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Bilateral arm training: why and who benefits?
No full textBilateral arm training has emerged as an approach that leads to positive outcomes in addressing upper extremity paresis after stroke. However, studies have not demonstrated improvements in all patients using current outcome measures. Furthermore, the rationale for using this type of training has been incompletely explained. The purpose of this article was to first review the theoretical justifications for the use of bilateral arm training by examining motor control and neural mechanisms underlying arm function and neural recovery, and second, to discuss examples of clinical studies using a variety of bilateral training strategies to identify who may benefit most from this approach. We argue that bilateral arm training is a necessary adjunct to unilateral training because bilateral re-training is important and best served through bilateral not unilateral training, and also, that bilateral training may help unilateral skill recovery through alternative putative mechanisms. Our review of the empirical evidence suggests that individuals at all levels of severity can benefit in some manner from bilateral training, but that not all approaches are effective for all severity levels. In addition to requesting more randomized controlled trials and studies of neurophysiological mechanisms we conclude the following: 1) Bilateral training can improve unilateral paretic limb functions of the upper extremity after stroke, however, specific training approaches need to be matched to baseline characteristics of the patients; 2) Given the importance of bilateral activities in daily life, there is a need to recognize, train and assess the important contribution of supportive role functions of the paretic arm used on its own and as part of complementary bilateral functional skills; 3) An assessment of bilateral and unilateral functioning which includes bilateral task analysis, as well as, evaluations of interlimb coordination should be included in all studies that include bilateral training; 4) Studies with thoughtful sequencing or combining of bilateral approaches or sequencing of bilateral and unilateral approaches are needed to assess if there are improved outcomes in paretic and bilateral limb function
Temporal and spatial control following bilateral versus unilateral training
No full textPrinciples of motor control and learning such as bilateral coordination and task-specificity, are increasingly incorporated in the design of upper extremity rehabilitation protocols for stroke survivors. Yet most studies investigating the efficacy of new protocols report composite scores of standardized tests, such as the Fugl-Meyer Upper Extremity test (FM) and the Wolf Motor Arm Test, rather than determining how the motor control and coordination of arm movements has changed. Here we present a sub-study of a larger randomized controlled trial comparing a bilateral and unilateral training protocol where participants were assessed on bilateral and unilateral arm reaching. Eligible participants for the arm reaching analysis were 9 (FM = 37) and 9 (FM = 34) in Bilateral Arm Training with Rhythmic Auditory Cueing (BATRAC) and Dose Matched Therapeutic Exercises (DMTE), respectively. Participants undertook 18 sessions of training for 6 weeks with 20 min of active training per session. For bilateral arm reaching, participants after BATRAC were faster, with increased peak acceleration, fewer movement units, and smoother hand paths for each arm. The BATRAC training group showed greater improvements with training than the DMTE group during bilateral reaching for parameters of movement units and smoothness of hand path. For unilateral arm reaching, participants were faster after DMTE for paretic arm reaching; however, this group did not improve to a greater extent than the BATRAC training group. Within group functional gains were seen after BATRAC on FM, Wolf Motor Arm Test (time and weight) and after DMTE on FM and Wolf Weight. There was a positive correlation between movement units and the time component of the Wolf Motor Arm Test. The reaching analysis demonstrates task-specificity in training since BATRAC improves performance in bilateral reaching and DMTE improves performance in unilateral reaching. Temporal/spatial control outcomes in studies of post-stroke interventions can identify functionally relevant motor control changes that are not captured by traditional standardized test
Accuracy of dynamic isometric force production: the influence of age and bimanual activation patterns
No full textThe purpose of this study was to investigate how children and adults control bimanual activities with the influence of kinematic variables minimized. Force and timing measures were analyzed in self-paced, isometric bimanual pinch tasks performed by 6-, 8-, 10-, 12-year-old, and adult subjects. Subjects (n = 84) performed four tasks (inphase symmetrical, antiphase reciprocal, inphase asymmetrical force-right high, inphase asymmetrical force-left high) cycling between low levels (10--30%) of maximal volitional force during three 15-s trials. Bimanual tasks requiring similar activation between the hands were performed more accurately, more quickly, and with less force and timing variability than tasks requiring different actions and/or levels of force to be produced simultaneously. Evidence of force entrainment between the hands was exhibited when force direction (increasing vs. decreasing) was similar between hands but greater relative force was required of the left hand. Lower accuracy and greater variability resulted when controlled decrement of force was required to reach the lower force targets as opposed to the upper force targets which required subjects to increase force. Subjects in the two youngest age groups exhibited lower force accuracy and greater force and timing variability relative to older children and adults. Twelve-year-old subjects approximated adults' performance in all variable
Developmental co-ordination disorder in socially disadvantaged Brazilian children
No full textBackground
The consequences of developmental co-ordination disorder (DCD) indicate a need for identification in order to provide adequate intervention. The goals of the study were to investigate DCD prevalence across age bands, gender, race and school performance; the motor difficulties of children with DCD, at-risk and typically developing children in the Movement Assessment Battery for Children (MABC) sub-tests across age bands and gender; and the relationship between motor outcomes, age, gender and socio-economic status (SES) in socially disadvantaged Brazilian children.
Methods
The MABC was administered to 1056 Brazilian children from 4 to 10 years old.
Results
Eighteen per cent of the children were screened as probable DCD (≤5th percentile) and a further 15% as at risk for DCD (>5th and ≤15th percentile). Significantly more children were screened with probable DCD at age 9–10 years (AB3: P = 0.00), whereas at risk classification was equally distributed across age bands (P = 0.12). Boys showed lower prevalence than girls of probable DCD and at risk for DCD (P = 0.04). Children (9–10 years) showed higher motor impairment in the manual dexterity test results. Children with probable DCD and at risk of DCD showed, in general, poor performance in balance and manual dexterity tasks. SES was the strongest predictor of motor outcomes, accounting for 21% of the variance in the MABC percentile scores.
Conclusions
The prevalence of probable and at-risk DCD cases as well as the percentage of female were higher than those found in the previous studies, and low SES enhances the risk of poor motor development
Comparison of four types of feedback on the golf putting task performance of novice adults
No full textPoststroke hemiparesis impairs the rate but not magnitude of adaptation of spatial and temporal locomotor features
No full textBackground: persons with stroke and hemiparesis walk with a characteristic pattern of spatial and temporal asymmetry that is resistant to most traditional interventions. It was recently shown in nondisabled persons that the degree of walking symmetry can be readily altered via locomotor adaptation. However, it is unclear whether stroke-related brain damage affects the ability to adapt spatial or temporal gait symmetry. Objective: determine whether locomotor adaptation to a novel swing phase perturbation is impaired in persons with chronic stroke and hemiparesis. Methods: participants with ischemic stroke (14) and nondisabled controls (12) walked on a treadmill before, during, and after adaptation to a unilateral perturbing weight that resisted forward leg movement. Leg kinematics were measured bilaterally, including step length and single-limb support (SLS) time symmetry, limb angle center of oscillation, and interlimb phasing, and magnitude of “initial” and “late” locomotor adaptation rates were determined. Results: all participants had similar magnitudes of adaptation and similar initial adaptation rates both spatially and temporally. All 14 participants with stroke and baseline asymmetry temporarily walked with improved SLS time symmetry after adaptation. However, late adaptation rates poststroke were decreased (took more strides to achieve adaptation) compared with controls. Conclusions: mild to moderate hemiparesis does not interfere with the initial acquisition of novel symmetrical gait patterns in both the spatial and temporal domains, though it does disrupt the rate at which “late” adaptive changes are produced. Impairment of the late, slow phase of learning may be an important rehabilitation consideration in this patient populatio
Bilateral and unilateral arm training improve motor function through differing neuroplastic mechanisms: a single-blinded randomized controlled trial
Full text linkBACKGROUND AND PURPOSE:
This randomized controlled trial tests the efficacy of bilateral arm training with rhythmic auditory cueing (BATRAC) versus dose-matched therapeutic exercises (DMTEs) on upper-extremity (UE) function in stroke survivors and uses functional magnetic resonance imaging (fMRI) to examine effects on cortical reorganization.
METHODS:
A total of 111 adults with chronic UE paresis were randomized to 6 weeks (3×/week) of BATRAC or DMTE. Primary end points of UE assessments of Fugl-Meyer UE Test (FM) and modified Wolf Motor Function Test Time (WT) were performed 6 weeks prior to and at baseline, after training, and 4 months later. Pretraining and posttraining, fMRI for UE movement was evaluated in 17 BATRAC and 21 DMTE participants.
RESULTS:
The improvements in UE function (BATRAC: FM Δ = 1.1 + 0.5, P = .03; WT Δ = -2.6 + 0.8, P < .00; DMTE: FM Δ = 1.9 + 0.4, P < .00; WT Δ = -1.6 + 0.7; P = .04) were comparable between groups and retained after 4 months. Satisfaction was higher after BATRAC than DMTE (P = .003). BATRAC led to significantly higher increase in activation in ipsilesional precentral, anterior cingulate and postcentral gyri, and supplementary motor area and contralesional superior frontal gyrus (P < .05). Activation change in the latter was correlated with improvement in the WMFT (P = .01).
CONCLUSIONS:
BATRAC is not superior to DMTE, but both rehabilitation programs durably improve motor function for individuals with chronic UE hemiparesis and with varied deficit severity. Adaptations in brain activation are greater after BATRAC than DMTE, suggesting that given similar benefits to motor function, these therapies operate through different mechanisms
Repetitive bilateral arm training with rhythmic auditory cueing improves motor function in chronic hemiparetic stroke
No full textBackground and purpose: chronic upper extremity hemiparesis is a leading cause of functional disability after stroke. We investigated the hypothesis that bilateral arm training with rhythmic auditory cueing (BATRAC) will improve motor function in the hemiparetic arm of stroke patients.Methods: in this single group pilot study we determined the effects of 6 weeks of BATRAC on 14 patients with chronic hemiparetic stroke (median time after stroke, 30 months) immediately after training and at 2 months after training. Four 5-minute periods per session (3 times per week) of BATRAC were performed with the use of a custom-designed arm training machine.Results: the patients showed significant and potentially durable increases in the following: Fugl-Meyer Upper Extremity Motor Performance Test of impairment (P<0.0004), Wolf Motor Function Test (performance time measure, P<0.02), and University of Maryland Arm Questionnaire for Stroke measuring daily use of the hemiparetic arm (P<0.002). Isometric strength improved in elbow flexion (P<0.05) and wrist flexion (P<0.02) for the paretic arm and in elbow flexion (P<0.02) and wrist extension (P<0.02) for the nonparetic arm. Active range of motion improved for paretic-side shoulder extension (P<0.01), wrist flexion (P<0.004), and thumb opposition (P<0.002), and passive range of motion improved for paretic wrist flexion (P<0.03).Conclusions: six weeks of BATRAC improves functional motor performance of the paretic upper extremity as well as a few changes in isometric strength and range of motion. These benefits are largely sustained at 8 weeks after training cessatio
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