Efficacy and Task Structure of Bimanual

Training Post Stroke: A Systematic Review

Angela Wolf, DPT,1 Rachel Scheiderer, DPT, 1 Nicholas Napolitan, DPT, 1
Courtney Belden, DPT, 1 Lauren Shaub, DPT,1 and Maureen Whitford, PhD, PT1
1
Department of Physical Therapy, Walsh University, North Canton, Ohio

Background: Bimanual training has been shown to be as effective as, but not superior to, unimanual paretic upper extremity
(UE) training interventions in improving paretic UE function and use post stroke. However, it is still unclear whether
different training interventions or task structures within bimanual interventions may differentially affect the outcomes.
Objective: The objectives of this review were to (1) systematically determine the efficacy of bimanual training in relation
to the International Classification of Functioning, Disability and Health model components and (2) explore the structure of
current bimanual training interventions. Method: A systematic review was conducted using Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eleven studies were accepted for review. Results: Three main
types of bimanual training emerged: functional task training (FTT), bilateral training with rhythmic auditory cues (BATRAC),
and robot-assisted training (RAT). Bimanual training is generally efficacious overall in improving paretic UE movement in
individuals with subacute and/or chronic stroke as compared with other interventions. FTT, BATRAC, and RAT showed
no significant differences compared with conventional therapy. Bimanual training may have greater proximal control
benefits but fewer benefits in terms of subjects’ perceived amount and quality of use as compared with constraint-induced
movement therapy. Conclusion: There were not enough data to draw any conclusions about the effects of bimanual task
symmetry or commonality of goal. Key words: bimanual, interlimb, rehabilitation, stroke, upper extremity

A
pproximately 795,000 people have a new
or recurrent stroke in the United States
annually.1 In addition to its total cost (esti-
mated at $312.6 billion in 2009), stroke is one of
the leading causes of long-term disability.1,2 People
are living longer after stroke with greater residual
deficits, reiterating the importance of improving
quality of life for survivors. Unilateral upper ex-
tremity (UE) motor deficits are extremely common
post stroke, affecting survivors’ ability to complete
activities of daily living (ADLs) without the use of
compensatory movements.3 Sixty-five percent of
patients at 6 months after stroke are unable to in-
corporate the paretic UE during functional tasks.4
Patients with stroke use their paretic UE 3 to 6
times less than the less affected UE.5
Specific effects of the stroke on bimanual UE
function are not as well documented,6 although it
has been established that individuals post stroke
use both hands together less than control subjects
do.7,8 A recent observational study indicated that
patients who have had a stroke use their paretic UE
Corresponding author: Angela Wolf, 7454 Baldwin Creek Drive,
Middleburg Heights, Ohio, 44130; phone: 440-364-0540; e-mail:
angelakwolf@gmail.com
almost exclusively in bimanual activities, although
the intensity with which they use their paretic
UE is much lower than that of the nonaffected
side.9 Greater bilateral arm use after stroke has
been associated with greater instrumental ADL
skill performance.8 This finding, in combination
with the fact that healthy subjects use both hands
together in everyday functional tasks more than
either hand alone,7,10,11 emphasizes the functional
relevance of bimanual hand use post stroke and
supports the investigation of bimanual training
post stroke.
As noted previously, bimanual hand use has
been shown to be ecologically valid in both
healthy people and patients with stroke. Bimanual
training post stroke, or the use of bilateral UEs
simultaneously during training, has been a rich
area of investigation. Interlimb coupling, the
tendency for temporal and spatial “yoking” of the 2
limbs during certain simultaneous movements,12-14
Top Stroke Rehabil 2014;21(3):181–196
© 2014 Thomas Land Publishers, Inc.
www.strokejournal.com
doi: 10.1310/tsr2103-181

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