Bilateral Arm Training

Evidence Reviewed as of before: 11-06-2018

Author(s)*: Annabel McDermott (OT); Nicol Korner-Bitensky (PhD OT); Tatiana Ogourtsova (PhD OT)

Introduction

Bilateral Arm Training (BAT) comprises repetitive practice of bilateral arm movements in symmetrical or alternating patterns. Traditionally, bilateral arm training was performed by linking both hands together so that the less-affected limb facilitated passive movement of the affected limb. Variations of bilateral arm training include bilateral isokinematic training (spatiotemporally identical active movements performed during functional tasks), use of mechanical devices to drive passive or active movement of the affected limb, or bilateral arm training with rhythmic auditory cueing or electromyography (EMG) stimulation.

The use of bilateral arm training in strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More rehabilitation is based on the assumption that symmetrical bilateral movements activate similar neural networks in both hemispheres, promoting neural plasticity and cortical repair that result in improved motor control in the affected limb. Bilateral arm training is suitable for use as an adjunct to other upper limb interventions and should involve repetitive movement during performance of novel, functional tasks.

Patient/Family Information

Author: Tatiana Ogourtsova PhD OT

What is bilateral arm training (BAT)?

Bilateral Arm Training is a type of rehabilitation that uses symmetrical (same) or alternating (opposite) movements of both arms. A strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More can disrupt the messages that are sent from your brain to your muscles; this can affect strength and movement in your arm/hand. Moving your arms during Bilateral Arm Training might send feedback to both sides of the brain (the affected and the non-affected hemispheres), which might increase brain activity. This in turn might help rebuild the side of the brain affected by the strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More, and the pathways in the brain that cause movement in the affected arm.

What is Bilateral Arm Training used for in people with stroke?

The goal of Bilateral Arm Training is to improve strength and use of the arm that was affected by the strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Are there different kinds of bilateral arm therapies?

Traditionally, Bilateral Arm Training was done by linking both hands together so that the less-affected arm helped to move the affected arm.

Variations of BAT include:

Isokinematic BAT – identical active movements of both arms
BAT with robotic or mechanical devices – the device drives the movement of the affected arm
BAT with rhythmic auditory cueing – music or a metronome are used to guide arm movements
BAT with electromyography (EMG) stimulation – an electrical stimulation is applied to the muscles of the affected arm during arm movements.

Does Bilateral Arm Training work for stroke?

The use of Bilateral Arm Training has been examined using high quality research studies. It was shown to improve arm function in some patients after strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. In particular, BAT and BAT with rhythmic auditory cueing were useful for patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More (more than 6 months after strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More) to improve movement, strength and function of the affected arm. It is important to note that results can vary from person to person.

What can I expect?

During traditional Bilateral Arm Training, you will practice repetitive and intensive exercises of both arms for 1-2 hours per day, 2-5 times per week for 2 weeks or more. In addition, your occupational therapistIn charge of the “assessment of personal and domestic care activities; evaluation and treatment of functional impairments related to change in sensorimotor, cognitive and perceptual abilities; prescription of wheelchairs and bathroom appliances; home visits; patient and family education.”(Suggested by Philips et al, 2002)
or physical therapistIn charge of the “assessment and treatment of motor functioning, including motor control, strength and physical conditioning; balance, gait and mobility retraining; home and community visits; patient and family education regarding mobility and safety issues.” (Suggested by Philips et al, 2002)
might choose other types of BAT (see above) to assist in moving and strengthening the affected arm. Your therapist will discuss with you the regime and type of BAT that is most suitable for you.

Who provides the treatment?

Bilateral Arm Training is usually administered by a physical therapistIn charge of the “assessment and treatment of motor functioning, including motor control, strength and physical conditioning; balance, gait and mobility retraining; home and community visits; patient and family education regarding mobility and safety issues.” (Suggested by Philips et al, 2002)
or an occupational therapistIn charge of the “assessment of personal and domestic care activities; evaluation and treatment of functional impairments related to change in sensorimotor, cognitive and perceptual abilities; prescription of wheelchairs and bathroom appliances; home visits; patient and family education.”(Suggested by Philips et al, 2002)
at a rehabilitation centre or at an out-patient clinic.

How long is the treatment period?

Bilateral Arm Training treatment regimens vary. Sessions may range from 45 minutes to 2 hours, from 2 to 5 times per week, and for 1 to 6 weeks. On average, it is delivered for 1 hour, 3 times per week for 4 weeks.

Are there any side effects or risks?

Bilateral Arm Training is usually administered by a trained health professional at a rehabilitation clinic. Your therapist will monitor your reactions to this therapy closely. It is important to report any feelings of discomfort or pain (such as pain at the shoulder of the affected arm). Your therapist will adjust the intensity and the duration of therapy according to your ability, endurance and progress.

Is Bilateral Arm Training for me?

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate moderate-strong evidence (Level 1b-1a) for an outcome.

A total of 40 studies (20 high quality RCTs, ten fair quality RCTs, three poor quality RCTs and seven non-randomized studies) that investigate the use of bilateral arm therapy in post-stroke upper limb rehabilitation were reviewed. Effects of bilateral arm training among patients in the acute (two studies), subacute (three studies) or chronic (30 studies) phase of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More recovery, or where the phase of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More recovery is not specific to one period (three studies) are reported. Types of bilateral arm training have been differentiated according to the following categories: generic bilateral arm training; device-driven bilateral arm training (passive/active movements using mechanical devices); bilateral arm training with rhythmic auditory cueing (BATRAC); and bilateral arm training with electromyography (EMG).

Overall, results indicate that bilateral arm training is not more effective than comparison therapies and is typically less effective than constraint induced movement therapies. Recent systematic reviews by Coupar et al., (2010) and van Delden et al (2012) drew similar conclusions. The first (Coupar et al., 2010), a Cochrane review that comprised 14 RCTs (ten of which were considered suitable for inclusion in this StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More Engine module), reported no statistically significant differences in performance of ADL, functional movement of the arm/hand or motor impairmentLoss of strength and coordination, decrease in arm or leg movement
between bilateral upper limb training vs. other specific upper limb (UL) interventions, usual care or no intervention, across all stages of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More rehabilitation. The more recent systematic reviewA systematic review is a summary of available research on a given topic that compares studies based on design and methods. It summarizes the findings of each, and points out flaws or potentially confounding variables that may have been overlooked. A critical analysis of each study is done in an effort to rate the value of its stated conclusions. The research findings are then summarized, and a conclusion is provided.
(van Delden et al., 2012) included nine RCTs (all of which are reviewed in this StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More Engine module; four of which were also reviewed by Coupar et al., 2010) and reported a marginally significant difference in UL motor function in favour of unilateral arm training vs. bilateral arm training among patients with acute or chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More and mild UL paresis, and a marginally significant difference in UL motor activity in favour of unilateral arm training vs. bilateral arm training among patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More and mild UL paresis. Other measures of upper limb impairment did not show significant differences between unilateral and bilateral arm therapy.

Different methods of bilateral arm training are more effective than others: a systematic reviewA systematic review is a summary of available research on a given topic that compares studies based on design and methods. It summarizes the findings of each, and points out flaws or potentially confounding variables that may have been overlooked. A critical analysis of each study is done in an effort to rate the value of its stated conclusions. The research findings are then summarized, and a conclusion is provided.
and meta-analysisMethod in which the results of two or more studies are statistically combined. Typically used when studies have few subjects, but similar designs. By increasing the available number of subjects, more weight can be given to the findings.
of bilateral arm training (Cauraugh et al., 2010) that included 16 comparison studies and eight pre-post design studies (15 of which were considered suitable for inclusion in this StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More Engine module), reported a significant effect of bilateral arm training combined with EMG-triggered neuromuscular stimulation, a weak trend for active and/or passive movements (i.e. using mechanical devices), and a small, non-significant effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the “effect size correlation”.
for pure bilateral therapy. While similar conclusions are drawn in the StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More Engine module, the systematic reviewA systematic review is a summary of available research on a given topic that compares studies based on design and methods. It summarizes the findings of each, and points out flaws or potentially confounding variables that may have been overlooked. A critical analysis of each study is done in an effort to rate the value of its stated conclusions. The research findings are then summarized, and a conclusion is provided.
also found a significant effect from BATRAC; discord with findings in the StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More Engine review may relate to the exclusion of several BATRAC studies from this module (see Excluded Studies for further information).

Results are organized according to stage of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More of participants and type of bilateral arm training used.

Results Table

View results table

Outcomes

Acute Phase

Dexterity

Conflicting

Two high quality RCTs (Morris et al., 2008; Morris & Van Wijck, 2012) investigated the effect of bilateral arm training on dexterity in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Conclusion: There is conflicting evidence (Level 4) from two high quality RCTs regarding the effect of bilateral arm training on dexterity in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. While a first high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found that bilateral arm training was not more effective, in the long term, than unilateral arm training; a second high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found that bilateral arm training is more effective, in the short term, than unilateral arm training in improving dexterity of patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More recovery.

Functional independence

Not effective

Health-related quality of life

Not effective

Mood / affect

Not effective

Motor function - upper extremity

Not effective

Two high quality RCTs (Morris et al., 2008; Morris & Van Wijck, 2012) investigated the effect of bilateral arm training on motor function in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that bilateral arm training is not more effective than a comparison intervention (unilateral arm training) in improving upper extremity motor function in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Subacute Phase

Dexterity

Not effective

Functional independence

Not effective

Grip strength

Not effective

Kinematics

Not effective

One poor quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Platz et al., 2001) investigated the effect of bilateral arm training on upper limb kinematics in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. This poor quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More randomized patients to receive bilateral or unilateral arm training. Movement kinematics during aiming tasks (movement time, spatial accuracy, variation of movement) were measured at post-treatment (1 week). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that bilateral arm training is not more effective than a comparison intervention (unilateral arm training) for improving upper limb movement kinematics in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Motor coordination - upper extremity

Not effective

Motor function - upper extremity

Not effective

Subacute Phase - Device-driven bilateral arm training

Dexterity

Not effective

Fatigue

Not effective

Functional independence

Not effective

Grip strength

Not effective

Motor function - upper extremity

Conflicting

Two high quality RCTs (Hesse et al., 2005, Hsieh et al., 2017) investigated the effect of device-driven bilateral arm training on upper extremity motor function in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Conclusion: There is conflicting evidence (Level 4) between two high quality RCTs regarding the effect of device-driven bilateral arm training on upper extremity motor function in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Results indicate that computerized bilateral arm training is more effective than EMG-driven electrical stimulation of paretic wrist extensors, whereas robot-assisted bilateral arm training is not more effective than task-oriented training.

Spasticity

Not effective

Stroke outcomes

Not effective

One high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Hsieh et al., 2017) investigated the effect of device-driven bilateral arm training on strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More outcomes in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. This high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More randomized patients to receive robot-assisted bilateral arm training + task-oriented training or time-matched task-oriented training alone. StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More outcomes were measured by the StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More Impact Scale (SIS – Strength, Hand function, ADL/IADL, Mobility domains) at post-treatment (4 weeks). A significant between-group difference was found for only one domain (SIS – Strength), favoring robot-assisted bilateral arm training vs. time-matched task-oriented training. No other significant between-group difference was found.

Wrist activity / rest cycles

Not effective

Wrist strength

Effective

Chronic Phase

Dexterity

Effective

Functional independence

Not effective

Four high quality RCTs (van der Lee et al., 1999; Lin et al., 2009; Lin et al., 2010;Lee et al., 2017) and one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Shim & Jung, 2015) investigated the effect of bilateral arm training on functional independence in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The fourth high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Lee et al., 2017) randomized patients to receive bilateral arm training using daily activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
or time-matched conventional occupational therapy using the Bobath approach; both groups received conventional occupational therapy. Functional independence was measured by the modified Barthel Index at baseline and at post-treatment (8 weeks). A significant between-group difference was found in change scores from baseline to post-treatment, favouring bilateral arm training vs. time-matched occupational therapy.

Conclusion: There is strong evidence (Level 1a) from 3 high quality RCTs that bilateral arm training is not more effective than comparison interventions (forced use therapy, mCIMT, conventional rehabilitation, occupational therapy upper limb training using neurodevelopmental techniques) for improving functional independence in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. In fact, one of these high quality RCTs found a significant between-group differences on a subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of a measure of functional independence in favor of a TCIMm compared to bilateral arm training.
Note: However, one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More and one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found that bilateral arm training is more effective than comparison interventions (time-matched conventional occupational therapy using the Bobath approach, unilateral arm training) in improving functional independence in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. The difference in measurement tools used and treatment duration across studies could potentially account for the discrepancies in findings.

Grip strength

Not effective

Kinematics - upper extremity

Effective

Four high quality RCTs (Summers et al., 2007; Lin et al., 2010; Wu et al., 2011; Wu et al., 2012) investigated the effect of bilateral arm training on upper extremity movement kinematics in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The third high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Wu et al., 2011) randomized patients to receive bilateral arm training, modified constraint induced movement therapy (mCIMT) or conventional rehabilitation. Upper extremity movement kinematics (NMT, NMU, PV, PPV) during unilateral and bilateral reach movements were measured at post-treatment (3 weeks). Comparison of bilateral arm training vs. conventional rehabilitation revealed significant between-group differences (unilateral/bilateral NMU, unilateral/bilateral PV), favouring bilateral arm training. Comparison of bilateral arm training vs. mCIMT revealed a significant between-group difference (unilateral NMU), favouring mCIMT.
Note: Significant between-group differences (unilateral/bilateral NMU) were found favouring mCIMT vs. conventional rehabilitation.

The fourth high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Wu et al., 2012) randomized patients to receive therapist-based bilateral arm training, robot-assisted bilateral arm training, or conventional rehabilitation. Upper extremity movement kinematics (NMT, NMU, NTrD, trunk contribution slope for the middle part during unilateral and bilateral movements, angular changes of shoulder flexion during unilateral and bilateral movements) were measured at post-treatment (4 weeks). Comparison of therapist-led bilateral arm training vs. conventional rehabilitation revealed significant between-group differences in unilateral kinematics (NMT, NMU, NTrD, trunk contribution slope for the middle part during unilateral movement) and bilateral kinematics (trunk contribution slope for the middle part during bilateral movement), favouring therapist-led bilateral arm training. Comparison of therapist-led bilateral arm training vs. robot-assisted bilateral arm training revealed significant differences in unilateral kinematics (trunk contribution slope for the middle part during unilateral movements), in favour of therapist-led bilateral arm training.
Note: Robot-assisted bilateral arm training results are reported in the device-drive bilateral arm training section.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs that bilateral arm training is more effective than comparison interventions (neurodevelopmental techniques, conventional rehabilitation) in improving upper extremity kinematics in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.
Note: However, one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found that bilateral arm training was not more effective than unilateral arm training.

NMT: Normalized movement time
NMU: Normalized movement unit
NTrD: Normalized trunk displacement
NTD: Normalized trajectory distance
PV: Peak velocity
PPV: Percentage peak velocity

Motor activity - upper extremity

Not effective

Five high quality RCTs (van der Lee et al., 1999; Lin et al., 2009; Lin et al., 2010; Wu et al., 2011; Wu et al., 2012), two fair quality RCTs (Shim & Jung, 2015; Sethy et al., 2016) and one poor quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Wu et al., 2010) investigated the effect of bilateral arm training on upper extremity motor activity in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Shim & Jung, 2015) randomized patients to receive bilateral or unilateral arm training using functional tasks. Upper extremity motor activity (paretic/non-paretic side: amount, intensity) was measured by Actisleep accelerometry at post-treatment (6 weeks). Significant between-group differences were found on both measures of upper extremity motor activity of the paretic limb (amount; intensity: reduced sedentary activity, increased moderate activity), favouring bilateral vs. unilateral arm training.

The second fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Sethy et al., 2016) randomized patients to receive bilateral arm training, mCIMT, or conventional occupational therapy. Upper extremity motor activity was measured by the MAL-AOU and MAL-QOM at baseline and at post-treatment (8 weeks). The bilateral arm training group demonstrated significant gains on both measures of motor activity from pre- to post-treatment.
Note: Between-group differences were not clearly reported, results are not used to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) More in the conclusion below.

The poor quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Wu et al., 2010) randomized patients to receive bilateral arm training or mCIMT. Upper extremity motor activity was measured by the MAL- AOU and MAL-QOM at post-treatment (3 weeks). Between-group differences were not reported and no within-group statistical analysis is available.
Note: Results are not used to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) More in the conclusion below.

Conclusion: There is strong evidence (Level 1a) from five high quality RCTs that bilateral arm training is not more effective than comparison interventions (forced use therapy, modified constraint induced movement therapy, conventional rehabilitation, neurodevelopmental techniques) for improving upper extremity motor activity in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. In fact, two high quality RCTs found that mCIMT was more effective than bilateral arm training.
Note: However, one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found that bilateral arm training is more effective than a comparison intervention (unilateral arm training using functional tasks) in improving upper extremity motor activity.

Motor function - upper extremity

Conflicting

Eight high quality RCTs (van der Lee et al., 1999; Suputtitada et al., 2004; Summers et al., 2007; Lin et al., 2009; Lin et al., 2010; Wu et al., 2011; Wu et al., 2012; Lee et al., 2017), four fair quality RCTs (Stoykov et al., 2009; Hayner et al., 2010; Singer et al., 2013; Sethy et al., 2016), and one poor quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Wu et al., 2010) investigated the effect of bilateral arm training on upper extremity motor function in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The fourth high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Lin et al., 2009) randomized patients to receive bilateral arm training, modified CIMT (mCIMT) or dose-matched conventional rehabilitation comprising neurodevelopmental therapy and compensatory practice of functional tasks. Upper extremity motor function was measured by the FMA-UE (Overall, Proximal, Distal scores) at post-treatment (3 weeks). Significant between-group differences were found on all measures of upper extremity motor function, favouring bilateral arm training vs. conventional rehabilitation. There were no significant differences between bilateral arm training and mCIMT.
Note: Significant between-group differences on two measures of upper extremity motor function (FMA-UE Overall, Distal scores) were found, favouring mCIMT vs. conventional rehabilitation.

The sixth high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Wu et al., 2011) randomized patients to receive bilateral arm training, mCIMT or conventional rehabilitation. Upper extremity motor function was measured by the Wolf-Motor Function Test (WMFT – Performance time, Functional ability, Strength) at post-treatment (3 weeks). No significant differences were found between bilateral arm training and mCIMT, or between bilateral arm training and conventional rehabilitation.
Note: Significant between-group differences on two measures of upper extremity motor function (WMFT – Performance time, Functional ability) were found at post-treatment, favouring mCIMT vs. conventional rehabilitation.

The seventh high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Wu et al., 2012) randomized patients to receive therapist-led bilateral arm training, robot-assisted bilateral arm training, or conventional rehabilitation. Upper extremity motor function was measured by the FMA-UE (Total, Proximal, Distal scores) at post-treatment (4 weeks). Comparison of therapist-led bilateral arm training vs. conventional rehabilitation revealed a significant between-group difference (FMA-UE Distal score), favouring therapist-led bilateral arm training. There were no differences between therapist-led and robot-assisted bilateral arm training.
Note: Robot-assisted bilateral arm training results are reported in the device-drive bilateral arm training section.

The eighth high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Lee et al., 2017) randomized patients to receive bilateral arm training using daily activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
or time-matched conventional occupational therapy using the Bobath approach; both groups received conventional occupational therapy. Upper extremity motor function was measured by the FMA-UE at post-treatment (8 weeks). A significant between-group differences was found for change scores from baseline to post-treatment, favouring bilateral arm training vs. time-matched occupational therapy.

The first fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Stoykov et al., 2009) randomized patients to receive functional bilateral or unilateral arm training. Upper extremity motor function was measured by the Motor Status Scale (MSS – Shoulder/elbow, Wrist/hand) and the Motor Assessment Scale (MAS – Upper arm function, Hand movements, Advanced hand activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
, Total score) at post-treatment (8 weeks). A significant between-group difference was found for only one measure of upper extremity motor function (MAS – Upper arm function), favouring bilateral vs. unilateral arm training.

The third fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Singer et al., 2013) randomized patients to receive bilateral or unilateral task-specific arm training. Upper extremity motor function was measured by the FMA-UE and the Arm Motor Ability Test at post-treatment (6 weeks) and follow-up (1 month, 3 months). No significant between-group differences were found at any time point.

The fourth fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Sethy et al., 2016) randomized patients to receive bilateral arm training, mCIMT, or conventional occupational therapy. Upper extremity motor function was measured by the FMA-UE (Proximal, Distal scores) and the ARAT at baseline and at post-treatment (8 weeks). The bilateral arm training group demonstrated significant improvements in some measures of motor function (FMA-UE – Proximal scores, ARAT) from pre- to post-treatment.
Note: Between-group differences were not clearly stated, results are not used to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) More in the conclusion below.

The poor quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Wu et al., 2010) randomized patients to receive bilateral arm training or mCIMT. Upper extremity motor function was measured by the FMA-UE and the ARAT at post-treatment (3 weeks). Between-group differences were not reported and no within-group statistical analysis is available.
Note: Results are not used to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) More in the conclusion below.

Conclusion: There is conflicting evidence (Level 4) regarding the use of bilateral arm training to improve upper extremity motor function in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. While five high quality RCTs found bilateral arm training was more effective than comparison interventions (unilateral movement training, dose-matched conventional rehabilitation comprising neurodevelopmental therapy and compensatory practice of functional tasks, occupational therapy upper limb training using neurodevelopmental techniques and Bobath approach), three high quality RCTs and two fair quality RCTs found it was not more effective than similar interventions (forced use therapy, mCIMT, conventional rehabilitation, unilateral task-specific arm training). In fact, one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More and one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found that mCIMT was more effective than bilateral arm training.

Pinch strength

Not effective

Conclusion: There is moderate evidence (Level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that bilateral arm training is not more effective than a comparison intervention (CIMT) for improving pinch strength in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. In fact, the high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found that CIMT was more effective than bilateral arm training.

Strength - upper extremity

Conflicting

Two fair quality RCTs (Stoykov et al., 2009; Shim & Jung, 2015) investigated the effect of bilateral arm training on upper extremity strength in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Conclusion: There is conflicting evidence (Level 4) between two fair quality RCTs regarding the effectiveness of bilateral arm training vs. unilateral arm training on upper extremity strength in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. While a first fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found that bilateral arm training was not more effective than unilateral arm training; a second fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found that bilateral arm training is more effective than unilateral arm training in improving upper extremity strength in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Stroke outcomes

Not effective

Two high quality RCTs (Lin et al., 2009; Wu et al., 2012) investigated the effects of bilateral arm training on strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More outcomes in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Lin et al., 2009) randomized patients to receive bilateral arm training, modified constraint induced therapy (mCIMT) or dose-matched conventional rehabilitation comprising neurodevelopmental therapy and compensatory practice of functional tasks. StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More outcomes were measured by the StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More Impact Scale (SIS – Total score, Strength, Memory, Emotion, Communication, ADL/IADL, Mobility, Hand function, Social participationAs defined by the International Classification of Functioning, Disability and Health, participation is an individual’s involvement in life situations in relation to health conditions, body functions or structures, activities, and contextual factors. Participation restrictions are problems an individual may have in the manner or extent of involvement in life situations. More) at post-treatment (3 weeks). Significant between-group differences were found on three domains (SIS – Total score, ADL/IADL, Social participationAs defined by the International Classification of Functioning, Disability and Health, participation is an individual’s involvement in life situations in relation to health conditions, body functions or structures, activities, and contextual factors. Participation restrictions are problems an individual may have in the manner or extent of involvement in life situations. More), favouring mCIMT vs. bilateral arm training. No significant differences between bilateral arm training and conventional rehabilitation were found.
Note: Significant between-group differences in three domains (SIS – Total score, ADL/IADL, Hand function) were found favouring mCIMT vs. conventional rehabilitation.

The second high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Wu et al., 2012) randomized patients to receive therapist-led bilateral arm training, robot-assisted bilateral arm training using the Bi-Manu-Track arm trainer, or conventional rehabilitation. StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More outcomes were measured by the SIS at post-treatment (4 weeks). No significant between-group differences were found between therapist-led bilateral arm training vs. conventional rehabilitation, or between therapist-led vs. robot-assisted bilateral arm training.
Note: Robot-assisted bilateral arm training results are reported in the device-drive bilateral arm training section.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that bilateral arm training is not more effective than comparison interventions (mCIMT, conventional rehabilitation) for improving strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More outcomes in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. In fact, one of the high quality RCTs found that mCIMT was more effective than bilateral arm training for improving strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More outcomes.

Chronic Phase - Bilateral Arm Training with electromyography (EMG) stimulation

Dexterity

Effective

Conclusion: There is limited evidence (Level 2b) from one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that bilateral arm training with EMG stimulation is effective in improving dexterity in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Kinematics - upper extremity

Effective

Two fair quality RCTs (Cauraugh & Kim, 2002; Cauraugh, Kim & Duley, 2005) investigated the effect of bilateral arm training with EMG stimulation on movement kinematics in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Cauraugh & Kim, 2002) randomized patients to receive bilateral arm training + EMG-triggered neuromuscular stimulation of wrist and finger extensors, unilateral arm training and EMG-triggered neuromuscular stimulation of wrist and finger extensors, or active wrist and finger extension exercises. Movement kinematics (motor reaction time) were measured at baseline and at post-treatment (2 weeks). A significant within-group difference was reported for bilateral arm training + EMG stimulation and unilateral arm training + EMG stimulation, but not for active wrist and finger extension exercises.
Note: Between-group differences were not clearly reported.

The second fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Cauraugh, Kim & Duley, 2005) randomized patients to receive bilateral or unilateral arm training with active EMG-neuromuscular stimulation. Movement kinematics (peak velocity, variability in peak velocity, percentage of total movement time in acceleration/deceleration phase, median reaction time, movement time) were measured at post-treatment (2 weeks). The bilateral arm training group demonstrated significant improvements in several movement kinematics measures (higher peak velocity when moving both arms together, less variability in peak velocity when moving the paretic limb alone, less percentage of total movement time in the deceleration phase when moving both arms together, movement time). The unilateral arm training group demonstrated high peak velocity when moving the paretic arm only.
Note: Between-group differences were not reported.

Conclusion: There is limited evidence (Level 2b) from two fair quality RCTs that bilateral arm training with EMG stimulation is effective in improving upper extremity movement kinematics in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Wrist strength

Effective

Conclusion: There is limited evidence (Level 2b) from one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that bilateral arm training with EMG stimulation is effective in improving wrist strength in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Chronic Phase - Bilateral Arm Training with Rhythmic Auditory Cueing (BATRAC)

Dexterity

Not effective

Two high quality RCTs (Dispa et al., 2013; Waller et al., 2014) and one poor quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Rosa et al., 2010) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on dexterity in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first high quality cross-over RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Dispa et al., 2013) randomized patients to receive bilateral movement therapy with rhythmic auditory cueing or unilateral movement therapy with rhythmic auditory cueing. Dexterity was measured by the Purdue Pegboard Test at post-treatment (4 weeks, 8 weeks). No significant between-group difference was found at either time point.

The poor quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Rosa et al., 2010) randomized patients to receive BATRAC or unilateral training. Dexterity was measured by the Purdue Pegboard Test at baseline and at post-treatment (6 weeks). Between-group difference was not reported. An improvement in dexterity was found in 3 of 3 unilateral training participants vs. 2 of 3 BATRAC participants. One participant from each group was not able to complete the assessment.
Note: This study is not used to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) More in the conclusion below.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that BATRAC is not more effective than comparison interventions (unilateral movement therapy with rhythmic auditory cueing, unilateral task-oriented training) in improving dexterity in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Fine motor coordination

Not effective

One non-randomized study (McCombe Waller & Whitall, 2004) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on fine motor coordination in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. This non-randomized study assigned patients to receive BATRAC. Fine motor coordination was measured by a finger tapping task (paretic/non-paretic hand consistency & rate) at baseline and at post-treatment (6 weeks). There was no significant improvement in fine motor coordination of the paretic hand. The non-paretic hand showed a significant improvement in finger tapping consistency but a significant decline in tapping rate post-treatment.

Conclusion: There is limited evidence (Level 2b) from one non-randomized study that receive BATRAC is not effective in improving fine motor coordination of the affected hand in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Functional use - upper extremity

Not effective

The high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Luft et al., 2004) randomized patients to receive BATRAC or dose-matched unilateral upper limb exercises based on neurodevelopmental techniques. Functional use of the upper extremity was measured by the University of Maryland Arm Questionnaire for StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More (UMAQS) at post-treatment (6 weeks). No significant between-group difference was found.

The first non-randomized study (Whitall et al., 2000) assigned patients to receive BATRAC. Functional use of the upper extremity was measured by the UMAQS at baseline, at post-treatment (6 weeks) and follow-up (2 months). There were significant improvements in daily use of the hemiparetic arm at both post-intervention measurement times compared to the baseline.

The second non-randomized study (McCombe Waller & Whitall, 2004) assigned patients to receive BATRAC. Functional use of the upper extremity was measured by the UMAQS at post-treatment (6 weeks). Significant improvement was found.

Grip strength

Not effective

The high quality cross-over RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Dispa et al., 2013) randomized patients to receive bilateral movement therapy with rhythmic auditory cueing or unilateral movement therapy with rhythmic auditory cueing. Grip-lift force coordination (preloading phase, loading phase, grip force max, hold ratio, cross-correlation coefficient, time shift) was measured by manipulandum sensors at post-treatment (4 weeks, 8 weeks). No significant between-group differences were found at either time point.

The non-randomized study (Whitall et al., 2000) assigned patients to receive BATRAC. Grip strength was measured by dynamometer at baseline, at post-treatment (6 weeks) and follow-up (2 months). No significant improvement was found at the two post-intervention measurement times compared to the baseline.

Kinematics - upper extremity

Not effective

Motor function - upper extremity

Not effective

Five high quality RCTs (Luft et al., 2004; Whitall et al., 2011; Dispa et al., 2013; Shahine & Shafshak, 2014; Waller et al., 2014), one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (McCombe Waller, Liu & Whitall, 2008), one poor quality RCT(Rosa et al., 2010) and two non-randomized studies (Whitall et al., 2000; McCombe Waller & Whitall, 2004) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on upper extremity motor function in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The third high quality cross-over RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Dispa et al., 2013) randomized patients to receive BATRAC or unilateral arm training with rhythmic auditory cueing. Upper extremity motor activity was measured by the ABILHAND Questionnaire at post-treatment (4 weeks, 8 weeks). No significant between-group difference was found at either time point.

The fifth high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Waller et al., 2014) randomized patients to receive BATRAC or unilateral task-oriented training for 6 weeks (phase 1), followed by unilateral task-oriented training for 6 weeks (phase 2). Upper extremity motor function was measured by the FMA-UE, modified WMFT (mWMFT), and the University of Maryland Arm Questionnaire for StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More (UMAQS) at baseline, at post-phase 1 (6 weeks), post-phase 2 (12 weeks) and follow-up (18 weeks). There were no significant differences between groups post-phase 1 (6 weeks). However, significant between-group differences were found for two measures of upper extremity motor function (mWMFT, UMAQS) change scores from baseline to post-phase 2 and from baseline to follow-up, favouring BATRAC vs. unilateral task-oriented training.

The fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (McCombe Waller, Liu & Whitall, 2008) randomized patients to receive BATRAC or unilateral upper limb training based on neurodevelopmental techniques. Upper extremity motor function was measured by the FMA-UE and mWMFT (Time, Strength scores) at post-treatment (6 weeks). Between-group differences were not reported. The BATRAC group demonstrated significant improvements on all measures of upper extremity motor function; the unilateral upper limb training group demonstrated significant improvements on two measures (FMA-UE; mWMFT – Strength).
Note: This study is not used to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) More in the conclusion below.

The poor quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Rosa et al., 2010) randomized patients to receive BATRAC or unilateral training. Upper extremity motor function was measured by the FMA-UE at baseline and at post-treatment (6 weeks). No between-group difference was reported. An improvement was found in 3 of 4 unilateral training group participants, vs. 1 of 4 BATRAC participants; 2 of 4 BATRAC participants demonstrated poorer upper extremity motor function at post-treatment.
Note: This study is not used to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) More in the conclusion below.

The first non-randomized study (Whitall et al., 2000) assigned patients to receive BATRAC. Upper extremity motor function was measured by the FMA-UE (Motor performance section) and the WMFT (Time, Strength, Function scores) at post-treatment (6 weeks) and follow-up (2 months). Significant improvements in two measures of upper extremity motor function (FMA-UE; WMFT – Time) were found at both time points.

The second non-randomized study (McCombe Waller & Whitall, 2004) assigned patients to receive BATRAC. Upper extremity motor function was measured by the FMA-UE and WMFT at post-treatment (6 weeks). Significant improvements in both measures of upper extremity motor function were found.

Conclusion: There is strong evidence (Level 1a) from five high quality RCTs that BATRAC is not more effective than comparison interventions (upper extremity exercises based on neurodevelopmental techniques, unilateral therapeutic exercises based on neurodevelopmental techniques, unilateral arm training with rhythmic auditory cueing, unilateral upper extremity rehabilitation, unilateral task-oriented training) for improving upper extremity motor function in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. A poor quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More reported poorer outcomes following BATRAC vs. unilateral training.
Note: However, one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More reported long-term benefits of BATRAC vs. unilateral task-oriented training. Furthermore, one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More and two non-randomized studies reported significant improvements in upper extremity motor function following BATRAC.

Motor recovery - upper extremity

Effective

Range of motion - upper extremity

Not effective

One non-randomized study (Whitall et al., 2000) investigated the use of bilateral arm training with rhythmic auditory cueing (BATRAC) on range of motion in the upper extremity in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. This non-randomized study assigned patients to receive BATRAC. Active and passive range of motion (aROM, pROM) at the shoulder (flexion, extension, abduction, adduction), elbow (flexion, extension), wrist (flexion, extension) and thumb (opposition) was measured at post-treatment (6 weeks) and follow-up (2 months). At post-treatment significant improvements in shoulder aROM (extension only), wrist aROM/pROM (flexion only), and thumb aROM (opposition) were found. At follow-up, improvements in wrist pROM (flexion only) and thumb aROM (opposition) were maintained.

Conclusion: There is limited evidence (Level 2b) from one non-randomized study that BATRAC is not effective for improving upper extremity range of motion in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.
Note: However, the study found significant and sustained improvements in wrist flexion and thumb opposition.

Satisfaction with activities and participation

Not effective

One high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Dispa et al., 2013) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on satisfaction with activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
and participationAs defined by the International Classification of Functioning, Disability and Health, participation is an individual’s involvement in life situations in relation to health conditions, body functions or structures, activities, and contextual factors. Participation restrictions are problems an individual may have in the manner or extent of involvement in life situations. More in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. This high quality cross-over RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More randomized patients to receive BATRAC or unilateral arm training with rhythmic auditory cueing. Satisfaction with activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
and participationAs defined by the International Classification of Functioning, Disability and Health, participation is an individual’s involvement in life situations in relation to health conditions, body functions or structures, activities, and contextual factors. Participation restrictions are problems an individual may have in the manner or extent of involvement in life situations. More was measured by the SATIS-Stroke Questionnaire at post-treatment (4 weeks, 8 weeks). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high-quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that bilateral arm training is not more effective than a comparison intervention (unilateral arm training with rhythmic auditory cueing) in improving satisfaction with activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
and participationAs defined by the International Classification of Functioning, Disability and Health, participation is an individual’s involvement in life situations in relation to health conditions, body functions or structures, activities, and contextual factors. Participation restrictions are problems an individual may have in the manner or extent of involvement in life situations. More in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Spasticity

Not effective

Strength - upper extremity

Not effective

Two high quality RCTs (Luft et al., 2004; Whitall et al., 2011) and one non-randomized study (Whitall et al., 2000) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on upper extremity strength in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The second high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Whitall et al., 2011) randomized patients to receive BATRAC or dose-matched unilateral therapeutic exercises based on neurodevelopmental techniques. Isometric shoulder strength (flexion/extension) and isokinetic elbow (flexion/extension) and wrist (flexion/extension) strength of the paretic/non-paretic limbs were measured by dynamometer at post-treatment (6 weeks) and at follow-up (4 months). No significant between-group differences in shoulder strength were found at either time point. Significant between-group differences in strength of the non-paretic elbow (flexion only) and non-paretic wrist (flexion only) were found at post-treatment, favouring BATRAC vs. neurodevelopmental techniques. Conversely, a significant between-group difference in strength of the paretic wrist (extension only) was found, favouring the neurodevelopmental approach vs. BATRAC. Differences remained significant at follow-up.

One non-randomized study (Whitall et al., 2000) assigned patients to receive BATRAC. Isometric strength of the paretic/non-paretic shoulder, elbow and wrist (flexion/extension) was measured at post-treatment (6 weeks) and follow-up (2 months). At post-treatment there were no significant changes in shoulder or elbow strength, but there was a significant improvement in paretic wrist strength (flexion only). At follow-up there was a significant improvement in non-paretic elbow strength (flexion only) and non-paretic wrist strength(extension).

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that BATRAC is not more effective than a comparison intervention (neurodevelopmental techniques) in improving paretic upper extremity strength (shoulder, elbow, wrist).
Note: BATRAC was more effective than neurodevelopmental techniques in improving non-paretic wrist and elbow strength, whereas the neurodevelopmental approach was more effective than BATRAC for improving paretic wrist strength. Furthermore, a non-randomized study found significant short-term improvements in paretic wrist strength (flexion only), and significant long-term improvements in non-paretic elbow strength (flexion only) and non-paretic wrist strength (extension), following a BATRAC.

Stroke outcomes

Not effective

One high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Whitall et al., 2011) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More outcomes in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. This high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More randomized patients to receive BATRAC or dose-matched unilateral therapeutic exercises based on neurodevelopmental techniques. StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More outcomes were measured with the StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More Impact Scale (SIS – Total, Emotion, Hand function, Strength domains) at post-treatment (6 weeks) and at follow-up (4 months). A significant between-group difference was found for one score (SIS – Total score) at follow-up only, favouring BATRAC vs. unilateral neurodevelopmental techniques.

Chronic Phase - Bilateral video game training

Motor function - upper extremity

Effective

One non-randomized study (Hijmans et al., 2011) investigated the effect of bilateral video game training on upper extremity motor function in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. This non-randomized design study assigned patients to receive unilateral mouse-based computer game training using the less-affected hand (phase 1), then a washout period of no training (phase 2), then bilateral video game training using the CyWee Z game controller (phase 3). Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity (FMA-UE), the Wolf-Motor Function Test (WMFT), and the Disabilities of Arm Shoulder and Hand (DASH) at baseline and following phase 1 (unilateral training, 2.5 weeks), phase 2 (washout period, approx. week 5) and phase 3 (bilateral training, 7.5 weeks). A significant improvement was found in one measure of upper extremity motor function (FMA-UE) from baseline to phase 3.

Conclusion: There is limited evidence (Level 2b) from one non-randomized study that bilateral video game training is effective for improving upper extremity motor function in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.
Note: However, results were only significant for 1 of 3 measures of upper extremity motor function used.

Chronic Phase - Device-driven bilateral arm training

Cognitive function

Not effective

Depression

Not effective

One fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Byl et al., 2013) investigated the effect of device-driven bilateral arm training on depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. This fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More randomized patients to receive bilateral robotic task specific repetitive training (TSRT) using the UL-EXO7 robotic orthosis, or unilateral robotic TSRT, or unilateral physical therapist-led TSRT. DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
was measured by the Beck DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Inventory at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that device-driven bilateral arm training is not more effective than comparison interventions (unilateral robotic training, unilateral therapist-led training) in improving depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Dexterity

Not effective

Functional independence

Not effective

The high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Lum et al., 2002) randomized patients to receive bilateral robot-assisted movement training using the MIT-MANUS robot manipulator or conventional upper limb rehabilitation using neurodevelopmental techniques. Functional independence was measured by the Functional Independence Measure (FIM) and the Barthel Index at mid-treatment (1 month), post-treatment (2 months) and follow-up (6 months). A significant between-group difference was found for one measure of functional independence (FIM) at follow-up (6 months) only, favouring bilateral robot-assisted movement training vs. neurodevelopmental techniques.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More and one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that device-driven bilateral arm training is not more effective than comparison interventions (neurodevelopmental techniques, unilateral robotic training, unilateral therapist-led training) for improving functional independence in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.
Note: The high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found long-term gains in functional independence in favour of bilateral device-driven bilateral arm training vs. neurodevelopmental techniques.

Grip strength

Not effective

The non-randomized study (Chang et al., 2007) assigned patients to receive robot-aided bilateral training using a bilateral force-induced isokinetic arm movement trainer (BFIAMT) and conventional rehabilitation. Grip strength was measured by a Jamar dynamometer at post-treatment (8 weeks) and follow-up (16 weeks). A significant improvement was found at both time points.

Kinematics

Effective

Thee high quality RCTs (Lum et al., 2002; Wu et al., 2012; Wu et al., 2013) and one non-RCT design study (Chang et al., 2007) investigated the effect of device-driven bilateral arm training on movement kinematics in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The second high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Wu et al., 2012) randomized patients to receive robot-assisted bilateral arm training using the Bi-Manu-Track arm trainer, therapist-led bilateral arm training, or conventional rehabilitation. Movement kinematics (NMT, NMU, NTD, trunk contribution slope for the middle part during unilateral and bilateral movement, angular changes of shoulder flexion during unilateral and bilateral movements) were measured at post-treatment (4 weeks). Comparison of robot-assisted bilateral arm training vs. conventional rehabilitation revealed significant differences (angular changes of normalized shoulder flexion during unilateral and bilateral movements), favouring robot-assisted bilateral arm training. Comparison of robot-assisted bilateral arm training vs. therapist-led bilateral arm training revealed a significant difference in one variable (angular changes of normalized shoulder flexion during unilateral movements), favouring robot-assisted bilateral arm training.
Note: There was a significant difference in one variable (unilateral trunk contribution slop for the middle part), in favour of therapist-led bilateral arm training vs. robot-assisted bilateral arm training; further therapist-led bilateral arm training results are reported in the bilateral arm training section above.

The third high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Wu et al., 2013) randomized patients to receive robot-assisted bilateral arm training using the Bi-Manu-Track arm trainer, robot-assisted unilateral arm training or conventional rehabilitation. Movement kinematics (NMT, NMU, trunk contribution, slope start/mid during unilateral and bilateral movements) were measured at post-treatment (4 weeks). Comparison of bilateral vs. unilateral robot-assisted arm training revealed a significant between-group difference for one variable (slope start during bilateral movement), favouring robot-assisted bilateral arm training. There were no significant differences between robot-assisted bilateral arm training and conventional rehabilitation.
Note: Comparison of robot-assisted unilateral arm training vs. conventional rehabilitation revealed a significant between-group difference for one measure (slope mid during bilateral movement), favouring conventional rehabilitation.

The non-randomized study (Chang et al., 2007) assigned patients to receive robot-aided bilateral training using a bilateral force-induced isokinetic arm movement trainer (BFIAMT) and conventional rehabilitation. Reaching movement kinematics (movement time, peak velocity, percentage of time to peak velocity, normalized jerk score) were measured at post-treatment (8 weeks) and follow-up (16 weeks). Significant improvements in all reaching movement kinematics were found at post-treatment, but these did not remain significant at follow-up.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs that device-driven bilateral arm training is more effective than comparison interventions (conventional upper limb rehabilitation using neurodevelopmental techniques, conventional rehabilitation,therapist-led bilateral arm training, or robot-assisted unilateral arm training) for improving kinematics in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Further, a non-randomized study found significant short-term improvement in reach kinematics following robot-aided bilateral training.

NMT: Normalized movement time
NMU: Normalized movement unit
NTD: Normalized trunk displacement

Motor activity - upper extremity

Not effective

Two high quality RCTs (Wu et al., 2012; Wu et al., 2013) investigated the effect of device-driven bilateral arm training on upper extremity motor activity in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Motor function - upper extremity

Not effective

Three high quality RCTs (Lum et al., 2002; Wu et al., 2012; Wu et al., 2013), two fair quality RCTs (Stinear et al., 2008; Byl et al., 2013), and two non-RCT design studies (Hesse et al., 2003; Chang et al., 2007) investigated the effect of device-driven bilateral arm training on the upper extremity motor function in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The third high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Wu et al., 2013) randomized patients to receive bilateral robot-assisted arm training using the Bi-Manu-Track arm trainer, unilateral robot-assisted arm training or conventional rehabilitation. Upper extremity motor function was measured by the Wolf-Motor Function Test (WMFT – Time, Functional ability scores) at post-treatment (4 weeks). Comparison of bilateral and unilateral robot-assisted arm training revealed a significant between-group difference on one measure (WMFT – Time), favouring unilateral vs. bilateral robot-assisted arm training. No other between-group differences were found.

The first non-randomized study (Hesse et al., 2003) assigned patients to receive bilateral arm training using a robotic arm trainer and conventional rehabilitation. Upper extremity motor function was measured by the Rivermead Motor Assessment at baseline, at post-treatment (3 weeks) and follow-up (3 months). No significant change was found at either time point.

The second non-randomized study (Chang et al., 2007) assigned patients to receive robot-aided bilateral training using a bilateral force-induced isokinetic arm movement trainer (BFIAMT) and conventional rehabilitation. Upper extremity motor function was measured by the FMA-UE and the Frenchay Arm Test at baseline, at post-treatment (8 weeks) and follow-up (16 weeks). A significant improvement was found for one measure of upper extremity motor function (FMA-UE) at both time points post-treatment.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that device-driven bilateral arm training is not more effective than comparison interventions (therapist-led bilateral arm training, conventional rehabilitation or unilateral robot-assisted arm training ) in improving upper extremity motor function in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. In fact, one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found that device-driven bilateral arm training was less effective than device-driven unilateral arm training on one measure of motor function. Further, one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found that device-driven bilateral arm training is not more effective than comparison intervention (therapist-led unilateral arm training) in improving upper extremity motor function.
Note: One high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found significant differences in one measure of upper extremity motor function, in favour of device-driven bilateral arm training vs. neurodevelopmental techniques. Similarly, one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found that bilateral arm training using a mechanical device was more effective in the long term than no arm training with no device for improving motor function. A non-randomized study also reported improved upper limb motor function following device-driven bilateral arm training.

Neurological recovery

Not effective

Pain

Not effective

Range of motion

Not effective

Spasticity - upper extremity

Not effective

The first non-randomized study (Hesse et al., 2003) assigned patients to receive bilateral arm training using a robotic arm trainer and conventional rehabilitation. Elbow spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
was measured by the MAS at baseline, at post-treatment (3 weeks) and follow-up (3 months). No significant change was found at either time point.

The second non-randomized study (Chang et al., 2007) provided patients with robot-aided bilateral training using a bilateral force-induced isokinetic arm movement trainer (BFIAMT) and conventional rehabilitation. Upper extremity spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
was measured by the MAS at post-treatment (8 weeks) and follow-up (16 weeks). No significant change was found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that device-driven bilateral arm training is not more effective than comparison interventions (unilateral robotic training, unilateral therapist-led training) in reducing upper extremity spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Further, two non-randomized studies found no improvements in upper extremity spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
following device-driven bilateral arm training.

Spasticity (wrist/finger)

Effective

One non-randomized study (Hesse et al., 2003) investigated the effect of device-driven bilateral arm training on wrist/finger spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. This non-randomized study assigned patients to receive bilateral arm training using a robotic arm trainer and conventional rehabilitation. Wrist/finger spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
was measured by the Modified Ashworth Scale at baseline, at post-treatment (3 weeks) and follow-up (3 months). A significant improvement was found at post-treatment but did not remain significant at follow-up.

Conclusion: There is limited evidence (Level 2b) from one non-RCT design study that device-driven bilateral arm training is effective in improving wrist/finger spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More in the short term.

Strength - upper extremity

Effective

The high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Lum et al., 2002) randomized patients to receive bilateral robot-assisted movement training using the MIT-MANUS robot manipulator or conventional upper limb rehabilitation using neurodevelopmental techniques. Shoulder strength (flexion/extension, abduction/adduction, internal/external rotation) and elbow strength (flexion/extension) was measured by torque at post-treatment (2 months). Significant between-group differences in some components of upper extremity strength (shoulder: flexion, abduction, adduction; elbow: flexion only) were found only at post-treatment, favouring bilateral robot-assisted movement training vs. neurodevelopmental techniques.

The non-randomized study (Chang et al., 2007) assigned patients to receive robot-aided bilateral training using a bilateral force-induced isokinetic arm movement trainer (BFIAMT) and conventional rehabilitation. Elbow strength (push/pull) was measured by the BFIAMT at post-treatment (8 weeks) and follow-up (16 weeks). A significant improvement was found at both time points.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that device-driven bilateral arm training is more effective than a comparison intervention (neurodevelopmental techniques) for improving upper extremity strength in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. One non-randomized study also found improvements in elbow strength following robot-aided bilateral training.
Note: However, a fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found that bilateral robotic training was not more effective than unilateral robotic training or unilateral therapist-led training in improving upper extremity strength.

Stroke outcomes

Effective

One high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Wu et al., 2012) investigated the effect of device-driven bilateral arm training on strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More outcomes in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. This high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More randomized patients to receive robot-assisted bilateral arm training using the Bi-Manu-Track arm trainer, therapist-led bilateral arm training, or conventional rehabilitation. StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More outcomes were measured by the StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More Impact Scale (SIS – Total, Strength, Memory, Emotion, Communication, ADL/IADL, Mobility, Hand function, Social participationAs defined by the International Classification of Functioning, Disability and Health, participation is an individual’s involvement in life situations in relation to health conditions, body functions or structures, activities, and contextual factors. Participation restrictions are problems an individual may have in the manner or extent of involvement in life situations. More, Physical function domain) at post-treatment (4 weeks). Comparison of robot-assisted bilateral arm training and conventional rehabilitation revealed significant between-group differences for some strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More outcomes (SIS – Total score, Strength, Physical function domain), favouring robot-assisted bilateral arm training. There were no significant differences between robot-assisted bilateral arm training and therapist-led bilateral arm training.
Note: Therapist-led bilateral arm training results are reported in the bilateral arm training section above.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that device-drive bilateral arm training is more effective than a comparison intervention (conventional rehabilitation) for improving some strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More outcomes in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Device-driven bilateral arm training was not more effective than therapist-led bilateral arm training.

Phase not specific to one period – Bilateral Arm Training with Rhythmic Auditory Cueing (BATRAC)

Dexterity

Not Effective

Motor activity - upper extremity

Not Effective

Motor function - upper extremity

Not Effective

Sensation

Not Effective

Strength - upper extremity

Not Effective

Stroke outcomes

Not Effective

One high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (van Delden et al., 2013) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More outcomes in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. This high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More randomized patients with acute/subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive BATRAC, modified constraint induced movement therapy (mCIMT) or conventional rehabilitation. StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More outcomes were measured by the StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More Impact Scale (SIS – Strength, Memory, Emotion, Communication, ADL/IADL, Mobility, Hand function, Social participationAs defined by the International Classification of Functioning, Disability and Health, participation is an individual’s involvement in life situations in relation to health conditions, body functions or structures, activities, and contextual factors. Participation restrictions are problems an individual may have in the manner or extent of involvement in life situations. More domains) at post-treatment (6 weeks) and follow-up (12 weeks). Significant between-group differences were found for two components (SIS – Strength, Emotion domains) at follow-up, favoring conventional rehabilitation vs. BATRAC.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that BATRAC is not more effective than comparison interventions (mCIMT, conventional rehabilitation) in improving strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More outcomes in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.
Note: In fact, BATRAC was found to be less effective than conventional rehabilitation in improving two strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More outcomes.

Phase not specific to one period - Device-driven bilateral arm training

Grip strength

Not effective

One non-randomized study (Stinear & Byblow, 2004) investigated the effect of device-driven bilateral arm training on grip strength in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. This non-randomized study assigned patients with subacute/chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive active-passive bimanual movement therapy using a Manipulada machine. Grip strength was measured at baseline and at post-treatment (4 weeks). No significant improvement was found.

Conclusion: There is limited evidence (Level 2b) from one non-randomized study that device-driven bilateral arm training is not effective in improving grip strength in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Motor function - upper extremity

Effective

Two non-randomized studies (Stinear & Byblow, 2004; Sampson et al., 2012) investigated the effect of device-driven bilateral arm training on upper extremity motor function in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first non-randomized study (Stinear & Byblow, 2004) assigned patients with subacute/chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive active-passive bimanual movement therapy using the Manipulada machine. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity (FMA-UE) at baseline and at post-treatment (4 weeks). A significant improvement was found at post-treatment.

The second non-randomized study (Sampson et al., 2012) assigned patients with subacute/chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive bilateral arm training using the BUiLT bilateral arm trainer. Upper extremity motor function was measured by the FMA-UE at baseline and at post-treatment (6 weeks). An improvement was found, however statistical data was not provided.
Note: This study is not used to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) More in the conclusion below.

Conclusion: There is limited evidence (Level 2b) from one non-randomized study that device-driven bilateral arm training is effective in improving upper extremity motor function in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. A second study also reported improvements following bilateral training using a device.

Strength - upper extremity

Not effective

Two non-randomized studies (Stinear & Byblow, 2004; Sampson et al., 2012) investigated the effect of device-driven bilateral arm training on upper extremity strength in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first non-randomized study (Stinear & Byblow, 2004) assigned patients with subacute/chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive active-passive bimanual movement therapy using the Manipulada machine. Wrist strength (flexion/extension) was measured at baseline and at post-treatment (4 weeks). No significant improvement was reported from baseline to post-treatment.

The second non-randomized study (Sampson et al., 2012) assigned patients with subacute/chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive bilateral arm training using the BUiLT bilateral arm trainer. Isometric strength at the shoulder (flexion, extension, abduction, external/internal rotation) and elbow (flexion/extension) was measured by dynamometer at post-treatment (6 weeks). Improved strength at the shoulder and elbow were reported, however statistical data was not provided.
Note: This study is not used to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) More in the conclusion below.

Conclusion: There is limited evidence (Level 2b) from one non-randomized study that device-driven bilateral arm training is not effective in improving upper extremity strength in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

References

Byl, N. N., Abrams, G. M., Pitsch, E., Fedulow, I., Kim, H., Simkins, M., … & Rosen, J. (2013). Chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More survivors achieve comparable outcomes following virtual task specific repetitive training guided by a wearable robotic orthosis (UL-EXO7) and actual task specific repetitive training guided by a physical therapistIn charge of the "assessment and treatment of motor functioning, including motor control, strength and physical conditioning; balance, gait and mobility retraining; home and community visits; patient and family education regarding mobility and safety issues." (Suggested by Philips et al, 2002)
. Journal of Hand Therapy, 26(4), 343-352.
http://www.sciencedirect.com/science/article/pii/S0894113013000720

Cauraugh, J.H. & Kim, S. (2002). Two coupled motor recovery protocols are better than one – electromyogram-triggered neuromuscular stimulation and bilateral movements. StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More, 33, 1589-94.
http://stroke.ahajournals.org/content/33/6/1589.short

Cauraugh, J.H., Kim, S.B., & Duley, A. (2005). Coupled bilateral movements and active neuromuscular stimulation: intralimb transfer evidence during bimanual aiming. Neuroscience Letters, 382, 39-44.
https://www.ncbi.nlm.nih.gov/pubmed/15911118

Cauraugh, J.H., Lodha, N., Naik, S.K., & Summers, J.J. (2010). Bilateral movement training and strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More motor recovery progress: A structured review and meta-analysisMethod in which the results of two or more studies are statistically combined. Typically used when studies have few subjects, but similar designs. By increasing the available number of subjects, more weight can be given to the findings.
. Human Movement Science, 29, 853-70.
https://www.ncbi.nlm.nih.gov/pubmed/19926154

Chang, J.J., Tung, W.L., Wu, W.L., Huang, M.H., & Su, F.C. (2007). Effects of robot-aided bilateral force-induced isokinetic arm training combined with conventional rehabilitation on arm motor function in patients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More. Archives of Physical Medicine and Rehabilitation, 88, 1332-8.
https://www.ncbi.nlm.nih.gov/pubmed/17908578

Coupar, F., Pollock, A., van Wijck, F., Morris, J., & Langhorne, P. (2010). Simultaneous bilateral training for improving arm function after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More. Cochrane Database of Systematic Reviews, 4. Art.No.: CD006432. DOI: 10.1002/14651858.CD006432.pub.2
https://www.ncbi.nlm.nih.gov/pubmed/20393947

Desrosiers, J., Bourbonnais, D., Corriveau, H., Gosselin, S., & Bravo, G. (2005). Effectiveness of unilateral and symmetrical bilateral task training for arm during the subacute phase after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More: a randomized controlled trial. Clinical Rehabilitation, 19, 581-93.
https://www.ncbi.nlm.nih.gov/pubmed/16180593

Dispa, D., Lejeune, T., & Thonnard, J. L. (2013). The effect of repetitive rhythmic precision grip task-oriented rehabilitation in chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More patients: a pilot study. International Journal of Rehabilitation Research, 36(1), 81-87.
http://journals.lww.com/intjrehabilres/Abstract/2013/03000/The_effect_of_repetitive_rhythmic_precision_grip.11.aspx

Hayner, K., Gibson, G., & Giles, G.M. (2010). Comparison of constraint-induced movement therapy and bilateral treatment of equal intensity in people with chronic upper-extremity dysfunction after cerebrovascular accident. American Journal of Occupational Therapy, 64, 528-39.
https://www.ncbi.nlm.nih.gov/pubmed/20825123

Hesse, S., Schulte-Tigges, G., Konrad, M., Bardeleben, A., & Werner, C. (2003). Robot-assisted arm trainer for the passive and active practice of bilateral forearm and wrist movements in hemiparetic subjects. Archives of Physical Medicine and Rehabilitation, 84, 915-20.
https://www.ncbi.nlm.nih.gov/pubmed/12808550

Hesse, S., Werner, C., Pohl, M., Rueckriem, S., Mehrholz, J., & Lingnau, M.L. (2005). Computerized arm training improves the motor control of the severely affected arm after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More – a single-blinded randomized trial in two centers. StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More, 36, 1960-6.
https://www.ncbi.nlm.nih.gov/pubmed/16109908

Hijmans, J.M., Hale, L.A., Satherley, J.A., McMillan, N.J., & King, M.J., (2011). Bilateral upper-limb rehabilitation after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More using a movement-based game controller. Journal of Rehabilitative Research & Development, 48(8), 1005-1014.
https://www.ncbi.nlm.nih.gov/pubmed/22068375

Hsieh, Y. W., Wu, C. Y., Wang, W. E., Lin, K. C., Chang, K. C., Chen, C. C., & Liu, C. T. (2017). Bilateral robotic priming before task-oriented approach in subacute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More rehabilitation: A pilot randomized controlled trial. Clinical Rehabilitation, 31(2), 225-233.
http://journals.sagepub.com/doi/abs/10.1177/0269215516633275

Lee, M. J., Lee, J. H., Koo, H. M., & Lee, S. M. (2017). Effectiveness of Bilateral Arm Training for Improving Extremity Function and ActivitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of Daily Living Performance in Hemiplegic Patients. Journal of StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More and Cerebrovascular Diseases, 26(5), 1020-1025.
http://www.sciencedirect.com/science/article/pii/S105230571630605X

Lin, K-C., Chang, Y-F., Wu, C-Y., & Chen, Y-A. (2009). Effects of constraint-induced therapyA form of intervention that involves restraining the unaffected upper or lower extremity in order to encourage movement of the affected limbs. For persons with USN, constraint-induced therapy involves restraining the unaffected arm or hand using a sling or padded mitt, in order to promote visual scanning and movement in the neglected hemispace.
versus bilateral arm training on motor performance, daily functions, and quality of life in strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More survivors. Neurorehabilitation and Neural Repair, 23(5), 441-448.
https://www.ncbi.nlm.nih.gov/pubmed/19118130

Lin, K-C., Chen, Y-A., Chen, C-L., Wu, C-Y., & Chang, Y-F. (2010). The effects of bilateral arm training on motor control and functional performance in chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More: a randomized controlled study. Neurorehabilitation and Neural Repair, 24(1), 42-51.
https://www.ncbi.nlm.nih.gov/pubmed/19729583

Luft, A.R., McCombe-Waller, S., Whitall, J., Forrester, L.W., Macko, R., Sorkin, J.D., Schulz, J.B., Goldberg, A.P., & Hanley, D.F. (2004). Repetitive bilateral arm training and motor cortex activation in chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More: a randomized controlled trial. The Journal of the American Medical Association, 292, 1853-61.
https://www.ncbi.nlm.nih.gov/pubmed/15494583

Lum, P.S., Burgar, C.G., Shor, P.C., Magmundar, M., & Van der Loos, M. (2002). Robot-assisted movement training compared with conventional therapy techniques for the rehabilitation of upper-limb motor function after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More. Archives of Physical Medicine and Rehabilitation, 83, 952-9.
https://www.ncbi.nlm.nih.gov/pubmed/12098155

McCombe Waller, S., Liu, W. & Whitall, J. (2008). Temporal and spatial control following bilateral versus unilateral training. Human Movement Science, 27, 749-58.
https://www.ncbi.nlm.nih.gov/pubmed/18639360

McCombe Waller, S. & Whitall, J. (2004). Fine motor control in adults with and without chronic hemiparesis: baseline comparison to nondisabled adults and effects of bilateral arm training. Archives of Physical Medicine and Rehabilitation, 85, 1076-83.
https://www.ncbi.nlm.nih.gov/pubmed/15241753

Morris, J.H. & Van Wijck, F. (2012). Responses of the less affected arm to bilateral upper limb task training in early rehabilitation after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More: a randomized controlled trial. Physical Medicine and Rehabilitation, 93, 1129-37.
https://www.ncbi.nlm.nih.gov/pubmed/22421627

Morris, J.H., van Wijke, F., Joice, S., Ogston, S.A., Cole, I., & MacWalter, R.S. (2008). A comparison of bilateral and unilateral upper-limb task training in early poststroke rehabilitation: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 89, 1237-45.
https://www.ncbi.nlm.nih.gov/pubmed/18586126

Platz, T., Bock, S., & Prass, K. (2001). Reduced skillfulness of arm motor behaviour among motor strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More 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, 39, 687-98.
https://www.ncbi.nlm.nih.gov/pubmed/11311299

Rosa, M., Vasconcelos, O., & Marques, A. (2010). The influence of two rehabilitation protocols in upper-limb function of strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More patients. International Journal of Therapy and Rehabilitation, 17(9), 464-70.
https://www.magonlinelibrary.com/doi/abs/10.12968/ijtr.2010.17.9.78036

Sampson, M., Shau, Y.W., & King, M.J. (2012). Bilateral upper limb trainer with virtual reality for post-stroke rehabilitation: case series report. Disability and Rehabilitation: Assistive Technology, 7(1), 55-62.
https://www.ncbi.nlm.nih.gov/pubmed/21446826

Sethy, D., Bajpai, P., Kujur, E. S., Mohakud, K., & Sahoo, S. (2016). Effectiveness of modified constraint induced movement therapy and bilateral arm training on upper extremity function after chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More: A comparative study. Open Journal of Therapy and Rehabilitation, 4(01), 1.
http://file.scirp.org/pdf/OJTR_2016021515264295.pdf

Shahine, E. M., & Shafshak, T. S. (2014). The effect of repetitive bilateral arm training with rhythmic auditory cueing on motor performance and central motor changes in patients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More. Egyptian Rheumatology and Rehabilitation, 41(1), 8.
http://err.eg.net/article.asp?issn=1110-161X;year=2014;volume=41;issue=1;spage=8;epage=13;aulast=Shahine

Shim, S., & Jung, J. (2015). Effects of bilateral training on motor function, amount of activity and activity intensity measured with an accelerometer of patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More. Journal of Physical Therapy Science, 27(3), 751-754.
https://www.jstage.jst.go.jp/article/jpts/27/3/27_jpts-2014-585/_article/-char/ja/

Singer, B.J., Vallence, A., Cleary, S., Cooper, I., & Loftus, A.M. (2013). The effect of EMG triggered electrical stimulation plus task practice on arm function in chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More patients with moderate-severe arm deficits. Restorative Neurology and Neuroscience, 31, 681-691.
https://www.ncbi.nlm.nih.gov/pubmed/23963340

Stinear, C.M., Barber, P.A., Coxon, J.P., Fleming, M.K., & Byblow, W.D. (2008). Priming the motor system enhances the effects of upper limb therapy in chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More. Brain, 131, 1381-90.
https://www.ncbi.nlm.nih.gov/pubmed/18356189

Stinear, J.W. & Byblow, W.D. (2004). Rhythmic bilateral movement training modulates corticomotor excitability and enhances upper limb motricity poststroke: a pilot study. Journal of Clinical Neurophysiology, 21(2), 124-31.
https://www.ncbi.nlm.nih.gov/pubmed/15284604

Stoykov, M.E., Lewis, G.N., & Corcos, D.M. (2009). Comparison of bilateral and unilateral training for upper extremity hemiparesis in strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More. Neurorehabilitation and Neural Repair, 23(9), 945-53.
https://www.ncbi.nlm.nih.gov/pubmed/19531608

Summers, J.J., Kagerer, F.A., Garry, M.I., Hiraga, C.Y., Loftus, A., & Cauraugh, J.H. (2007). Bilateral and unilateral movement training on upper limb function in chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More patients: a TMS study. Journal of the Neurological Sciences, 252, 76-82.
https://www.ncbi.nlm.nih.gov/pubmed/17134723

Suputtitada, a., Suwanwela, N.C., & Tumvitee, S. (2004). Effectiveness of constraint-induced movement therapy in chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More patients. Journal of the Medical Association of Thailand, 87(12), 1482-90.
https://www.ncbi.nlm.nih.gov/pubmed/15822545

van Delden, A. L. E., Peper, C. L. E., Nienhuys, K. N., Zijp, N. I., Beek, P. J., & Kwakkel, G. (2013). Unilateral versus bilateral upper limb training after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More. StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More, STROKEAHA-113.
http://stroke.ahajournals.org/content/strokeaha/early/2013/07/18/STROKEAHA.113.001969.full.pdf

van Delden, A. L. E., Beek, P. J., Roerdink, M., Kwakkel, G., & Peper, C. L. E. (2015). Unilateral and bilateral upper-limb training interventions after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More have similar effects on bimanual coupling strength. Neurorehabilitation and Neural Repair, 29(3), 255-267.
http://journals.sagepub.com/doi/abs/10.1177/1545968314543498

van Delden, A.E.Q., Peper, C.E., Beek, P.J., & Kwakkel, G. (2012). Unilateral versus bilateral upper limb exercise therapy after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More: a systematic reviewA systematic review is a summary of available research on a given topic that compares studies based on design and methods. It summarizes the findings of each, and points out flaws or potentially confounding variables that may have been overlooked. A critical analysis of each study is done in an effort to rate the value of its stated conclusions. The research findings are then summarized, and a conclusion is provided.
. Journal of Rehabilitation Medicine, 44, 106-17.
https://www.ncbi.nlm.nih.gov/pubmed/22266762

van der Lee, J.H., Wagenaar, R.C., Lankhorst, G.J., Vogelaar, T.W., Deville, W.L., & Bouter, L.M. (1999). Forced use of the upper extremity in chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More patients – results from a single-blind randomized clinical trial. StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More, 30, 2369-75.
https://www.ncbi.nlm.nih.gov/pubmed/10548673

Waller, S. M., Whitall, J., Jenkins, T., Magder, L. S., Hanley, D. F., Goldberg, A., & Luft, A. R. (2014). Sequencing"The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step" (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007))
bilateral and unilateral task-oriented training versus task oriented training alone to improve arm function in individuals with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More. BMC Neurology, 14(1), 236.
https://bmcneurol.biomedcentral.com/articles/10.1186/s12883-014-0236-6

Whitall, J., McCombe Waller, S., Silver, K.H.C., & Macko, R.F. (2000). Repetitive bilateral arm training with rhythmic auditory cueing improves motor function in chronic hemiparetic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More. StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More, 31, 2390-5.
https://www.ncbi.nlm.nih.gov/pubmed/11022069

Whitall, J., McCombe Waller, S., Sorkin, J.D., Forrester, L.W., Macko, R.F., Hanley, D.F. Goldberg, A.P., & Luft, A. (2011). Bilateral and unilateral arm training improve motor function through differing neuroplastic mechanisms: a single-blinded randomized controlled trial. Neurorehabilitation and Neural Repair, 25(2), 118-29.
https://www.ncbi.nlm.nih.gov/pubmed/20930212

Wu, C.Y., Chuang, L.L., Lin, K.C., Chen, H.C., & Tsay, P.K. (2011). Randomized trial of distributed constraint- induced therapy versus bilateral arm training for the rehabilitation of upper-limb motor control and function after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More. Neurorehabilitation and Neural Repair, 25(2), 130-9.
https://www.ncbi.nlm.nih.gov/pubmed/20947493

Wu, C.Y., Hsieh, Y.W., Lin, K.C., Chuang, L.L., Chang, Y.F., Liu, H.L., Chen, C.L., Lin, K.H., & Wai, Y.Y. (2010). Brain reorganization after bilateral arm training and distributed constraint-induced therapyA form of intervention that involves restraining the unaffected upper or lower extremity in order to encourage movement of the affected limbs. For persons with USN, constraint-induced therapy involves restraining the unaffected arm or hand using a sling or padded mitt, in order to promote visual scanning and movement in the neglected hemispace.
in strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More patients: a preliminary functional magnetic resonance imaging study. Chang Gung Medical Journal, 33, 628-38.
https://www.ncbi.nlm.nih.gov/pubmed/21199608

Wu, C.Y., Yang, C.L., Chen, M.D., Lin, K.C., & Wu, L.L. (2013). Unilateral versus bilateral robot-assisted rehabilitation on arm-trunk control and functions post strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More: a randomized controlled trial. Journal of Neuroengineering and Rehabilitation, 10, 35.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3640972/

Wu, C.Y., Yang, C.L., Chuang, L.L., Lin, K.C., Chen, H.C., Chen, M.D., & Huang, W.C. (2012). Effect of therapist-based versus robot-assisted bilateral arm training on motor control, functional performance, and quality of life after chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More: a clinical trial. Physical Therapy, 92(8), 1006-16.
https://www.ncbi.nlm.nih.gov/pubmed/22517782

Excluded Studies

Chuang, L. L., Chen, Y. L., Chen, C. C., Li, Y. C., Wong, A. M. K., Hsu, A. L., & Chang, Y. J. (2017). Effect of EMG-triggered neuromuscular electrical stimulation with bilateral arm training on hemiplegic shoulder pain and arm function after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More: a randomized controlled trial. Journal of Neuroengineering and Rehabilitation, 14(1), 122.

Reason for exclusion: Both group received bilateral upper extremity training following their respective treatment of neuromuscular electrical stimulation or transcutaneous electrical nerve stimulation.

Hsieh, Y. W., Liing, R. J., Lin, K. C., Wu, C. Y., Liou, T. H., Lin, J. C., & Hung, J. W. (2016). Sequencing"The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step" (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007))
bilateral robot-assisted arm therapy and constraint-induced therapyA form of intervention that involves restraining the unaffected upper or lower extremity in order to encourage movement of the affected limbs. For persons with USN, constraint-induced therapy involves restraining the unaffected arm or hand using a sling or padded mitt, in order to promote visual scanning and movement in the neglected hemispace.
improves reach to press and trunk kinematics in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More. Journal of Neuroengineering and Rehabilitation, 13(1), 31.

Reason for exclusion: Both group received bilateral upper extremity training using the Bi-Manu-Track exoskeleton.

Jung, N. H., Kim, K. M., Oh, J. S., & Chang, M. (2013). The effects of bilateral arm training on reaching performance and activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of daily living of strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More patients. Journal of Physical Therapy Science, 25(4), 449-452.

Reason for exclusion: Not RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More; outcomes of interest available in RCTs for the population studied (i.e. patients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More).

Lee, S., Kim, Y., & Lee, B. H. (2016). Effect of Virtual Reality‐based Bilateral Upper Extremity Training on Upper Extremity Function after StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More: A Randomized Controlled Clinical Trial. Occupational Therapy International, 23(4), 357-368.

Reason for exclusion: Both group received bilateral upper extremity training; the intervention group received bilateral upper extremity training within a virtual reality context.

Mudie, M.H. & Matyas, T.A. (1996). Upper extremity retraining following strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More: effects of bilateral practice. Journal of NeuroEngineering and Rehabilitation, 10, 167-84.

Mudie, M.H. & Matyas, T.A. (2000). Can simultaneous bilateral movement involve the undamaged hemisphere in reconstruction of neural networks damaged by strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More? Disability and Rehabilitation, 22(1/2), 23-7.

Rodrigues, L. C., Farias, N. C., Gomes, R. P., & Michaelsen, S. M. (2016). Feasibility and effectiveness of adding object-related bilateral symmetrical training to mirror therapy in chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More: A randomized controlled pilot study. Physiotherapy Theory and Practice, 32(2), 83-91.

Reason for exclusion: Both group received bilateral upper extremity training; the intervention group received bilateral upper extremity training with the mirror, whereas in the control group the mirror was covered.

Song, G. B. (2015). The effects of task-oriented versus repetitive bilateral arm training on upper limb function and activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of daily living in strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More patients. Journal of Physical Therapy Science, 27(5), 1353-1355.

Reason for exclusion: Both group received a form of bilateral upper extremity training.

Yu, G. H., Lee, J. S., Kim, S. K., & Cha, T. H. (2017). Effects of interactive metronome training on upper extremity function, ADL and QOL in strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More patients. NeuroRehabilitation, (Preprint), 1-8.

Reason for exclusion: Both group received a form of bilateral upper extremity training.