapy session lasting 30 minutes 5 times a week for 8 weeks. The experimental group received an additional session of bilateral arm training lasting 30 minutes, and the control group received an additional session of general occupational therapy lasting 30 minutes. The FuglMeyer assessment (FMA), Box and Block Test (BBT), and modified Barthel index (MBI) were used for evaluation. Results: In both the experimental and control groups, the FMA, BBT, and MBI scores were significantly higher after the intervention than before the intervention (P < .05). The changes in the FMA, BBT, and MBI scores were greater in the experimental group than in the control group (P < .05). Conclusions: Bilateral arm training along with general occupational therapy might be more effective than occupational therapy alone for improving upper limb function and ADL performance in hemiplegic stroke patients. Key Words: Stroke—bilateral arm training—upper extremity function—activities of daily living. © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.
From the *Department of Occupational Therapy, Graduate School of Rehabilitation Science, Daegu University, Gyeongsan-si, Republic of Korea; †Department of Physical Therapy, College of Nursing and Healthcare Sciences, Dong-Eui University, Busan, Republic of Korea; ‡Department of Physical Therapy, College of science, Kyungsung University, Busan, Republic of Korea; and §Department of Occupational Therapy, College of Rehabilitation Science, Daegu University, Gyeongsan-si, Republic of Korea. Received September 1, 2016; revision received November 30, 2016; accepted December 8, 2016. Address correspondence to Sun-Min Lee, PT, PhD, Department of Occupational Therapy, College of Rehabilitation Science, Daegu University, 201, Daegudae-ro Gyeongsan-si, Gyeongsangbuk-do 38453, Republic of Korea. E-mail: [email protected]. 1052-3057/$ - see front matter © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2016.12.008
1020
Introduction Stroke is a cerebrovascular disorder that occurs when the brain cannot receive inputs from the motor and sensory nerves because of insufficient blood supply to the brain or cerebral hemorrhage in the brain.1 Stroke generally accompanies hemiparesis, and over 50% of stroke patients lose control of the arm temporarily or permanently owing to upper limb paralysis and are unable to perform activities of daily living (ADL).2 Among hemiplegic patients, 30%-60% cannot perform bilateral coordination tasks, which affects independent ADL3 and causes severe physical and psychological pain.4 Bilateral movement therapy, which encourages the simultaneous use of the limbs on both the affected and nonaffected sides, has been reported to be helpful for motor
Journal of Stroke and Cerebrovascular Diseases, Vol. 26, No. 5 (May), 2017: pp 1020–1025
EFFECTIVENESS OF BILATERAL ARM TRAINING
function recovery in hemiplegic patients and has been used for treating these patients.5,6 Bilateral upper limb training has been shown to activate the central nervous system and stimulate the cerebral hemisphere.7 Parker et al8 reported that 90% of the nerve fibers in the cerebral cortex and spinal cord control contralateral movement and the remaining 10% control ipsilateral movement, and that movement of the upper limb on the nonaffected side can influence movement of the upper limb on the affected side. Staines et al9 found that the activation of the cortical region on the affected side is higher when the limbs on both sides are moved than when the limb on only the affected side is moved. Additionally, it has been shown that the performance of an ambidextrous task causes a complex interaction between both hemispheres, increasing the activity of the upper limb on the affected side.10 Utley and Sugden11 reported that, in hemiplegic patients, the movement of the hand on the affected side was faster when using both hands than when using only the hand on the affected side. Most previous studies are concerned with the functional movement of the upper limb on the affected side. However, studies on the effectiveness of bilateral arm training for improving ADL performance in hemiplegic stroke patients are lacking. The present study investigated the effectiveness of bilateral arm training for improving upper limb function and ADL performance in hemiplegic stroke patients.
Methods Participants A total of 31 hemiplegic stroke patients were considered for inclusion in the present study. The inclusion criteria were as follows: (1) follow-up of at least 6 months after a diagnosis of hemiplegia due to stroke, (2) a score of over 24 points in the Mini-Mental State Examination— Korean version and ability to communicate, (3) a stage of over 3 in Brunnstrom recovery staging for the affected upper limb, and (4) ability to sit independently without assistance tools. The exclusion criteria were as follows: (1) visual perception and cognitive deficits, (2) joint contracture or limitations in the joint range of motion, and (3) inability to perform the motor program because of neurological or psychological problems. Among the 31 patients considered for inclusion, 1 patient was unable to participate regularly and was excluded. Therefore, 30 patients were finally included in the present study. Using a computer-generated random number table, the participants were randomly divided into an experimental group (bilateral arm training, n = 15) and a control group (general occupational therapy, n = 15). The flowchart of study inclusion in presented in Figure 1. All participants provided written informed consent, and the present study was approved by the institutional review board of Daegu University.
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Procedure and Interventions All participants in both the experimental and control groups received a uniform general occupational therapy session lasting 30 minutes 5 times a week for 8 weeks. The experimental group received an additional session of bilateral arm training lasting 30 minutes, and the control group received an additional session of general occupational therapy lasting 30 minutes. General occupational therapy incorporated the Bobath approach, which involves neurodevelopmental treatment that boosts normal postural reactions and restrains abnormal reflective patterns, stretching exercises for enhancing flexibility of the paralyzed upper limbs, resistance movements for increasing the muscle strength of the upper limb on the affected side, and fine motor training for improving hand manipulation skills and dexterity. Bilateral arm training incorporated 5 tasks, including dishwashing, making coffee, typing, cutting fruit, and folding laundry, which are commonly performed in daily life.
Outcome Measurements All assessments were performed by an experienced occupational therapist who was blinded to the group allocation. The Fugl-Meyer assessment (FMA) was used for the evaluation of upper extremity function. It is a quantitative assessment tool for motor function of the upper limbs in hemiplegic patients.12 The assessment includes 18 items for the shoulder, elbow, or lower limb, 5 items for the wrist, 7 items for the hand and fingers, and 3 items for upper limb coordination.13 Scores were given according to the completion of an item as follows: no completion, 0 points; partial completion, 1 point; and completion, 2 points. The maximum achievable score is 66 points. The test–retest credibility value (r = .99) and inter-rater reliability value (r = .99) indicated very high reliability and validity.14 Additionally, the Box and Block Test (BBT) was used. This test assesses hand manipulation and hand dexterity in physically handicapped patients.15 The test involves moving 1-inch cube blocks (2.5 cm × 2.5 cm × 2.5 cm) from a rectangular box container (53.7 cm × 25.4 cm × 8.5 cm) to another container, and the number of blocks moved by each hand in 60 seconds is determined.16 The test– retest credibility values (right hand, r = .94; left hand, r = .99) and inter-rater reliability values (right hand, r = 1.00; left hand, r = .99) indicated very high reliability and validity.17 Moreover, the modified Barthel index (MBI) was used. This index assesses the degree of ADL independence and includes the following 10 items: feeding, personal hygiene, bathing, dressing, toilet use, bladder control, bowel control, ambulation, transfer, and stair climbing, and the maximum achievable score is 100.18 The score range of 1-24 indicates total dependence, 25-49 indicates severe dependence, 50-74 indicates moderate dependence, 75-90 indicates mild dependence, and 91-99 indicates minimal dependence, and
M.-J. LEE ET AL.
1022 Enrollment
Assessed for eligibility (n = 31)
Excluded (n = 1) - Declined to participate
Randomized (n = 30)
Experimental group Allocated to intervention (n = 15) 30 minutes of bilateral arm training + 30 minutes of general occupational therapy
Lost to follow-up (n = 0)
Allocation
Follow-Up
Discontinued intervention (n = 0)
Control group Allocated to intervention (n = 15) 30 minutes of general occupational therapy + 30 minutes of general occupational therapy
Lost to follow-up (n = 0) Discontinued intervention (n = 0)
Analysed (n = 15) Excluded from analysis (n = 0)
Analysis
Figure 1.
Analysed (n = 15) Excluded from analysis (n = 0)
Flowchart of patient selection.
a score of 100 indicates complete independence. The interrater reliability value (r = .95) and intrarater reliability value (r = .89) indicated high reliability.19
Statistical Analysis Frequency analysis using descriptive statistics was performed to analyze the general characteristics of the participants. An independent t-test was used to compare the initial scores of the FMA, BBT, and MBI between the 2 groups before the intervention. A paired t-test was used to compare the scores of the FMA, BBT, and MBI in each group before and after the intervention. Additionally, an independent t-test was used to compare the changes in the scores of the FMA, BBT, and MBI between the 2 groups. All analyses were performed using SPSS version 18.0 (IBM Corp., Armonk, NY). The statistical significance level was set at .05.
Results The general characteristics of the study participants are presented in Table 1. The FMA, BBT, and MBI scores were not significantly different between the experimental group
and the control group at baseline (P > .05; Table 2). In both the experimental and control groups, the FMA, BBT, and MBI scores were significantly higher after the intervention than before the intervention (P < .05; Table 3). The changes in the FMA, BBT, and MBI scores were greater in the experimental group than in the control group (P < .05; Table 4).
Discussion The FMA and BBT scores, indicating recovery of upper limb function, were higher after the intervention than before the intervention in both the experimental and control groups, and the changes in the scores were higher in the experimental group than in the control group. These results indicated that performing bilateral arm training and general occupational therapy together was more effective than performing only general occupational therapy for the recovery of upper limb function. Particularly, shoulder abduction, external rotation, and the elbow extension score of the FMA were high among the FMA items. Bilateral arm training had a greater effect on the proximal part of the upper limb with regard to motor performance than the effect with constraint-induced therapy.20
EFFECTIVENESS OF BILATERAL ARM TRAINING
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Table 1. Characteristics of participants
General characteristics
Bilateral arm task training group (n = 15)
Control group (n = 15)
Persons (%)
Persons (%)
9 (60.0) 6 (40.0) 57.33 ± 9.88 8 (53.3) 7 (46.7) 10 (66.7) 5 (33.3) 4 (26.7) 3 (20.0) 8 (53.3)
10 (66.7) 5 (33.3) 54.60 ± 16.03 9 (60.0) 6 (40.0) 9 (60.0) 6 (40.0) 5 (33.3) 5 (33.3) 5 (33.3)
Division
Sex
Male Female
Age (years) Lesion type
Hemorrhagic Ischemic Right Left 7-12 13~24 25 and above
Affected side Time since stroke (months)
Bilateral movement is based on the theoretical principles of coordination between the affected and nonaffected sides and of the neural crosstalk model.21 The activation of the primary motor and somatosensory cortices on the affected side is better when focusing on both sides than when focusing on only the affected side, and limb movement on the affected side is improved by moving the limbs on the nonaffected side.9 Unilateral movements cause inhibition of neural plasticity in the ipsilateral hemisphere, whereas symmetrical bilateral movements activate both cerebral hemispheres, decreasing interhemispheric inhibition and facilitating limb
Table 2. Comparison of the baseline in the two groups Mean ± SD
FMA score BBT MBI score
Bilateral arm task training group
Occupational therapy group
P
48.73 ± 16.42 25.46 ± 10.41 74.33 ± 9.91
46.60 ± 12.03 20.86 ± 14.96 66.13 ± 15.07
.69 .34 .09
Abbreviations: BBT, Box and Block Test; FMA, Fugl-Meyer Motor Function Assessment; MBI, modified Barthel index; SD, standard deviation.
recovery on the affected side.22,23 Thus, bilateral movements influence the coupling effects of both sides of the hemispheres in the central nervous system through corpus callosum and subcortical neural circuits.24,25 Bilateral priming accelerated recovery of the upper limb function in the initial weeks after subacute stroke.26 Lewisand and Byblow27 reported that the use of both hands on the affected and nonaffected sides improves upper limb function. In a study by Hijmans et al,28 14 chronic stroke patients who had experienced stroke 6 months previously were instructed to play various computer games, such as sports games and puzzle games, and to operate the controller using both hands. The authors found that upper extremity function on the affected side improved significantly after 3 weeks of operating the game controller using both hands. Furthermore, Cauraugh et al29 reported that the maximum limb velocity and movement time were higher after bilateral arm training than before training. The MBI scores, indicating ADL performance, were higher after the intervention than before the intervention in both the experimental and control groups, and the changes in the scores were higher in the experimental group than in the control group. These results indicated that performing bilateral arm training along with general occupational therapy together was more effective than
Table 3. Changes in parameters before and after treatment Bilateral arm task training group (mean ± SD)
FMA score BBT MBI score
Occupational therapy group (mean ± SD)
Before treatment
After treatment
P
Before treatment
After treatment
P
48.73 ± 16.42 25.46 ± 10.41 74.33 ± 9.91
57.40 ± 13.35 32.06 ± 12.48 77.80 ± 10.12
.00** .00** .00**
46.60 ± 12.03 20.86 ± 14.96 62.73 ± 18.64
47.40 ± 12.44 21.46 ± 15.01 66.13 ± 15.07
.02* .04* .01*
Abbreviations: BBT, Box and Block Test; FMA, Fugl-Meyer Motor Function Assessment; MBI, modified Barthel index; SD, standard deviation. *P < .05, **P < .01 by paired t-test.
M.-J. LEE ET AL.
1024
Table 4. Comparison of the differences after treatment in the two groups Mean ± SD Bilateral arm task training group
Occupational therapy group
P
8.67 ± 4.43 6.60 ± 4.21 3.47 ± 3.93
.80 ± 1.15 .60 ± 1.06 3.40 ± 4.47
.04 .04 .02
FMA score BBT MBI score
Abbreviations: BBT, Box and Block Test; FMA, Fugl-Meyer Motor Function Assessment; MBI, modified Barthel index; SD, standard deviation.
performing only general occupational therapy for improving ADL performance. In a particular subtest of selfcare, dressing improved in the MBI. Desrosiers et al30 reported that bilateral arm training significantly improved ADL performance; however, in their study, there was no significant difference in the improvement of ADL performance between bilateral arm training and conventional physical therapy and occupational therapy of the hand. Lin et al20 compared bilateral upper limb training with general occupational therapy in 20 stroke patients for 3 weeks and reported that the improvement in the ADL performance was greater in the group that received bilateral upper limb training than in the group that received general occupational therapy. The present study has some limitations. This study included patients who met the selection criteria; therefore, it might be difficult to generalize the result to all hemiplegic patients. In addition, we could not assess the influence of sensory function on motor performance because this study did not evaluate sensory function. Additionally, the training program for ADL performance used in this study might be difficult to apply to patients with a relatively low functional level. Hence, diverse ambidextrous actionoriented movement programs appropriate for the functional level of patients should be developed and their effectiveness should be assessed.
Conclusions Bilateral arm training along with general occupational therapy might be more effective than occupational therapy alone for improving upper limb function and ADL performance in hemiplegic stroke patients. Thus, bilateral arm training should be considered as an important clinical intervention in hemiplegic patients.
References 1. Sharp SA, Brouwer BJ. Isokinetic strength training of the hemiparetic knee: effects on function and spasticity. Arch Phys Med Rehabil 1997;78:1231-1236.
2. Wu CY, Chen CL, Tsai WC, et al. A randomized controlled trial of modified constraint-induced movement therapy for elderly stroke survivors: changes in motor impairment, daily functioning, and quality of life. Arch Phys Med Rehabil 2007;88:273-278. 3. Heller A, Wade DT, Wood VA, et al. Arm function after stroke: measurement and recovery over the first three months. J Neurol Neurosurg Psychiatry 1987;50:714-719. 4. Pendleton HM, Schultz-Krohn W. Pedretti’s occupational therapy: practice skills for physical dysfunction. St. Louis: Elsevier Health Science, 2013. 5. Latimer CP, Keeling J, Lin B, et al. The impact of bilateral therapy on upper limb function after chronic stroke: a systematic review. Disabil Rehabil 2010;32:1221-1231. 6. Van Delden AEQ, Peper CE, Beek PJ, et al. Unilateral versus bilateral upper limb exercise therapy after stroke: a systematic review. J Rehabil Med 2012;44:106-117. 7. McCombe Waller S, Whitall J. Bilateral arm training: why and who benefits. Neurorehabilitation 2008;23:29-41. 8. Parker F, Tzourio N, Blond S, et al. Evidence for a common network of brain structures involved in parkinsonian tremor and voluntary repetitive movement. Brain Res 1992;584:11-17. 9. Staines WR, McIlroy WE, Graham SJ, et al. Bilateral movement enhances ipsilesional cortical activity in acute stroke: a pilot functional MRI study. Neurology 2001;56:401-404. 10. Sabaté M, González B, Rodríguez M. Brain lateralization of motor imagery: motor planning asymmetry as a cause of movement lateralization. Neuropsychologia 2004;42:1041-1049. 11. Utely A, Sugden D. Interlimb coupling in children with hemiplegic cerebral palsy during reaching and grasping at speed. Dev Med Child Neurol 1998;40:396-404. 12. Gladstone DJ, Danells CJ, Black SE. The Fugl-Meyer assessment of motor recovery after stroke: a critical review of its measurement properties. Neurorehabil Neural Repair 2002;16:232-240. 13. Fugl-Meyer AR, Jaasko L, Leyman I, et al. The post-stroke hemiplegic patient. 1. A method for evaluation of physical performance. Scand J Rehabil Med 1975;7:13-31. 14. Duncan PW, Propst M, Nelson SG. Reliability of the Fugl-Meyer assessment of sensorimotor recovery following cerebrovascular accident. Phys Ther 1983;63:1606-1610. 15. Mathiowetz V, Volland G, Kashman N, et al. Adult norms for the Box and Block Test of manual dexterity. Am J Occup Ther 1985;39:386-391. 16. Trombly CA, Radomski MV. Occupational therapy for physical dysfunction. Baltimore (MD): Lippincott Williams &Wilkins, 2002. 17. Platz T, Pinkowski C, van Wijck F, et al. Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, Action Research Arm Test and Box and Block Test: a multicentre study. Clin Rehabil 2005;19:404-411. 18. Küçükdeveci AA, Yavuzer G, Tennant A, et al. Adaptation of the modified Barthel Index for use in physical medicine and rehabilitation in Turkey. Scand J Rehabil Med 2000;32:87-92. 19. Shah S, Vanclay F, Cooper B. Improve the sensitivity of the Barthel index for stroke rehabilitation. J Clin Epidemiol 1989;42:703-709. 20. Lin KC, Chang YF, Wu CY, et al. Effects of constraintinduced therapy versus bilateral arm training on motor performance, daily functions, and quality of life in stroke survivors. Neurorehabil Neural Repair 2009;23:441448.
EFFECTIVENESS OF BILATERAL ARM TRAINING 21. Luft AR, McCombe-Waller S, Whitall J, et al. Repetitive bilateral arm training and motor cortex activation in chronic stroke: a randomized controlled trial. JAMA 2004;292:1853-1861. 22. 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. 23. Cauraugh JH, Summers JJ. Neural plasticity and bilateral movements: a rehabilitation approach for chronic stroke. Prog Neurobiol 2005;75:309-320. 24. van Delden ALE, Beek PJ, Roerdink M, et al. Unilateral and bilateral upper-limb training interventions after stroke have similar effects on bimanual coupling strength. Neurorehabil Neural Repair 2015;29:255-267. 25. Stinear CM, Barber PA, Smale PR, et al. Functional potential in chronic stroke patients depends on corticospinal tract integrity. Brain 2007;130:170-180.
1025 26. Stinear CM, Petoe MA, Anwar S, et al. Bilateral priming accelerates recovery of upper limb function after stroke a randomized controlled trial. Stroke 2014;45:205-210. 27. Lewisand GN, Byblow WD. Neurophysiological and behavioural adaptations to a bilateral training intervention in individuals following stroke. Clin Rehabil 2004;18:48-59. 28. Hijmans JM, Hale LA, Satherley JA, et al. Bilateral upper-limb rehabilitation after stroke using a movementbased game controller. J Rehabil Res Dev 2011;48:10051013. 29. Cauraugh JH, Kim SB, Duley A. Coupled bilateral movements and active neuromuscular stimulation: intralimb transfer evidence during bimanual aiming. Neurosci Lett 2005;382:39-44. 30. Desrosiers J, Bourbonnais D, Corriveau H, et al. Effectiveness of unilateral and symmetrical bilateral task training for arm during the subacute phase after stroke: a randomized controlled trial. Clin Rehabil 2005;19:581-593.
OT, MSc,*
Jung-Hoon Lee, PT, PhD,† Hyun-Mo Koo, Sun-Min Lee, PT, PhD§
PT, PhD,‡
and
Background: Bilateral movement therapy, which encourages simultaneous use of the limbs on both the affected and nonaffected sides, is known to help in motor function recovery in hemiplegic patients. However, studies on the effectiveness of bilateral arm training for improving upper limb function and activities of daily living (ADL) performance in hemiplegic stroke patients are lacking. The present study investigated the effectiveness of bilateral arm training for improving upper limb function and ADL performance in hemiplegic stroke patients. Methods: The study included 30 hemiplegic stroke patients. The patients were randomly divided into an experimental group (n = 15) and a control group (n = 15). All patients received a uniform general occupational therapy session lasting 30 minutes 5 times a week for 8 weeks. The experimental group received an additional session of bilateral arm training lasting 30 minutes, and the control group received an additional session of general occupational therapy lasting 30 minutes. The FuglMeyer assessment (FMA), Box and Block Test (BBT), and modified Barthel index (MBI) were used for evaluation. Results: In both the experimental and control groups, the FMA, BBT, and MBI scores were significantly higher after the intervention than before the intervention (P < .05). The changes in the FMA, BBT, and MBI scores were greater in the experimental group than in the control group (P < .05). Conclusions: Bilateral arm training along with general occupational therapy might be more effective than occupational therapy alone for improving upper limb function and ADL performance in hemiplegic stroke patients. Key Words: Stroke—bilateral arm training—upper extremity function—activities of daily living. © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.
From the *Department of Occupational Therapy, Graduate School of Rehabilitation Science, Daegu University, Gyeongsan-si, Republic of Korea; †Department of Physical Therapy, College of Nursing and Healthcare Sciences, Dong-Eui University, Busan, Republic of Korea; ‡Department of Physical Therapy, College of science, Kyungsung University, Busan, Republic of Korea; and §Department of Occupational Therapy, College of Rehabilitation Science, Daegu University, Gyeongsan-si, Republic of Korea. Received September 1, 2016; revision received November 30, 2016; accepted December 8, 2016. Address correspondence to Sun-Min Lee, PT, PhD, Department of Occupational Therapy, College of Rehabilitation Science, Daegu University, 201, Daegudae-ro Gyeongsan-si, Gyeongsangbuk-do 38453, Republic of Korea. E-mail: [email protected]. 1052-3057/$ - see front matter © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2016.12.008
1020
Introduction Stroke is a cerebrovascular disorder that occurs when the brain cannot receive inputs from the motor and sensory nerves because of insufficient blood supply to the brain or cerebral hemorrhage in the brain.1 Stroke generally accompanies hemiparesis, and over 50% of stroke patients lose control of the arm temporarily or permanently owing to upper limb paralysis and are unable to perform activities of daily living (ADL).2 Among hemiplegic patients, 30%-60% cannot perform bilateral coordination tasks, which affects independent ADL3 and causes severe physical and psychological pain.4 Bilateral movement therapy, which encourages the simultaneous use of the limbs on both the affected and nonaffected sides, has been reported to be helpful for motor
Journal of Stroke and Cerebrovascular Diseases, Vol. 26, No. 5 (May), 2017: pp 1020–1025
EFFECTIVENESS OF BILATERAL ARM TRAINING
function recovery in hemiplegic patients and has been used for treating these patients.5,6 Bilateral upper limb training has been shown to activate the central nervous system and stimulate the cerebral hemisphere.7 Parker et al8 reported that 90% of the nerve fibers in the cerebral cortex and spinal cord control contralateral movement and the remaining 10% control ipsilateral movement, and that movement of the upper limb on the nonaffected side can influence movement of the upper limb on the affected side. Staines et al9 found that the activation of the cortical region on the affected side is higher when the limbs on both sides are moved than when the limb on only the affected side is moved. Additionally, it has been shown that the performance of an ambidextrous task causes a complex interaction between both hemispheres, increasing the activity of the upper limb on the affected side.10 Utley and Sugden11 reported that, in hemiplegic patients, the movement of the hand on the affected side was faster when using both hands than when using only the hand on the affected side. Most previous studies are concerned with the functional movement of the upper limb on the affected side. However, studies on the effectiveness of bilateral arm training for improving ADL performance in hemiplegic stroke patients are lacking. The present study investigated the effectiveness of bilateral arm training for improving upper limb function and ADL performance in hemiplegic stroke patients.
Methods Participants A total of 31 hemiplegic stroke patients were considered for inclusion in the present study. The inclusion criteria were as follows: (1) follow-up of at least 6 months after a diagnosis of hemiplegia due to stroke, (2) a score of over 24 points in the Mini-Mental State Examination— Korean version and ability to communicate, (3) a stage of over 3 in Brunnstrom recovery staging for the affected upper limb, and (4) ability to sit independently without assistance tools. The exclusion criteria were as follows: (1) visual perception and cognitive deficits, (2) joint contracture or limitations in the joint range of motion, and (3) inability to perform the motor program because of neurological or psychological problems. Among the 31 patients considered for inclusion, 1 patient was unable to participate regularly and was excluded. Therefore, 30 patients were finally included in the present study. Using a computer-generated random number table, the participants were randomly divided into an experimental group (bilateral arm training, n = 15) and a control group (general occupational therapy, n = 15). The flowchart of study inclusion in presented in Figure 1. All participants provided written informed consent, and the present study was approved by the institutional review board of Daegu University.
1021
Procedure and Interventions All participants in both the experimental and control groups received a uniform general occupational therapy session lasting 30 minutes 5 times a week for 8 weeks. The experimental group received an additional session of bilateral arm training lasting 30 minutes, and the control group received an additional session of general occupational therapy lasting 30 minutes. General occupational therapy incorporated the Bobath approach, which involves neurodevelopmental treatment that boosts normal postural reactions and restrains abnormal reflective patterns, stretching exercises for enhancing flexibility of the paralyzed upper limbs, resistance movements for increasing the muscle strength of the upper limb on the affected side, and fine motor training for improving hand manipulation skills and dexterity. Bilateral arm training incorporated 5 tasks, including dishwashing, making coffee, typing, cutting fruit, and folding laundry, which are commonly performed in daily life.
Outcome Measurements All assessments were performed by an experienced occupational therapist who was blinded to the group allocation. The Fugl-Meyer assessment (FMA) was used for the evaluation of upper extremity function. It is a quantitative assessment tool for motor function of the upper limbs in hemiplegic patients.12 The assessment includes 18 items for the shoulder, elbow, or lower limb, 5 items for the wrist, 7 items for the hand and fingers, and 3 items for upper limb coordination.13 Scores were given according to the completion of an item as follows: no completion, 0 points; partial completion, 1 point; and completion, 2 points. The maximum achievable score is 66 points. The test–retest credibility value (r = .99) and inter-rater reliability value (r = .99) indicated very high reliability and validity.14 Additionally, the Box and Block Test (BBT) was used. This test assesses hand manipulation and hand dexterity in physically handicapped patients.15 The test involves moving 1-inch cube blocks (2.5 cm × 2.5 cm × 2.5 cm) from a rectangular box container (53.7 cm × 25.4 cm × 8.5 cm) to another container, and the number of blocks moved by each hand in 60 seconds is determined.16 The test– retest credibility values (right hand, r = .94; left hand, r = .99) and inter-rater reliability values (right hand, r = 1.00; left hand, r = .99) indicated very high reliability and validity.17 Moreover, the modified Barthel index (MBI) was used. This index assesses the degree of ADL independence and includes the following 10 items: feeding, personal hygiene, bathing, dressing, toilet use, bladder control, bowel control, ambulation, transfer, and stair climbing, and the maximum achievable score is 100.18 The score range of 1-24 indicates total dependence, 25-49 indicates severe dependence, 50-74 indicates moderate dependence, 75-90 indicates mild dependence, and 91-99 indicates minimal dependence, and
M.-J. LEE ET AL.
1022 Enrollment
Assessed for eligibility (n = 31)
Excluded (n = 1) - Declined to participate
Randomized (n = 30)
Experimental group Allocated to intervention (n = 15) 30 minutes of bilateral arm training + 30 minutes of general occupational therapy
Lost to follow-up (n = 0)
Allocation
Follow-Up
Discontinued intervention (n = 0)
Control group Allocated to intervention (n = 15) 30 minutes of general occupational therapy + 30 minutes of general occupational therapy
Lost to follow-up (n = 0) Discontinued intervention (n = 0)
Analysed (n = 15) Excluded from analysis (n = 0)
Analysis
Figure 1.
Analysed (n = 15) Excluded from analysis (n = 0)
Flowchart of patient selection.
a score of 100 indicates complete independence. The interrater reliability value (r = .95) and intrarater reliability value (r = .89) indicated high reliability.19
Statistical Analysis Frequency analysis using descriptive statistics was performed to analyze the general characteristics of the participants. An independent t-test was used to compare the initial scores of the FMA, BBT, and MBI between the 2 groups before the intervention. A paired t-test was used to compare the scores of the FMA, BBT, and MBI in each group before and after the intervention. Additionally, an independent t-test was used to compare the changes in the scores of the FMA, BBT, and MBI between the 2 groups. All analyses were performed using SPSS version 18.0 (IBM Corp., Armonk, NY). The statistical significance level was set at .05.
Results The general characteristics of the study participants are presented in Table 1. The FMA, BBT, and MBI scores were not significantly different between the experimental group
and the control group at baseline (P > .05; Table 2). In both the experimental and control groups, the FMA, BBT, and MBI scores were significantly higher after the intervention than before the intervention (P < .05; Table 3). The changes in the FMA, BBT, and MBI scores were greater in the experimental group than in the control group (P < .05; Table 4).
Discussion The FMA and BBT scores, indicating recovery of upper limb function, were higher after the intervention than before the intervention in both the experimental and control groups, and the changes in the scores were higher in the experimental group than in the control group. These results indicated that performing bilateral arm training and general occupational therapy together was more effective than performing only general occupational therapy for the recovery of upper limb function. Particularly, shoulder abduction, external rotation, and the elbow extension score of the FMA were high among the FMA items. Bilateral arm training had a greater effect on the proximal part of the upper limb with regard to motor performance than the effect with constraint-induced therapy.20
EFFECTIVENESS OF BILATERAL ARM TRAINING
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Table 1. Characteristics of participants
General characteristics
Bilateral arm task training group (n = 15)
Control group (n = 15)
Persons (%)
Persons (%)
9 (60.0) 6 (40.0) 57.33 ± 9.88 8 (53.3) 7 (46.7) 10 (66.7) 5 (33.3) 4 (26.7) 3 (20.0) 8 (53.3)
10 (66.7) 5 (33.3) 54.60 ± 16.03 9 (60.0) 6 (40.0) 9 (60.0) 6 (40.0) 5 (33.3) 5 (33.3) 5 (33.3)
Division
Sex
Male Female
Age (years) Lesion type
Hemorrhagic Ischemic Right Left 7-12 13~24 25 and above
Affected side Time since stroke (months)
Bilateral movement is based on the theoretical principles of coordination between the affected and nonaffected sides and of the neural crosstalk model.21 The activation of the primary motor and somatosensory cortices on the affected side is better when focusing on both sides than when focusing on only the affected side, and limb movement on the affected side is improved by moving the limbs on the nonaffected side.9 Unilateral movements cause inhibition of neural plasticity in the ipsilateral hemisphere, whereas symmetrical bilateral movements activate both cerebral hemispheres, decreasing interhemispheric inhibition and facilitating limb
Table 2. Comparison of the baseline in the two groups Mean ± SD
FMA score BBT MBI score
Bilateral arm task training group
Occupational therapy group
P
48.73 ± 16.42 25.46 ± 10.41 74.33 ± 9.91
46.60 ± 12.03 20.86 ± 14.96 66.13 ± 15.07
.69 .34 .09
Abbreviations: BBT, Box and Block Test; FMA, Fugl-Meyer Motor Function Assessment; MBI, modified Barthel index; SD, standard deviation.
recovery on the affected side.22,23 Thus, bilateral movements influence the coupling effects of both sides of the hemispheres in the central nervous system through corpus callosum and subcortical neural circuits.24,25 Bilateral priming accelerated recovery of the upper limb function in the initial weeks after subacute stroke.26 Lewisand and Byblow27 reported that the use of both hands on the affected and nonaffected sides improves upper limb function. In a study by Hijmans et al,28 14 chronic stroke patients who had experienced stroke 6 months previously were instructed to play various computer games, such as sports games and puzzle games, and to operate the controller using both hands. The authors found that upper extremity function on the affected side improved significantly after 3 weeks of operating the game controller using both hands. Furthermore, Cauraugh et al29 reported that the maximum limb velocity and movement time were higher after bilateral arm training than before training. The MBI scores, indicating ADL performance, were higher after the intervention than before the intervention in both the experimental and control groups, and the changes in the scores were higher in the experimental group than in the control group. These results indicated that performing bilateral arm training along with general occupational therapy together was more effective than
Table 3. Changes in parameters before and after treatment Bilateral arm task training group (mean ± SD)
FMA score BBT MBI score
Occupational therapy group (mean ± SD)
Before treatment
After treatment
P
Before treatment
After treatment
P
48.73 ± 16.42 25.46 ± 10.41 74.33 ± 9.91
57.40 ± 13.35 32.06 ± 12.48 77.80 ± 10.12
.00** .00** .00**
46.60 ± 12.03 20.86 ± 14.96 62.73 ± 18.64
47.40 ± 12.44 21.46 ± 15.01 66.13 ± 15.07
.02* .04* .01*
Abbreviations: BBT, Box and Block Test; FMA, Fugl-Meyer Motor Function Assessment; MBI, modified Barthel index; SD, standard deviation. *P < .05, **P < .01 by paired t-test.
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Table 4. Comparison of the differences after treatment in the two groups Mean ± SD Bilateral arm task training group
Occupational therapy group
P
8.67 ± 4.43 6.60 ± 4.21 3.47 ± 3.93
.80 ± 1.15 .60 ± 1.06 3.40 ± 4.47
.04 .04 .02
FMA score BBT MBI score
Abbreviations: BBT, Box and Block Test; FMA, Fugl-Meyer Motor Function Assessment; MBI, modified Barthel index; SD, standard deviation.
performing only general occupational therapy for improving ADL performance. In a particular subtest of selfcare, dressing improved in the MBI. Desrosiers et al30 reported that bilateral arm training significantly improved ADL performance; however, in their study, there was no significant difference in the improvement of ADL performance between bilateral arm training and conventional physical therapy and occupational therapy of the hand. Lin et al20 compared bilateral upper limb training with general occupational therapy in 20 stroke patients for 3 weeks and reported that the improvement in the ADL performance was greater in the group that received bilateral upper limb training than in the group that received general occupational therapy. The present study has some limitations. This study included patients who met the selection criteria; therefore, it might be difficult to generalize the result to all hemiplegic patients. In addition, we could not assess the influence of sensory function on motor performance because this study did not evaluate sensory function. Additionally, the training program for ADL performance used in this study might be difficult to apply to patients with a relatively low functional level. Hence, diverse ambidextrous actionoriented movement programs appropriate for the functional level of patients should be developed and their effectiveness should be assessed.
Conclusions Bilateral arm training along with general occupational therapy might be more effective than occupational therapy alone for improving upper limb function and ADL performance in hemiplegic stroke patients. Thus, bilateral arm training should be considered as an important clinical intervention in hemiplegic patients.
References 1. Sharp SA, Brouwer BJ. Isokinetic strength training of the hemiparetic knee: effects on function and spasticity. Arch Phys Med Rehabil 1997;78:1231-1236.
2. Wu CY, Chen CL, Tsai WC, et al. A randomized controlled trial of modified constraint-induced movement therapy for elderly stroke survivors: changes in motor impairment, daily functioning, and quality of life. Arch Phys Med Rehabil 2007;88:273-278. 3. Heller A, Wade DT, Wood VA, et al. Arm function after stroke: measurement and recovery over the first three months. J Neurol Neurosurg Psychiatry 1987;50:714-719. 4. Pendleton HM, Schultz-Krohn W. Pedretti’s occupational therapy: practice skills for physical dysfunction. St. Louis: Elsevier Health Science, 2013. 5. Latimer CP, Keeling J, Lin B, et al. The impact of bilateral therapy on upper limb function after chronic stroke: a systematic review. Disabil Rehabil 2010;32:1221-1231. 6. Van Delden AEQ, Peper CE, Beek PJ, et al. Unilateral versus bilateral upper limb exercise therapy after stroke: a systematic review. J Rehabil Med 2012;44:106-117. 7. McCombe Waller S, Whitall J. Bilateral arm training: why and who benefits. Neurorehabilitation 2008;23:29-41. 8. Parker F, Tzourio N, Blond S, et al. Evidence for a common network of brain structures involved in parkinsonian tremor and voluntary repetitive movement. Brain Res 1992;584:11-17. 9. Staines WR, McIlroy WE, Graham SJ, et al. Bilateral movement enhances ipsilesional cortical activity in acute stroke: a pilot functional MRI study. Neurology 2001;56:401-404. 10. Sabaté M, González B, Rodríguez M. Brain lateralization of motor imagery: motor planning asymmetry as a cause of movement lateralization. Neuropsychologia 2004;42:1041-1049. 11. Utely A, Sugden D. Interlimb coupling in children with hemiplegic cerebral palsy during reaching and grasping at speed. Dev Med Child Neurol 1998;40:396-404. 12. Gladstone DJ, Danells CJ, Black SE. The Fugl-Meyer assessment of motor recovery after stroke: a critical review of its measurement properties. Neurorehabil Neural Repair 2002;16:232-240. 13. Fugl-Meyer AR, Jaasko L, Leyman I, et al. The post-stroke hemiplegic patient. 1. A method for evaluation of physical performance. Scand J Rehabil Med 1975;7:13-31. 14. Duncan PW, Propst M, Nelson SG. Reliability of the Fugl-Meyer assessment of sensorimotor recovery following cerebrovascular accident. Phys Ther 1983;63:1606-1610. 15. Mathiowetz V, Volland G, Kashman N, et al. Adult norms for the Box and Block Test of manual dexterity. Am J Occup Ther 1985;39:386-391. 16. Trombly CA, Radomski MV. Occupational therapy for physical dysfunction. Baltimore (MD): Lippincott Williams &Wilkins, 2002. 17. Platz T, Pinkowski C, van Wijck F, et al. Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, Action Research Arm Test and Box and Block Test: a multicentre study. Clin Rehabil 2005;19:404-411. 18. Küçükdeveci AA, Yavuzer G, Tennant A, et al. Adaptation of the modified Barthel Index for use in physical medicine and rehabilitation in Turkey. Scand J Rehabil Med 2000;32:87-92. 19. Shah S, Vanclay F, Cooper B. Improve the sensitivity of the Barthel index for stroke rehabilitation. J Clin Epidemiol 1989;42:703-709. 20. Lin KC, Chang YF, Wu CY, et al. Effects of constraintinduced therapy versus bilateral arm training on motor performance, daily functions, and quality of life in stroke survivors. Neurorehabil Neural Repair 2009;23:441448.
EFFECTIVENESS OF BILATERAL ARM TRAINING 21. Luft AR, McCombe-Waller S, Whitall J, et al. Repetitive bilateral arm training and motor cortex activation in chronic stroke: a randomized controlled trial. JAMA 2004;292:1853-1861. 22. 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. 23. Cauraugh JH, Summers JJ. Neural plasticity and bilateral movements: a rehabilitation approach for chronic stroke. Prog Neurobiol 2005;75:309-320. 24. van Delden ALE, Beek PJ, Roerdink M, et al. Unilateral and bilateral upper-limb training interventions after stroke have similar effects on bimanual coupling strength. Neurorehabil Neural Repair 2015;29:255-267. 25. Stinear CM, Barber PA, Smale PR, et al. Functional potential in chronic stroke patients depends on corticospinal tract integrity. Brain 2007;130:170-180.
1025 26. Stinear CM, Petoe MA, Anwar S, et al. Bilateral priming accelerates recovery of upper limb function after stroke a randomized controlled trial. Stroke 2014;45:205-210. 27. Lewisand GN, Byblow WD. Neurophysiological and behavioural adaptations to a bilateral training intervention in individuals following stroke. Clin Rehabil 2004;18:48-59. 28. Hijmans JM, Hale LA, Satherley JA, et al. Bilateral upper-limb rehabilitation after stroke using a movementbased game controller. J Rehabil Res Dev 2011;48:10051013. 29. Cauraugh JH, Kim SB, Duley A. Coupled bilateral movements and active neuromuscular stimulation: intralimb transfer evidence during bimanual aiming. Neurosci Lett 2005;382:39-44. 30. Desrosiers J, Bourbonnais D, Corriveau H, et al. Effectiveness of unilateral and symmetrical bilateral task training for arm during the subacute phase after stroke: a randomized controlled trial. Clin Rehabil 2005;19:581-593.