The upper limbs after stroke: exploring effects of bilateral training and determinants of recovery

Abstract

Background: Bilateral task training (BT) may improve upper limb (UL) recovery on the affected as well as non-affected side in longstanding stroke however for acute stroke its effects on physical and psychosocial outcomes compared to unilateral training (UT) has not been clearly established. Furthermore, clinical and demographic factors that influence UL training responses and predict UL recovery are also unclear for acute stroke. PrimaryAims: To compare effects of BT and UT on: • ipsilesional and contralesional UL outcomes • anxiety, depression and health related quality of life (HRQOL) Secondary Aims: To investigate: • which clinical and demographic factors influence contralesional training responses • predictors of UL activity limitation over time for the sample as a whole • UL dysfunction as a predictor of HRQOL six months after stroke for the sample as a whole Design: Single-blinded randomised controlled trial, with outcome assessment at baseline (T1), after 6 weeks training (T2), and 18 week follow-up (T3). Participants: 106 in-patients randomised to receive BT (n=56) or UT (n=50) 2 to 4 weeks after stroke onset. Intervention: Supervised BT or UT for 20 minutes on 5 weekdays, over 6 weeks, using a standardised programme developed for the study. Outcome Measures: UL outcomes: Action Research Arm Test (ARAT), Rivermead Motor Assessment (UL scale), Nine-Hole Peg Test (9HPT). Secondary measures: Modified Barthel Index, Hospital Anxiety and Depression Scale, and Nottingham Health Profile. Assessment was conducted by a blinded assessor. Results: Between the two groups, there were no significant differences at T1 or T2 on any contralesional UL measure or on any psychosocial measure (p>0.05). At T3, 9HPT (p=0.03) and ARAT pinch section scores (p=0.04) in the UT group were significantly higher. None of the selected clinical or demographic factors significantly influenced training responses. BT significantly improved ipsilesional dexterity between T1 and T2 (p=0.04). For the sample as a whole, early ARAT and MBI scores significantly predicted contralesional ARAT scores at T2 and T3. Anxiety, depression and UL impairment significantly predicted overall HRQOL at T3. Conclusions: BT was no more effective than UT for the affected arm – in fact UT was more effective for dexterity. BT was more effective than UT, however, for short-term recovery of ipsilesional dexterity. Future studies should determine optimal BT characteristics for contraand ipsilesional recovery in stroke populations with differing levels of severity. Knowledge of predictors of UL activity limitation and HRQOL will enable therapists to target rehabilitation at factors that most influence these important outcomes.