Skip to main content
  • Original article
  • Open access
  • Published:

The effect of repetitive bilateral arm training with rhythmic auditory cueing on motor performance and central motor changes in patients with chronic stroke

Abstract

Objective

The aim of this study was to compare the effects of bilateral arm training with auditory cueing (BATRAC) versus control intervention on motor performance of the upper extremity (UE) and to explore the central neurophysiological mechanism underlying this effect in moderately impaired chronic stroke patients.

Design

This was a randomized-controlled clinical trial.

Materials and Methods

Overall, 76 chronic stroke patients (mean age = 50.2 ± 6.2 years), 6–67 months after the onset of the first stroke were enrolled. They received either BATRAC (with both UE trained simultaneously in symmetric and asymmetric patterns) or control intervention (unilateral therapeutic exercises for the paretic UE). Each session lasted for 1 h, scheduled as three sessions/week (on an alternate day) for 8 successive weeks. Outcome measures included the Fugl-Meyer motor performance test for the UE (FMUE) and percutaneous transcranial magnetic stimulation to elicit motor-evoked potential (MEP) in paretic abductor pollicis brevis muscle.

Results

Group comparisons indicated a significantly better improvement in the MEP parameters (transcranial magnetic stimulation threshold, central motor conduction time, and MEP amplitude) in the BATRAC group. The FMUE scores increased in both groups, but there was no significant difference between groups in the FMUE scores.

Conclusion

These findings recommend the use of BATRAC in chronic stroke patients not only to improve motor performance but also to induce central neurophysiological effects.

References

  1. Dobkin BH. Strategies for stroke rehabilitation. Lancet Neurol 2004; 3:528–536.

    Article  Google Scholar 

  2. Mayo NE, Wood-Dauphinee S, Ahmed S, Gordon C, Higgins J, McEwen S, Salbach N. Disablement following stroke. Disabil Rehabil 1999; 21:258–268.

    Article  CAS  Google Scholar 

  3. 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; 31:2390–2395.

    Article  CAS  Google Scholar 

  4. Van Peppen RPS, Kwakkel G, Wood-Dauphinee S, Hendriks HJM, van der Wees PJ, Dekker J. The impact of physical therapy on functional outcomes after stroke: what’s the evidence?. Clin Rehabil 2004; 18:833–862.

    Article  Google Scholar 

  5. 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.

    Article  Google Scholar 

  6. 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; 292:1853–1861.

    Article  CAS  Google Scholar 

  7. McCombe Waller S, Whitall J. Fine motor control in adults with and without chronic hemiparesis: baseline comparison to nondisabled adults and effects of bilateral arm training. Arch Phys Med Rehabil 2004; 85:1076–1083.

    Article  Google Scholar 

  8. McCombe Waller S, Whitall J. Hand dominance and side of stroke affect rehabilitation in chronic stroke. Clin Rehabil 2005; 19:544–551.

    Article  Google Scholar 

  9. McCombe Waller S, Whitall J. Bilateral arm training: why and who benefits? NeuroRehabilitation 2008; 23:29–41.

    Article  Google Scholar 

  10. Stoykov ME, Lewis G, Corcos DM. Comparison of bilateral and unilateral training for upper extremity hemiparesis in stroke. Neurorehabil Neural Repair 2009; 23:945–953.

    Article  Google Scholar 

  11. Volpe BT, Lynch D, Rykman-Berland A, Ferraro M, Galgano M, Hogan N, et al. Intensive sensorimotor arm training mediated by therapist or robot improves hemiparesis in patients with chronic stroke. Neurorehabil Neural Repair 2008; 22:305–310.

    Article  Google Scholar 

  12. Chan M, Tong R, Chung K. Bilateral upper limb training with functional electric stimulation in patients with chronic stroke. Neurorehabil Neural Repair 2009; 23:357–365.

    Article  Google Scholar 

  13. 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.

    Article  CAS  Google Scholar 

  14. 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.

    Article  Google Scholar 

  15. Chang JJ, Tung WL, Wu WL, Huang MH, Su FC. Effects of robotaided 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.

    Article  Google Scholar 

  16. 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.

    Article  Google Scholar 

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

    Article  Google Scholar 

  18. 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.

    Article  Google Scholar 

  19. 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.

    Article  Google Scholar 

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

    PubMed  CAS  Google Scholar 

  21. Kwakkel G, Kollen BJ, van der Grond J, Prevo AJ. Probability of regaining dexterity in the flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. Stroke 2003; 34:2181–2186.

    Article  Google Scholar 

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

    Article  CAS  Google Scholar 

  23. Woodbury ML, Velozo CA, Richards LG, Duncan PW, Studenski S, Lai SM. Longitudinal stability of the Fugl-Meyer assessment of upper extremity. Arch Phys Med Rehabil 2008; 89:1563–1590.

    Article  Google Scholar 

  24. Chen R, Cros D, Curra A, Lazzaro VD, Lefaucheur JP, Magistris MR, et al. The clinical diagnostic utility of transcranial magnetic stimulation: report of an IFCN committee. Clin Neurophysiol 2008; 119:504–532.

    Article  Google Scholar 

  25. Dvorak J, Herdmann J, Vohnkas S. Motor evoked potentials by means of magnetic stimulation in disorders of the spine. Methods Clin Neurophysiol 1998;3:45–64.

    Google Scholar 

  26. Whitall J, McCombe-Waller S, Sorkin JD, Forrester LW, Macko RF, Hanley DF, et al. Bilateral and unilateral arm training improve motor function through differing neuroplastic mechanisms: a single-blinded randomized controlled trial. Neurorehabil Neural Repair 2011; 25:118–129.

    Article  Google Scholar 

  27. Lin KC, Chen YA, Chen CL, Wu CY, Chang YF. The effects of bilateral arm training on motor control and functional performance in chronic stroke: a randomized controlled study. Neurorehabil Neural Repair 2010; 24:42–51.

    Article  Google Scholar 

  28. Schaal S, Sternad D, Osu R, Kawato M. Rhythmic arm movement is not discrete. Nat Neurosci 2004; 7:1136–1143.

    Article  CAS  Google Scholar 

  29. Kreisel SH, Hennerici MG, Bazner H. Pathophysiology of stroke rehabilitation: the natural course of clinical recovery, use-dependent plasticity and rehabilitative outcome. Cerebrovasc Dis 2007; 23:243–255.

    Article  Google Scholar 

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

    Article  Google Scholar 

  31. Cauraugh JH, Kim S-B, Summers JJ. Chronic stroke longitudinal motor improvements: cumulative learning evidence found in the upper extremity. Cerebrovasc Dis 2008; 25:115–121.

    Article  Google Scholar 

  32. Stinear CM, Barber PA, Coxon JP, Fleming MK, Byblow WD. Priming the motor system enhances the effects of upper limb therapy in chronic stroke. Brain 2008; 131:1381–1390.

    Article  Google Scholar 

  33. Ciaramelli E, Grady CL, Moscovitch M. Top-down and bottom-up attention to memory: a hypothesis (atom) on the role of the posterior parietal cortex in memory retrieval. Neuropsychologia 2008; 46:1828–1851.

    Article  Google Scholar 

  34. Ackerley SJ, Stinear CM, Byblow WD. The effect of coordination mode on use-dependent plasticity. Clin Neurophysiol 2007; 118:1759–1766.

    Article  Google Scholar 

  35. Thaut MH, Leins AK, Rice RR, Argstatter H, Kenyon GP, Mcintosh GC, et al. Rhythmic auditory stimulation improves gait more than NDT/Bobath training in near-ambulatory patients early poststroke: a single-blind, randomized trial. Neurorehabil Neural Repair 2007; 21:455–459.

    Article  CAS  Google Scholar 

  36. Platz T, Bock S, Prass K. Reduced skillfulness of arm motor behavior 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.

    Article  CAS  Google Scholar 

  37. 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.

    PubMed  CAS  Google Scholar 

  38. Summers JJ, Kagerer FA, Garry Ml, 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.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Enas M. Shahine MD.

Rights and permissions

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and permissions

About this article

Cite this article

Shahine, E.M., Shafshak, T.S. The effect of repetitive bilateral arm training with rhythmic auditory cueing on motor performance and central motor changes in patients with chronic stroke. Egypt Rheumatol Rehabil 41, 8–13 (2014). https://doi.org/10.4103/1110-161X.128128

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.4103/1110-161X.128128

Keywords