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Stroke upper extremity rehabilitation:
Effect of bilateral arm training
Damayanti Sethy, Surjeet Sahoo1, Eva S. Kujur, Pankaj Bajpai

Website:
Abstract:
www.ijhas.in 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.
DOI:
10.4103/ijhas.IJHAS_125_17 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

Introduction alternative strategies are needed to reduce

the long‑term disabilities and functional

S troke is the third leading cause of

death and the leading cause of adult
disability.[1] Upper limb hemiparesis is a
impairment resulting from upper extremity
hemiparesis.[1]

Department of common impairment underlying disability Various conventional treatment techniques

Occupational Therapy, are used for upper extremity management
after cerebrovascular accident. Dysfunction
National Institute for
Locomotor Disabilities, from upper extremity hemiparesis impairs in patients with stroke using the principles
Kolkata, West Bengal, performance of many daily activities such of Bobath neurodevelopmental Therapy,
1
Department of Psychiatry, as dressing, bathing, self‑care, and writing, Brunnstrom movement therapy,
IMS and SUM Hospital, Rood’s techniques, and Proprioceptive
thus reducing functional independence.
Siksha O Anusandhan
University, Bhubaneswar, In fact, only 5% of adults regain full arm Neuromuscular Facilitation developed
Odisha, India function after stroke and 20% regain no by Knott and Voss. [3] The efficacy of
functional use.[2] Restoration of full function these approaches with regard to transfer
Address for to the stroke‑affected upper extremity is of treatment effect in life situation is
correspondence:
Ms. Damayanti Sethy, a major problem in rehabilitation. Hence, questionable.[4]  Only one‑third of all stroke
Department of patients regain some dexterity within
Occupational Therapy, This is an open access journal, and articles are
6 months using conventional treatment
National Institute for distributed under the terms of the Creative Commons programs.[5]
Locomotor Disabilities, Attribution‑NonCommercial‑ShareAlike 4.0 License, which
BT Road, Bonhoogly, allows others to remix, tweak, and build upon the work How to cite this article: Sethy D, Sahoo S, Kujur ES,
Kolkata ‑ 700 090, non‑commercially, as long as appropriate credit is given and Bajpai P. Stroke upper extremity rehabilitation: Effect
West Bengal, India. the new creations are licensed under the identical terms. of bilateral arm training. Int J Health Allied Sci
E‑mail: damayanti.sethy@ 2018;7:217-21.
gmail.com For reprints contact: reprints@medknow.com

© 2018 International Journal of Health & Allied Sciences | Published by Wolters Kluwer ‑ Medknow 217
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Sethy, et al.: BAT for stroke upper extremity recovery
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
Design
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.
218 International Journal of Health & Allied Sciences - Volume 7, Issue 4, October‑December 2018
Outcome measures
• F u g l ‑ M e y e r m e a s u r e m e n t o f p h y s i c a l
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]
Procedure
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
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Sethy, et al.: BAT for stroke upper extremity recovery

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
Table 1: Characteristics of the patient population
Characteristics Mean (SD) Significance
BAT group CT
Number of patients 14 14
Age range (years) 57.34 (11.92) 57.59 (11.03)
Sex (male/female) 10/04 9/5
Side of lesion, number 9/5 10/4
of left/right
Months since stroke 13.09 (2.86) 13.82 (3.01)
mMMSE score 86.39 (10.86) 84.21 (12.01)
MAS score 0.59 (0.32) 0.60 (0.30)
Extension at MCP joint 11.19 (2.33) 10.66 (2.11)
Extension at wrist joint 22.38 (3.11) 21.92 (3.00)
BAT = Bilateral arm training, CT = Conventional therapy, mMMSE =
Modified Mini‑Mental State Examination, MAS = Modified Ashworth Scale,
MCP = Metacarpophalangeal, SD = Standard deviation
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
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).
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
0.686 section Test scores showed significant improvements in
0.892 the bilateral arm training group (P = 0.001). Patients in
0.660 BAT group had greater gains than conventional therapy
patients (P = 0.693).
0.812
0.777 The MAL test scores showed significant improvement
0.514 on posttest  (P  =  0.00). Post hoc analysis revealed that
0.892 the posttest score of AOU  (P  =  0.001) and quality
0.415 of movement  (QOM)  (P  =  0.000) are significantly
higher than the pretest score both in BAT and
conventional therapy group. Although there was

Table 2: Descriptive and inferential statistics for the outcome measures

Outcome measure, Pretest Postrest f P
mean (SD) BAT CT BAT CT
ARA 33.14 (5.60) 33.60 (2.34) 44.4 (8.29) 33.78 (3.28) 8.219 0.001
FMA 37.28 (5.01) 38.28 (2.33) 44.78 (6.26) 36.92 (3.22) 8.444 0.001
MAL AOU 1.71 (0.41) 1.73 (0.44) 2.4 (.64) 1.7 (0.65) 11.777 0.000
QOM 2.57 (0.42) 2.14 (0.66) 3.64 (0.49) 2.71 (0.62) 45.190 0.000
MAL = Motor Activity Log, AOU = Amount of use, SD = Standard deviation, ARA = Action research arm, FMA = Fugl‑Meyer Assessment, QOM = Quality of
movement, BAT = Bilateral arm training, CT = Conventional therapy

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Sethy, et al.: BAT for stroke upper extremity recovery
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.
Discussion
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
220 International Journal of Health & Allied Sciences - Volume 7, Issue 4, October‑December 2018
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
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
Nil.
Conflicts of interest
There are no conflicts of interest.
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