1. BILATERAL UPPER EXTREMITY TRAINING Arthur Chu, SPT; Donovan Shields, SPT; Sasha Spadoni, SPT5/14/2010

2. Learning Objectives (1/2) After this presentation the learner will be able to:  Describe bimanual upper extremity training (BT) and its effectiveness following stroke  Describe the common BT approaches  Discuss the neuroplastic changes that occur with BT  Describe how the nature and timing of BT can affect recovery post stroke

3. Learning Objectives (2/2) After this presentation the learner will be able to:  Define the roles of the corticospinal vs. ipsilateral and bilateral spinal tracts in BT  Discuss the implications of interhemispheric disinhibition, as they apply to BT  Describe the limitations for use of constraint induced therapy (CIT) in children  Define unilateral training (UT) and BT and their use in rehabilitation for CP

4. History and Rationale of Bimanual UE Training  BT originally investigated by Mudie and Matyas in 1996  BT may enable activation of the damaged hemisphere via interhemispheric connections C.P. Latimer, et al., 2010  Developed to address the use of bilateral arm movements with many ADLs and is hypothesized to be a more functional training method than UT

5. What is Bimanual UE Training?  BT involves using both the involved and uninvolved upper extremities in completing tasks in either symmetrical or alternating motions  Most common intervention is the Bimanual Arm Training with Rhythmic Auditory Cueing (BATRAC)  Other interventions include  Isolated muscle repetitive task training  Whole arm function training McCombe Waller, et al., 2008

6. BATRAC  Involves using a mechanical device that alternates push and pull actions along with auditory cueing  Hand and wrist are fixed and repetitive reaching actions are completed  Several studies have shown increased functional gains in individuals who used BATRAC, however, studies have not shown this method to be more effective than unilateral training McCombe Waller, et al., 2008

7. Other Bimanual Interventions  Isolated muscle training  Trains individual muscle groups in bimanual tasks  Wrist flexors and extensors  Limited data shows effectiveness  Whole arm function training  Involves grasp, reach and release McCombe Waller, et al., 2008

8. Neural Mechanisms of BT  A widely accepted theory of bilateral movements is that symmetrical bilateral activities simultaneously activate same neural networks in either hemisphere  With unilateral activities, there believed to be interhemispheric inhibition which prevents the contralateral hemisphere from moving the opposite limb  Bimanual training decreases the interhemispheric inhibition by activation of both hemispheres simultaneously  Right and left hemispheres have symmetrical organization for hand control in the motor cortex which are both activated during BAT J.H. Cauraugh, et al., 2005

9. Neural Mechanisms of BT  There are several theories that describe neural mechanisms for BT  Most commonly supported theories include  Motor cortex disinhibition  Use of ipsilateral pathways from contralesional hemisphere J.H. Cauraugh, et al., 2005

10. Motor Cortex Disinhibition  Following stroke, transcranial magnetic stimulation has shown disruption of transcallosal inhibition which causes an imbalance between the two hemispheres  This is believed to cause an over-excitation of the non lesioned hemisphere and increased inhibition of the ipsilateral, lesioned hemisphere  Bimanual UE training is believed to help restore the balance between the two hemispheres and allow for greater improvement in the recovery of function in the hemiplegic extremity C.P. Latimer, et al., 2010

11. Ipsilateral Pathways  Believed that the contralesional hemisphere adapts to take over function of the lesioned hemisphere  Neuroplastic reorganization from intact neurons may help regenerate function in the affected upper extremity  Encourages use of injured as well as uninjured extremity for maximal neuroplastic changes C.P. Latimer, et al., 2010

12.  Systematic Review to evaluate evidence for bilateral upper extremity training as an effective treatment method following stroke  Looked at chronic stroke patients (>6 mo) to rule out spontaneous recovery  9 studies were included in the systematic review

13. Outcome Measures  Upper Extremity Portion of Fugl-Meyer Assessment (FMA)  Frenchay Arm Test (FAT)  Rivermead Motor Assessment - arm portion (RMA)  Wolf Motor Function Test (WFMT)  Modified Motor Assessment Scale (modMAS) C.P. Latimer, et al., 2010

14. Results  BT for the upper extremity following chronic stroke appears to be an effective intervention in restoring upper limb function  The BATRAC was most common and had most consistent positive results  More RCTs needed to substantiate this evidence C.P. Latimer, et al., 2010

15. J. H. Morris, et al., 2008 (N=106)  Bilateral (BT) vs. Unilateral Training (UT) in acute stroke patients  UE recovery relation to severity of initial impairment

16. Outcome Measures  Action Research Arm Test (ARAT)  Rivermead Motor Assessment (RMA)  Nine-Hole Peg Test (9HPT)  Modified Barthel Index (MBI)  Nottingham Health Profile (NHP)  Hospital Anxiety and Depression Scale (HADS) J. H. Morris, et al., 2008

17. Results  Both groups improved, but no significant differences between groups  EXCEPT: ARAT (pinch) and 9HPT, in favor of UT group J. H. Morris, et al., 2008

18. Why did the BT group do the same or worse as the UT group?  Nature of the intervention  Influence of task constraints  Dual task challenge  Timing of the intervention  Acute vs. chronic stroke Time dependent J. H. Morris, et al., 2008

19. Why did the UT group demonstrate better fine manual dexterity?  Task specificity and transfer of learning  Contralateral corticospinal tract vs. ipsilateral and bilateral spinal tracts J. H. Morris, et al., 2008

20. Other Considerations  No significant difference between groups in MBI, independence in ADLs, even though the UT group improved in dexterity  No significant difference in HRQOL and mood, despite the increase in dexterity in the UT group J. H. Morris, et al., 2008

21. K. Lin, et al., 2010 (N=33)  Effectiveness of BT vs. control intervention (CI) in chronic stroke patients (s/p=13 months) with regards to motor and functional gains

22. Outcome Measures  Normalized Movement Time (nMT)  Normalized Total Distance (nTD)  The Percentage of Movement Time at which Peak Velocity occurs (PPV)  Fugl-Meyer Assessment (FMA)  Functional Independence Measure (FIM)  Amount of Use (AOU)  Quality of Movement (QOM) K. Lin, et al., 2010

23. Results  All the kinematic movement outcome measures were significantly different, in favor of BT  Except PPV from at post treatment in the unilateral task  At post treatment, only the FMA was significantly different between BT and CI, in favor of BT K. Lin, et al., 2010

24. Why was BT better for movement straightness and efficiency?  Limb-coupling mechanism  Similar temporal and spatial parameters  Interhemispheric disinhibition  Cortical reorganization  Template from unaffected hemisphere K. Lin, et al., 2010

25. Why was there a PPV difference in bilateral, but not unilateral tasks?  Movement of only the affected arm  Undamaged hemisphere unable to generate template Interhemispheric disinhibition  Objectives affecting control strategy  Movement sequencing in bilateral tasks K. Lin, et al., 2010

26. Why was BT better for FMA?  Rebalanced interhemispheric activation and inhibition  Repetitive practice K. Lin, et al., 2010

27. Why was there no difference in FIM?  Specificity and sensitivity of the test  Aim of the test  High functioning stroke patients  Transfer of learning to ADLs  Symmetrical training K. Lin, et al., 2010

28. As a PT, what should you take from these articles?  Be aware of:  How the complexity of a movement can affect its effectiveness  The time frame of your stroke patient  How applicable your intervention is to the patient’s goals/daily life  The full extent of your patient’s injury  The difference in mechanisms of BT vs. UT  The type of movement and how it’s practiced

29. Temporal and Spatial Control Following BT vs. UT Purpose: To determine if bilateral training will show improvements in both bilateral and unilateral control parameters and if unilateral training improves unilateral but not bilateral control. Methods  18 participants were selected and randomized into two groups.  BT with rhythmic auditory cueing n=9 (5 males, 4 females)  Dose matched therapeutic exercise program n=9 ( 7 females, 2 males)  BATRAC consisted of 6 weeks of 1 hour session 3 times per week.  Reach was cued with a metronome (rate did not change over 6 weeks)  DMTE consisted of 6 weeks of 1 hour session 3 times per week.  UT based upon NDT S. McCombe Waller, et al., 2008

30. Outcome Measures  Movement time to complete task  Peak velocity  Peak acceleration  Number of units derived from ant-post displacement data S. McCombe Waller, et al., 2008  Hand path ratio that were derived from ant-post and med-lat displacement data in horizontal plane

31. Results Bilateral Reach Tasks  Between group changes favored BATRAC group for:  Variable of movement unit in the paretic arm  hand path accuracy in paretic and non-paretic arms  Within group changes favored BATRAC group for:  Movement time-P, NP  Peak acceleration-P, NP  Movement units-P, NP  Hand path accuracy-NP  Peak velocity did not change for either group  DMTE group did not demonstrate any within group changes for any measures for bilateral reach trials S. McCombe Waller, et al., 2008

32. Results Unilateral Reach Tasks  Both groups demonstrated similar results for all measures except the DMTE group:  Reduced movement time in paretic arm Conclusion  Spatial accuracy improved for the BATRAC group in both arms but temporal control did not improve between groups because rate of exercise did not increase during the training period. Temporal parameters did improve for the BATRAC within group. Implications  Bilateral training did not transfer to unilateral control  “Task Specificity”- Unilateral tasks require unilateral training and bilateral tasks require bilateral training to improve post stroke arm function S. McCombe Waller, et al., 2008

33. Efficacy of a Hand-Arm Bimanual Intensive Therapy (HABIT) in Children with Hemiplegic CP: A RCT  Purpose: To examine the efficacy of HABIT in improving the frequency and quality of bimanual hand use in children with hemiplegic cerebral palsy.  Potential limitations exist for CIT use in children  Potentially invasive to restrain non-involved UE  Used for adults to overcome non-use of hemiplegic UE. A. Gordon, et al., 2007

34. Methods  20 children with hemiplegic CP were selected into study age range (3y 6mo-15y 6mo) mild to moderate hand involvement  Structured bimanual practice  6 hours per day for 10 days  Two types of structured practice: Whole task and Part task  Treatment Intensity  Treatment group 44 hours structured practice (36 in whole task and 8 in part task)  Remainder of time in transition, toileting and choosing activities  At home involved UE use 1.4h/day during10 day intervention and 1.7h/day 1 month after intervention A. Gordon, et al., 2007

35. Outcome Measures  Ability of child to use affected (assisting) UE during bimanual activities  Percent of time hand was used during activities  Gross and fine motor function to detect changes in hand use  Caregivers' perceptions how much and how well child used affected UE in unimanual and bimanual tasks  Affected UE unimanual efficiency  If a change in movement pattern occurred A. Gordon, et al., 2007

36. Results  There were improved scores on all tests for the treatment group  However results of frequency of affected hand use could have been impacted  Members from both groups participated in CIMT prior to participation in the study  Quality and quantity of movement did not correlate  Task dependent A. Gordon, et al., 2007

37. Conclusion  HABIT is less invasive than CIMT  Bimanual therapy should be used in conjunction with other treatments  Training bimanual skills improved bimanual function in this specific population  More compliance with home exercise programs  Higher motivation and easier tasks  Children quickly adapt to use their unaffected UE  Structure the environment  Task specific activities A. Gordon, et al., 2007

38. Review the Learning Objectives  Describe BT and its effectiveness following stroke  Describe the common BT approaches  Discuss the neuroplastic changes that occur with BT  Describe how the nature and timing of BT can affect recovery post stroke  Define the roles of the corticospinal vs. ipsilateral and bilateral spinal tracts in BT  Discuss the implications of interhemispheric disinhibition, as they apply to BT  Describe the limitations for use of CIT in children  Define UT and BT and their use in rehabilitation for CP

39. References  Christopher Paul Latimer, Justine Keeling, Broderick Lin, Meredith Henderson, and Leigh Anne Hale. The Impact of Bilateral Therapy on Upper Limb Function after Chronic Stroke: A Systematic Review. NeuroRehabilitation. 2008; 0(0): 1-11.  Sandy McCombe Waller and Jill Whitall. Bilateral arm training: Why and who benefits? NeuroRehabiliation. 2008; 23(1): 29-41  James H. Cauraugh and Jeffery J. Summers. Neural plasticity and bilateral movements: A rehabilitation approach for chronic stroke. Progress in Neurobiology. 2005; 75(5): 309-320.  J. H. Morris, F. Wijck, S. Joice, S. A. Ogston, I. Cole, R. S. MacWalter. A Comparison of Bilateral and Unilateral Upper-Limb Task Training in Early Poststroke Rehabilitation: A Randomized Control Trial. Archives of Physical Medicine and Rehabilitation. 2008; 89:1237-45.  Keh-chung Lin, Yi-an Chen, Chia-ling Chen, Ching-yi Wu, and Ya-fen Chang. The Effects of Bilateral Arm Training on Motor Control and Functional Performance in Chronic Stroke: A Randomized Controlled Study. Neurorehabilitation and Neural Repair. 2010; 24(1): 42-51.  A. Gordon, J. Schneider, A. Chinnan, and J. Charles. Efficacy of a Hand Arm Bimanual Intensive Therapy in Children with Hemiplegic Cerebral Palsy: a Randomized Control Trial. Developmental Medicine and Child Neurology. 2007; 49: 830-838.  S. McCombe Waller, W. Liu, and J. Whitall. Temporal and Spatial Control following Bilateral versus Unilateral Training. Human Movement Science. 2008; 27(5): 749-758.